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Wendt B, Cremers M, Ista E, van Dijk M, Schoonhoven L, Nieuwboer MS, Vermeulen H, Van Dulmen SA, Huisman-de Waal G. Low-value home-based nursing care: A national survey study. J Adv Nurs 2024; 80:1891-1901. [PMID: 37983754 DOI: 10.1111/jan.15970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/13/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023]
Abstract
AIMS To explore potential areas of low-value home-based nursing care practices, their prevalence and related influencing factors of nurses and nursing assistants working in home-based nursing care. DESIGN A quantitative, cross-sectional design. METHODS An online survey with questions containing scaled frequencies on five-point Likert scales and open questions on possible related influencing factors of low-value nursing care. The data collection took place from February to April 2022. Descriptive statistics and linear regression were used to summarize and analyse the results. RESULTS A nationwide sample of 776 certified nursing assistants, registered nurses and nurse practitioners responded to the survey. The top five most delivered low-value care practices reported were: (1) 'washing the client with water and soap by default', (2) 'application of zinc cream, powders or pastes when treating intertrigo', (3) 'washing the client from head to toe daily', (4) 're-use of a urinary catheter bag after removal/disconnection' and (5) 'bladder irrigation to prevent clogging of urinary tract catheter'. The top five related influencing factors reported were: (1) 'a (general) practitioner advices/prescribes it', (2) 'written in the client's care plan', (3) 'client asks for it', (4) 'wanting to offer the client something' and (5) 'it is always done like this in the team'. Higher educational levels and an age above 40 years were associated with a lower provision of low-value care. CONCLUSION According to registered nurses and certified nursing assistants, a number of low-value nursing practices occurred frequently in home-based nursing care and they experienced multiple factors that influence the provision of low-value care such as (lack of) clinical autonomy and handling clients' requests, preferences and demands. The results can be used to serve as a starting point for a multifaceted de-implementation strategy. REPORTING METHOD STROBE checklist for cross-sectional studies. PATIENT OR PUBLIC CONTRIBUTION No Patient or Public Contribution. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Nursing care is increasingly shifting towards the home environment. Not all nursing care that is provided is effective or efficient and this type of care can therefore be considered of low-value. Reducing low-value care and increasing appropriate care will free up time, improve quality of care, work satisfaction, patient safety and contribute to a more sustainable healthcare system.
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Affiliation(s)
- Benjamin Wendt
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Milou Cremers
- Department of Internal Medicine, Section of Nursing Science, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erwin Ista
- Department of Internal Medicine, Section of Nursing Science, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Monique van Dijk
- Department of Internal Medicine, Section of Nursing Science, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lisette Schoonhoven
- Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, United Kingdom
| | - Minke S Nieuwboer
- Academy of Health and Vitality, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Hester Vermeulen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Simone A Van Dulmen
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
| | - Getty Huisman-de Waal
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
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Zheng J, Lu Y, Li W, Zhu B, Yang F, Shen J. Prevalence and determinants of defensive medicine among physicians: a systematic review and meta-analysis. Int J Qual Health Care 2023; 35:mzad096. [PMID: 38060672 DOI: 10.1093/intqhc/mzad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/12/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
Defensive medicine, characterized by physicians' inclination toward excessive diagnostic tests and procedures, has emerged as a significant concern in modern healthcare due to its high prevalence and detrimental effects. Despite the growing concerns among healthcare providers, policymakers, and physicians, comprehensive synthesis of the literature on the prevalence and determinants of defensive medicine among physicians has yet been reported. A comprehensive literature search was conducted to identify eligible studies published between 1 January 2000 and 31 December 2022, utilizing six databases (i.e. Web of Science, PubMed, Embase, Scopus, PsycINFO, and Cochrane Library). A meta-analysis was conducted to determine the prevalence and determinants of defensive medicine. Of the 8892 identified articles, 64 eligible studies involving 35.9 thousand physicians across 23 countries were included. The overall pooled prevalence of defense medications was 75.8%. Physicians engaged in both assurance and avoidance behaviors, with the most prevalent subitems being increasing follow-up and avoidance of high-complication treatment protocols. The prevalence of defensive medicine was higher in the African region [88.1%; 95% confidence interval (CI): 80.4%-95.8%] and lower-middle-income countries (89.0%; 95% CI: 78.2%-99.8%). Among the medical specialties, anesthesiologists (92.2%; 95% CI: 89.2%-95.3%) exhibited the highest prevalence. Further, the pooled odds ratios (ORs) of the nine factors at the individual, relational, and organizational levels were calculated, and the influence of previous experience in medical-legal litigation (OR: 1.65; 95% CI: 1.13-2.18) should be considered. The results of this study indicate a high global prevalence of defensive medicine among physicians, underscoring the necessity of implementing targeted interventions to reduce its use, especially in certain regions and specialties. Policymakers should implement measures to improve physicians' medical skills, enhance physician-patient communication, address physicians' medical-legal litigation fears, and reform the medical liability system. Future research should focus on devising and assessing interventions to reduce the use of defensive medicine and to improve the quality of patient care.
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Affiliation(s)
- Junyao Zheng
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
- China Institute for Urban Governance, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China
| | - Yongbo Lu
- School of Public Policy and Administration, Xi'an Jiaotong University, 28 West Xianning Road, Xi'an 710049, China
| | - Wenjie Li
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
| | - Bin Zhu
- School of Public Health and Emergency Management, Southern University of Science and Technology, 1008 Xueyuan Road, Shenzhen, Guangdong 518005, China
| | - Fan Yang
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
- China Institute for Urban Governance, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China
| | - Jie Shen
- Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai 200030, China
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Ropers FG, Rietveld S, Rings EHHM, Bossuyt PMM, van Bodegom-Vos L, Hillen MA. Diagnostic testing in children: A qualitative study of pediatricians' considerations. J Eval Clin Pract 2023; 29:1326-1337. [PMID: 37221991 DOI: 10.1111/jep.13867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
AIMS AND OBJECTIVES Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation. METHOD We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes. RESULTS Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes. CONCLUSION We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.
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Affiliation(s)
- Fabienne G Ropers
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Rietveld
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick M M Bossuyt
- Amsterdam University Medical Centers, University of Amsterdam, Epidemiology & Data Science, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Leti van Bodegom-Vos
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Marij A Hillen
- Amsterdam University Medical Centers, location AMC, Amsterdam Public Health, Medical Psychology, Amsterdam, The Netherlands
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Lang G, Ingvarsson S, Hasson H, Nilsen P, Augustsson H. Organizational influences on the use of low-value care in primary health care - a qualitative interview study with physicians in Sweden. Scand J Prim Health Care 2022; 40:426-437. [PMID: 36325746 PMCID: PMC9848255 DOI: 10.1080/02813432.2022.2139467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM The aim was (1) to explore organizational factors influencing the use of low-value care (LVC) as perceived by primary care physicians and (2) to explore which organizational strategies they believe are useful for reducing the use of LVC. DESIGN Qualitative study with semi-structured focus group discussions (FGDs) analyzed using qualitative content analysis. SETTING Six publicly owned primary health care centers in Stockholm. SUBJECTS The participants were 31 primary care physicians. The number of participants in each FGD varied between 3 and 7. MAIN OUTCOME MEASURES Categories and subcategories reporting organizational factors perceived to influence the use of LVC and organizational strategies considered useful for reducing the use of LVC. RESULTS Four types of organizational factors (resources, care processes, improvement activities, and governance) influenced the use of LVC. Resources involved time to care for patients, staff knowledge, and working tools. Care processes included work routines and the ways activities and resources were prioritized in the organization. Improvement activities involved performance measurement and improvement work to reduce LVC. Governance concerned organizational goals, higher-level decision making, and policies. Physicians suggested multiple strategies targeting these factors to reduce LVC, including increased patient-physician continuity, adjusted economic incentives, continuous professional development for physicians, and gatekeeping functions which prevent unnecessary appointments and guide patients to the appropriate point of care. . CONCLUSION The influence of multiple organizational factors throughout the health-care system indicates that a whole-system approach might be useful in reducing LVC.KEY POINTSWe know little about how organizational factors influence the use of low-value care (LVC) in primary health care.Physicians perceive organizational resources, care processes, improvement activities, and governance as influences on the use of LVC and LVC-reducing strategies.This study provides insights about how these factors influence LVC use.Strategies at multiple levels of the health-care system may be warranted to reduce LVC.
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Affiliation(s)
- Gabriella Lang
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- CONTACT Gabriella Lang Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, SE 171 77, Sweden
| | - Sara Ingvarsson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Henna Hasson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Region Stockholm, Stockholm, Sweden
| | - Per Nilsen
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Hanna Augustsson
- Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
- Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), Region Stockholm, Stockholm, Sweden
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Litchfield I, Kingston B, Narga D, Turner A. The move towards integrated care: Lessons learnt from managing patients with multiple morbidities in the UK. Health Policy 2022; 126:777-785. [DOI: 10.1016/j.healthpol.2022.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022]
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Noels E, Lugtenberg M, Wakkee M, Ramdas KHR, Bindels PJE, Nijsten T, van den Bos RR. Process evaluation of a multicentre randomised clinical trial of substituting surgical excisions of low-risk basal cell carcinomas from secondary to primary care. BMJ Open 2022; 12:e047745. [PMID: 35197331 PMCID: PMC8867327 DOI: 10.1136/bmjopen-2020-047745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES In 2016, the SKINCATCH Trial, a clustered multi-centre randomised trial, was initiated to assess whether low-risk basal cell carcinomas (BCCs) can be treated by general practitioners (GPs) without loss of quality of care. The trial intervention consisted of a tailored 2-day educational course on skin cancer management. The aim of this process evaluation was to investigate GPs' exposure to the intervention, implementation of the intervention and experiences with the intervention and trial. RESEARCH DESIGN AND METHODS Data on exposure to the intervention, implementation and experiences were obtained at several points during the trial. Complementary quantitative components (ie, surveys, database analysis, medical record analysis) and qualitative components (ie, interviews and focus groups) were used. Quantitative data were analysed using descriptive statistics; qualitative data were summarised (barrier interviews) or audiorecorded, transcribed verbatim and thematically analysed using Atlas.Ti (focus groups). RESULTS Following a 100% intervention exposure, results concerning the implementation of the trial showed that aside from the low inclusion rate of patients with low-risk BCCs (n=54), even less excisions of low-risk BCCs were performed (n=40). Although the intervention was experienced as highly positive, several barriers were mentioned regarding the trial including administrative challenges, lack of time and high workload of GPs, low volume of BCC patients and patients declining to participate or requesting a referral to a dermatologist. CONCLUSIONS Although GPs' participation in the highly valued training was optimal, several barriers may have contributed to the low inclusion and excision rate of low-risk BCCs. While some of the issues were trial-related, other barriers such as low patient-volume and patients requesting referrals are applicable outside the trial setting as well. This may question the feasibility of substitution of surgical excisions of low-risks BCCs from secondary to primary care in the current Dutch setting. TRIAL REGISTRATION NUMBER Trial NL5631 (NTR5746).
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Affiliation(s)
- Eline Noels
- Dermatology, Erasmus MC Rotterdam, Rotterdam, The Netherlands
| | | | - Marlies Wakkee
- Dermatology, Erasmus MC Rotterdam, Rotterdam, The Netherlands
| | | | | | - Tamar Nijsten
- Dermatology, Erasmus MC Rotterdam, Rotterdam, The Netherlands
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Tummers J, Tobi H, Schalk B, Tekinerdogan B, Leusink G. State of the practice of health information systems: a survey study amongst health care professionals in intellectual disability care. BMC Health Serv Res 2021; 21:1247. [PMID: 34794424 PMCID: PMC8603513 DOI: 10.1186/s12913-021-07256-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 10/20/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Care for people with an Intellectual Disability (ID) is complex: multiple health care professionals are involved and use different Health Information Systems (HISs) to store medical and daily care information on the same individuals. The objective of this study is to identify the HISs needs of professionals in ID care by addressing the obstacles and challenges they meet in their current HISs. METHODS We distributed an online questionnaire amongst Dutch ID care professionals via different professional associations and care providers. 328 respondents answered questions on their HISs. An inventory was made of HIS usage purposes, problems, satisfaction and desired features, with and without stratification on type of HIS and care professional. RESULTS Typical in ID care, two types of HISs are being used that differ with respect to their features and users: Electronic Client Dossiers (ECDs) and Electronic Patient Dossiers (EPDs). In total, the respondents mentioned 52 unique HISs. Groups of care professionals differed in their satisfaction with ECDs only. Both HIS types present users with difficulties related to the specifics of care for people with an ID. Particularly the much needed communication between the many unique HISs was reported a major issue which implies major issues with inter-operability. Other problems seem design-related as well. CONCLUSION This study can be used to improve current HISs and design new HISs that take ID care professionals requirements into account.
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Affiliation(s)
- Joep Tummers
- Information Technology, Wageningen University & Research, Hollandseweg 1, 6701KN, Wageningen, The Netherlands
- Department of Primary and Community Care, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Hilde Tobi
- Biometris, Wageningen University & Research, Droevendaalsesteeg 1, 6706OB, Wageningen, The Netherlands
| | - Bianca Schalk
- Department of Primary and Community Care, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Bedir Tekinerdogan
- Information Technology, Wageningen University & Research, Hollandseweg 1, 6701KN, Wageningen, The Netherlands.
| | - Geraline Leusink
- Department of Primary and Community Care, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
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Whether Public Hospital Reform Affects the Hospital Choices of Patients in Urban Areas: New Evidence from Smart Card Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18158037. [PMID: 34360330 PMCID: PMC8345807 DOI: 10.3390/ijerph18158037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/25/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022]
Abstract
The effects of public hospital reforms on spatial and temporal patterns of health-seeking behavior have received little attention due to small sample sizes and low spatiotemporal resolution of survey data. Without such information, however, health planners might be unable to adjust interventions in a timely manner, and they devise less-effective interventions. Recently, massive electronic trip records have been widely used to infer people's health-seeking trips. With health-seeking trips inferred from smart card data, this paper mainly answers two questions: (i) how do public hospital reforms affect the hospital choices of patients? (ii) What are the spatial differences of the effects of public hospital reforms? To achieve these goals, tertiary hospital preferences, hospital bypass, and the efficiency of the health-seeking behaviors of patients, before and after Beijing's public hospital reform in 2017, were compared. The results demonstrate that the effects of this reform on the hospital choices of patients were spatially different. In subdistricts with (or near) hospitals, the reform exerted the opposite impact on tertiary hospital preference compared with core and periphery areas. However, the reform had no significant effect on the tertiary hospital preference and hospital bypass in subdistricts without (or far away from) hospitals. Regarding the efficiency of the health-seeking behaviors of patients, the reform positively affected patient travel time, time of stay at hospitals, and arrival time. This study presents a time-efficient method to evaluate the effects of the recent public hospital reform in Beijing on a fine scale.
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van Gool K, Mu C, Hall J. Does more investment in primary care improve health system performance? Health Policy 2021; 125:717-724. [PMID: 33906796 DOI: 10.1016/j.healthpol.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 02/04/2021] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
This study examines the association between primary care investment and performance, in 34 OECD countries for 2005-15. Specifically, we explore whether an increasing investment in primary care is associated with improved performance, and whether particular characteristics of organisation and delivery are associated with a better return on primary care investment. We take advantage of new data sources that provide rich information on health and health systems as well as economic and distributional characteristics. Multilevel modelling was utilised to analyse cross-country variation. The results show that greater investment in primary care does not improve health system performance for complex targets (i.e., no reduction in preventable hospital admissions) though there is modest improvement in breast and cervical cancer screening rates. We also found that those countries in which GPs are more aware of health promotion/preventive activities achieve higher screening rates with the same amount of investment. The findings imply that primary care investment strategies need to look beyond high-level expenditure and characteristics of primary care strength, to institutional and funding arrangements and how these link to policy goals. Despite broad enthusiasm for strengthening primary care in general, we conclude that primary care policy needs to be appropriately targeted to improve health system performance.
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Affiliation(s)
- Kees van Gool
- Center for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Australia
| | - Chunzhou Mu
- Center for Quantitative Economics, Jilin University, No. 2699 Qianjin Avenue, Gaoxin District, Changchun 130012, China.
| | - Jane Hall
- Center for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Australia
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Mulyanto J, Wibowo Y, Kringos DS. Exploring general practitioners' perceptions about the primary care gatekeeper role in Indonesia. BMC FAMILY PRACTICE 2021; 22:5. [PMID: 33397307 PMCID: PMC7780672 DOI: 10.1186/s12875-020-01365-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/27/2020] [Indexed: 11/16/2022]
Abstract
Background In the current healthcare delivery system funded by National Health Insurance (NHI) in Indonesia, the gatekeeper role of primary care services is critical to ensuring equal healthcare access for the population. To be effective, gatekeeping relies on the performance of general practitioners (GPs). However, the perceptions held by Indonesian GPs about their gatekeeper role are not yet well documented. This study describes the self-perceived knowledge, attitudes and performance of Indonesian GPs with respect to the gatekeeper role and explores associated factors. Methods We conducted a cross-sectional study of all primary care facilities (N = 75) contracted by the regional NHI office in the Banyumas district. The 73 participating GPs completed a written questionnaire that assessed their knowledge, attitudes and performance in relation to the gatekeeper role. Personal and facility characteristics were analysed in a generalised linear model as possible associating factors, as well as for the association between GPs’ knowledge and attitude with performance as gatekeepers. Results GPs scored relatively high in the domains of knowledge and performance but scored lower in their attitudes towards the gatekeeper role of primary care. In the full-adjusted model, no factors were significantly associated with the knowledge score. Work experience as GPs, private or civil service employment status and rural or urban location of the primary care facility were linked to attitude scores. Full- or part-time employment and type of facility were factors associated with the performance score. Attitude scores were positively associated with performance score. Conclusion GPs in Indonesia are knowledgeable and report that they adequately perform their function as gatekeepers in primary care. However, their attitudes towards the gatekeeper function are less positive. Attitudes and performance with respect to the primary care gatekeeper role are likely influenced more by contextual factors such as location and type of facility than by personal factors. Efforts to address contextual issues could include improvements in practice standards for privately practising physicians and public information campaigns about gatekeeping regulations. Such efforts will be crucial to improving the gatekeeper role of primary care in Indonesia and assuring efficient access to high-quality care for all. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-020-01365-w.
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Affiliation(s)
- Joko Mulyanto
- Department of Public Health and Community Medicine, Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia. .,Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam; and Amsterdam Public Health Research Institute, Amsterdam, Netherlands.
| | - Yudhi Wibowo
- Department of Public Health and Community Medicine, Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia
| | - Dionne S Kringos
- Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam; and Amsterdam Public Health Research Institute, Amsterdam, Netherlands
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Engels A, König HH, Magaard JL, Härter M, Hawighorst-Knapstein S, Chaudhuri A, Brettschneider C. Depression treatment in Germany - using claims data to compare a collaborative mental health care program to the general practitioner program and usual care in terms of guideline adherence and need-oriented access to psychotherapy. BMC Psychiatry 2020; 20:591. [PMID: 33317480 PMCID: PMC7737360 DOI: 10.1186/s12888-020-02995-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 12/03/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Societies strive for fast-delivered, evidence-based and need-oriented depression treatment within budget constraints. To explore potential improvements, selective contracts can be implemented. Here, we evaluate if the German collaborative psychiatry-neurology-psychotherapy contract (PNP), which extends the gatekeeping-based general practitioner (GP) program, improved guideline adherence or need-oriented and timely access to psychotherapy compared to usual care (UC). METHODS We conducted a retrospective observational cohort study based on health insurance claims data. After we identified patients with depression who were on sick leave due to a mental disorder in 2015, we applied entropy balancing to adjust for selection effects and employed chi-squared tests to compare guideline adherence of the received treatment between PNP, the GP program and UC. Subsequently, we applied an extended cox regression to assess need-orientation by comparing the relationship between accumulated sick leave days and waiting times for psychotherapy across health plans. RESULTS N = 23,245 patients were included. Regarding guideline adherence, we found no significant differences for most severity subgroups; except that patients with a first moderate depressive episode received antidepressants or psychotherapy more often in UC. Regarding need-orientation, we observed that the effect of each additional month of sick leave on the likelihood of starting psychotherapy was increased by 6% in PNP compared to UC. Irrespective of the health plan, we found that within the first 12 months only between 24.3 and 39.7% (depending on depression severity) received at least 10 psychotherapy sessions or adequate pharmacotherapy. CONCLUSIONS The PNP contract strengthens the relationship between sick leave days and the delay until the beginning of psychotherapy, which suggests improvements in terms of need-oriented access to care. However, we found no indication for increased guideline adherence and - independent of the health plan - a gap in sufficient utilization of adequate treatment options.
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Affiliation(s)
- Alexander Engels
- Department of Health Economics and Health Services Research, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Building W37, 20246, Hamburg, Germany.
| | - Hans-Helmut König
- grid.13648.380000 0001 2180 3484Department of Health Economics and Health Services Research, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Building W37, 20246 Hamburg, Germany
| | - Julia Luise Magaard
- grid.13648.380000 0001 2180 3484Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- grid.13648.380000 0001 2180 3484Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Ariane Chaudhuri
- grid.491710.a0000 0001 0339 5982AOK Baden-Württemberg, Stuttgart, Germany
| | - Christian Brettschneider
- grid.13648.380000 0001 2180 3484Department of Health Economics and Health Services Research, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Building W37, 20246 Hamburg, Germany
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12
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Ingvarsson S, Augustsson H, Hasson H, Nilsen P, von Thiele Schwarz U, von Knorring M. Why do they do it? A grounded theory study of the use of low-value care among primary health care physicians. Implement Sci 2020; 15:93. [PMID: 33087154 PMCID: PMC7579796 DOI: 10.1186/s13012-020-01052-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/09/2020] [Indexed: 12/01/2022] Open
Abstract
Background The use of low-value care (LVC) is widespread and has an impact on both the use of resources and the quality of care. However, few studies have thus far studied the factors influencing the use of LVC from the perspective of the practitioners themselves. The aim of this study is to understand why physicians within primary care use LVC. Methods Six primary health care centers in the Stockholm Region were purposively selected. Focus group discussions were conducted with physicians (n = 31) working in the centers. The discussions were coded inductively using a grounded theory approach. Results Three main reasons for performing LVC were identified. Uncertainty and disagreement about what not to do was related to being unaware of the LVC status of a practice, guidelines perceived as conflicting, guidelines perceived to be irrelevant for the target patient population, or a lack of trust in the guidelines. Perceived pressure from others concerned patient pressure, pressure from other physicians, or pressure from the health care system. A desire to do something for the patients was associated with the fact that the visit in itself prompts action, symptoms to relieve, or that patients' emotions need to be reassured. The three reasons are interdependent. Uncertainty and disagreement about what not to do have made it more difficult to handle the pressure from others and to refrain from doing something for the patients. The pressure from others and the desire to do something for the patients enhanced the uncertainty and disagreement about what not to do. Furthermore, the pressure from others influenced the desire to do something for the patients. Conclusions Three reasons work together to explain primary care physicians’ use of LVC: uncertainty and disagreement about what not to do, perceived pressure from others, and the desire to do something for the patients. The reasons may, in turn, be influenced by the health care system, but the decision nevertheless seemed to be up to the individual physician. The findings suggest that the de-implementation of LVC needs to address the three reasons from a systems perspective.
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Affiliation(s)
- Sara Ingvarsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
| | - Hanna Augustsson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), SE-171 29, Stockholm, Stockholm Region, Sweden
| | - Henna Hasson
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine (CES), SE-171 29, Stockholm, Stockholm Region, Sweden
| | - Per Nilsen
- Department of Health, Medical and Caring Sciences, Linköping University, Linköping, Sweden
| | - Ulrica von Thiele Schwarz
- Procome Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden.,School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden
| | - Mia von Knorring
- Leadership in Healthcare and Academia Research Group, Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77, Stockholm, Sweden
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13
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Zhou Z, Zhao Y, Shen C, Lai S, Nawaz R, Gao J. Evaluating the effect of hierarchical medical system on health seeking behavior: A difference-in-differences analysis in China. Soc Sci Med 2020; 268:113372. [PMID: 32979776 DOI: 10.1016/j.socscimed.2020.113372] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 12/15/2022]
Abstract
The unbalanced allocation of healthcare resources and the underutilization of primary care facilities are the core problems that restrict the current healthcare reforms in China. In order to encourage residents to go to primary care facilities, China implemented the Hierarchical Medical System (HMS) in 2015. This study aims to evaluate the effect of HMS on health seeking behavior in China using panel data. Statistics for the study were derived from China Family Panel Studies (CFPS) 2012, 2014, 2016 and 2018, and China health and family planning statistical yearbook 2012, 2014, 2016 and 2018. We employed the difference-in-differences (DID) model with multiple periods. In total, 61,932 residents were incorporated for a final sample covered 25 provinces. The results indicated that the implementation of HMS had a significantly positive effect on the probability of urban residents going to primary care facilities for contact. However, the effect of HMS was not significant for rural residents. Basic health insurance was a significant factor for directing residents to primary care facilities. Self-assessed health, chronic disease, economic level and educational status were also found to be focal factors of health seeking behavior. In conclusion, the introduction of HMS has led to improved health seeking behavior and is worth putting more effort into. For policy makers, basic medical insurance is still an important health policy that enables systematic health seeking behavior. Initiatives to continue to expand the adjustment range of economic incentives should be adopted to promote the implementation of HMS. However, the effect of HMS in chronic disease is poor and efforts to formulate chronic disease as a breakthrough to HMS should be carried out. Moreover, the government should increase the publicity of HMS.
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Affiliation(s)
- Zhongliang Zhou
- School of Public Policy and Administration, Xi'an Jiaotong University, No. 28 Xianning West Road, Xi'an, 710049, Shaanxi, China.
| | - Yaxin Zhao
- School of Public Health, Health Science Center, Xi'an Jiaotong University, No.76 West Yanta Road, Xi'an, 710061, Shaanxi, China.
| | - Chi Shen
- School of Public Policy and Administration, Xi'an Jiaotong University, No. 28 Xianning West Road, Xi'an, 710049, Shaanxi, China.
| | - Sha Lai
- School of Public Policy and Administration, Xi'an Jiaotong University, No. 28 Xianning West Road, Xi'an, 710049, Shaanxi, China.
| | - Rashed Nawaz
- School of Public Policy and Administration, Xi'an Jiaotong University, No. 28 Xianning West Road, Xi'an, 710049, Shaanxi, China.
| | - Jianmin Gao
- School of Public Policy and Administration, Xi'an Jiaotong University, No. 28 Xianning West Road, Xi'an, 710049, Shaanxi, China.
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14
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Kool RB, Verkerk EW, Winnemuller LJ, Wiersma T, Westert GP, Burgers JS, van Dulmen SA. Identifying and de-implementing low-value care in primary care: the GP's perspective-a cross-sectional survey. BMJ Open 2020; 10:e037019. [PMID: 32499273 PMCID: PMC7279641 DOI: 10.1136/bmjopen-2020-037019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE General practitioners have an important role in reducing low-value care as gatekeepers of the health system. The aim of this study was to assess the experiences of Dutch general practitioners regarding low-value care and to identify their needs to decrease low-value primary care. DESIGN We performed a cross-sectional study. PARTICIPANTS We sent a survey to 500 general practitioners. SETTING Primary care in the Netherlands. PRIMARY AND SECONDARY OUTCOMES The survey contained questions about the provision of low-value care and on clinical cases about lumbosacral spine X-rays in patients with low back pain and vitamin B12 laboratory tests without an evidence-based indication. We also asked general practitioners what they needed to reduce low-value care. RESULTS A total of 182 general practitioners (37%) responded. 67% indicated that low-value care practices are regularly provided in general practice. 57% of the general practitioners have seen negative consequences of low-value care, in particular side effects of medication. The most provided low-value care practices are medication prescriptions such as antibiotics and laboratory tests such as vitamin B12 tests. The most reported drivers are patient-related. General practitioners want to maintain a good relationship with their patients by offering their patients an intervention instead of watchful waiting. Lack of time also plays a major role. In order to reduce low-value care, general practitioners suggested that educating patients on the value of tests and treatments might help. Supporting general practitioners and other healthcare professionals with clear guidelines as well as having more time for consultation were also mentioned by general practitioners. CONCLUSION General practitioners are aware of providing unnecessary care despite their role as gatekeepers and have reasons for this. They need support in order to change their practice. This support might consist of better education of healthcare professionals and providing more time for consultation. Local and national media, such as websites and television, could be used to educate patients while guidelines could support professionals in reducing low-value care.
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Affiliation(s)
- Rudolf Bertijn Kool
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Eva W Verkerk
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lieke Ja Winnemuller
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tjerk Wiersma
- Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Gert P Westert
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jaco S Burgers
- Dutch College of General Practitioners, Utrecht, The Netherlands
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Simone A van Dulmen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
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15
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Dinsdale E, Hannigan A, O'Connor R, O'Doherty J, Glynn L, Casey M, Hayes P, Kelly D, Cullen W, O'Regan A. Communication between primary and secondary care: deficits and danger. Fam Pract 2020; 37:63-68. [PMID: 31372649 DOI: 10.1093/fampra/cmz037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Timely and accurate communication between primary and secondary care is essential for delivering high-quality patient care. OBJECTIVE The aim of this study is to evaluate the content contained in both referral and response letters between primary and secondary care and measure this against the recommended national guidelines. METHODS Using an observational design, senior medical students and their general practice supervisors applied practice management software to identify 100 randomly selected adults, aged greater than 50 years, from a generated list of consults over a 2-year period (2013-2015). All data included in referral and response letters for these adults were examined and compared with the gold standard templates that were informed by international guidelines. RESULTS Data from 3293 referral letters and 2468 response letters from 68 general practices and 17 hospitals were analysed. The median time that had elapsed between a patient being referred and receiving a response letter was 4 weeks, ranging from 1 week for Emergency Department referral letters to 7 weeks for orthopaedic surgery referral letters. Referral letters included the reason for referral (98%), history of complaint (90%) and current medications (82%). Less commonly included were management prior to referral (65%) and medication allergies (57%). The majority of response letters included information on investigations (73%), results (70%) and follow-up plan (85%). Less commonly, response letters included medication changes (30%), medication lists (33%) and secondary diagnoses (13%). CONCLUSIONS Future research should be aimed at developing robust strategies to addressing communication gaps reported in this study.
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Affiliation(s)
- Elsa Dinsdale
- Graduate Entry Medical School, Department of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Ailish Hannigan
- Graduate Entry Medical School, Department of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Ray O'Connor
- Graduate Entry Medical School, Department of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Jane O'Doherty
- Graduate Entry Medical School, Department of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Liam Glynn
- Graduate Entry Medical School, Department of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Monica Casey
- Graduate Entry Medical School, Department of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Peter Hayes
- Graduate Entry Medical School, Department of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Dervla Kelly
- Graduate Entry Medical School, Department of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Walter Cullen
- School of Medicine, Health Sciences Centre, University College Dublin, Dublin, Ireland
| | - Andrew O'Regan
- Graduate Entry Medical School, Department of Education and Health Sciences, University of Limerick, Limerick, Ireland
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16
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Bunnik EM, Aarts N. What do patients with unmet medical needs want? A qualitative study of patients' views and experiences with expanded access to unapproved, investigational treatments in the Netherlands. BMC Med Ethics 2019; 20:80. [PMID: 31706313 PMCID: PMC6842468 DOI: 10.1186/s12910-019-0420-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 10/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with unmet medical needs sometimes resort to non-standard treatment options, including the use of unapproved, investigational drugs in the context of clinical trials, compassionate use or named-patient programs. The views and experiences of patients with unmet medical needs regarding unapproved, investigational drugs have not yet been examined empirically. METHODS In this qualitative study, exploratory interviews and focus groups were held with patients with chronic or life-threatening diseases (n = 39), about topics related to non-standard treatment options, such as the search for non-standard treatment options, patients' views of the moral obligations of doctors, and the conditions under which they would or would not wish to use non-standard treatment options, including expanded access to unapproved, investigational drugs. RESULTS Respondents had very little knowledge about and/or experience with existing opportunities for expanded access to investigational drugs, although some respondents were actively looking for non-standard treatment options. They had high expectations of their treating physicians, assuming them to be aware of non-standard treatment options, including clinical trials elsewhere and expanded access programs, and assuming that they would inform their patients about such options. Respondents carefully weighed the risks and potential benefits of pursuing expanded access, citing concerns related to the scientific evidence of the safety and efficacy of the drug, side effects, drug-drug interactions, and the maintaining of good quality of life. Respondents stressed the importance of education and assertiveness to obtain access to good-quality health care, and were willing to pay out of pocket for investigational drugs. Patients expressed concerns about equal access to new and/or non-standard treatment options. CONCLUSION When the end of a standard treatment trajectory comes into view, patients may prefer that treating physicians discuss non-standard treatment options with them, including opportunities for expanded access to unapproved, investigational drugs. Although our respondents had varying levels of understanding of expanded access programs, they seemed capable of making well-considered choices with regard to non-standard treatment options and had realistic expectations with regard to the safety and efficacy of such options. Dutch patients might be less likely to fall prey to false hope than often presumed.
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Affiliation(s)
- Eline M Bunnik
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Centre Rotterdam, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands.
| | - Nikkie Aarts
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Centre Rotterdam, Wytemaweg 80, 3015, CN, Rotterdam, The Netherlands
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17
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Rolke K, Wenner J, Razum O. Shaping access to health care for refugees on the local level in Germany – Mixed-methods analysis of official statistics and perspectives of gatekeepers. Health Policy 2019; 123:845-850. [DOI: 10.1016/j.healthpol.2019.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
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18
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Groeneveld GH, van de Peppel RJ, de Waal MWM, Verheij TJM, van Dissel JT. Clinical factors, C-reactive protein point of care test and chest X-ray in patients with pneumonia: A survey in primary care. Eur J Gen Pract 2019; 25:229-235. [PMID: 31455104 PMCID: PMC6853238 DOI: 10.1080/13814788.2019.1649651] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: In patients with an acute lower respiratory tract infection (LRTI), general practitioners (GPs) often find it challenging to decide to prescribe antibiotics or not. C-reactive protein (CRP) point of care test (POCT), and chest X-ray are diagnostic tests that can optimize the treatment decision. However, their usefulness in clinical practice is unknown. Objectives: To determine the proportion of Dutch GPs using CRP and chest X-ray in patients with an acute LRTI. To determine whether clinical factors and C-reactive protein point of care test affect the behaviour in requesting chest X-rays. Methods: In 2014, a questionnaire was sent to a random sample of 900 Dutch GPs. Outcome parameters are the use of CRP and chest X-ray, the percentage of GPs who guide their decision in requesting chest X-rays by CRP testing and the GP’s expectation regarding presence or absence of pneumonia. In addition, considerations for requesting chest X-rays were assessed. Results: Two hundred and fifty-five completed questionnaires (29%) were returned. In 2014, 54% of the responding GPs used the CRP test. These GPs tend to use fewer chest X-rays (p = 0.07). GPs overestimate the chance that pneumonia will be present on the radiograph. Seventy percent consider the possibility of abnormalities other than pneumonia as the main reason for requesting a chest X-ray. Conclusion: In patients with an acute lower respiratory tract infection, GPs report that CRP results affect their behaviour regarding the request of a chest X-ray in patients with lower respiratory tract infection and therefore research is needed to substantiate the use of these diagnostic tools for this purpose.
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Affiliation(s)
- Geert H Groeneveld
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert J van de Peppel
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Margot W M de Waal
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Theo J M Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaap T van Dissel
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands.,Centre for Infectious Disease Control, Dutch National Institute for Public Health and the Environment, Bilthoven, The Netherlands
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19
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Noels EC, Hollestein LM, van Egmond S, Lugtenberg M, van Nistelrooij LPJ, Bindels PJE, van der Lei J, Stern RS, Nijsten T, Wakkee M. Healthcare utilization and management of actinic keratosis in primary and secondary care: a complementary database analysis. Br J Dermatol 2019; 181:544-553. [PMID: 30636037 PMCID: PMC6850060 DOI: 10.1111/bjd.17632] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2019] [Indexed: 12/25/2022]
Abstract
Background The high prevalence of actinic keratosis (AK) requires the optimal use of healthcare resources. Objectives To gain insight in to the healthcare utilization of people with AK in a population‐based cohort, and the management of AK in a primary and secondary care setting. Methods A retrospective cohort study using three complementary data sources was conducted to describe the use of care, diagnosis, treatment and follow‐up of patients with AK in the Netherlands. Data sources consisted of a population‐based cohort study (Rotterdam Study), routine general practitioner (GP) records (Integrated Primary Care Information) and nationwide claims data (DRG Information System). Results In the population‐based cohort (Rotterdam Study), 69% (918 of 1322) of participants diagnosed with AK during a skin‐screening visit had no previous AK‐related visit in their GP record. This proportion was 50% for participants with extensive AK (i.e. ≥ 10 AKs; n = 270). Cryotherapy was the most used AK treatment by both GPs (78%) and dermatologists (41–56%). Topical agents were the second most used treatment by dermatologists (13–21%) but were rarely applied in primary care (2%). During the first AK‐related GP visit, 31% (171 of 554) were referred to a dermatologist, and the likelihood of being referred was comparable between low‐ and high‐risk patients, which is inconsistent with the Dutch general practitioner guidelines for ‘suspicious skin lesions’ from 2017. Annually, 40 000 new claims representing 13% of all dermatology claims were labelled as cutaneous premalignancy. Extensive follow‐up rates (56%) in secondary care were registered, while only 18% received a claim for a subsequent cutaneous malignancy in 5 years. Conclusions AK management seems to diverge from guidelines in both primary and secondary care. Underutilization of field treatments, inappropriate treatments and high referral rates without proper risk stratification in primary care, combined with extensive follow‐up in secondary care result in the inefficient use of healthcare resources and overburdening in secondary care. Efforts directed to better risk differentiation and guideline adherence may prove useful in increasing the efficiency in AK management. What's already known about this topic? The prevalence of actinic keratosis (AK) is high and, in particular, multiple AKs are a strong skin cancer predictor. The high prevalence of AK requires optimal use of healthcare resources. Nevertheless, (population based) AK healthcare utilization and management data are very rare.
What does this study add? Although AK‐related care already consumes substantial resources, about 70% of the AK population has never received care. Primary care AK management demonstrated underutilization of topical therapies and high referral rates without proper risk stratification, while in secondary care the extensive follow‐up schedules were applied. This inefficient use of healthcare resources highlights the need for better harmonization and risk stratification to increase the efficiency of AK care.
Linked Comment: https://doi.org/10.1111/bjd.17862. https://doi.org/10.1111/bjd.18269 available online https://www.bjdonline.com/article/
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Affiliation(s)
- E C Noels
- Department of Dermatology, Erasmus University Medical Centre, Rotterdam, the Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - L M Hollestein
- Department of Dermatology, Erasmus University Medical Centre, Rotterdam, the Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - S van Egmond
- Department of Dermatology, Erasmus University Medical Centre, Rotterdam, the Netherlands.,Department of Public Health, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - M Lugtenberg
- Department of Dermatology, Erasmus University Medical Centre, Rotterdam, the Netherlands.,Department of Public Health, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | | | - P J E Bindels
- Department of General Practice, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - J van der Lei
- Department of Medical Informatics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - R S Stern
- Department of Dermatology, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, U.S.A
| | - T Nijsten
- Department of Dermatology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - M Wakkee
- Department of Dermatology, Erasmus University Medical Centre, Rotterdam, the Netherlands
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20
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Gamst-Jensen H, Frishknecht Christensen E, Lippert F, Folke F, Egerod I, Brabrand M, Tolstrup JS, Thygesen LC, Huibers L. Impact of caller's degree-of-worry on triage response in out-of-hours telephone consultations: a randomized controlled trial. Scand J Trauma Resusc Emerg Med 2019; 27:44. [PMID: 30975160 PMCID: PMC6458647 DOI: 10.1186/s13049-019-0618-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 03/20/2019] [Indexed: 11/17/2022] Open
Abstract
Background Telephone triage entails assessment of urgency and direction of flow in out-of-hours (OOH) services, while visual cues are inherently lacking. Triage tools are recommended but current tools fail to provide systematic assessment of the caller’s perspective. Research demonstrated that callers can scale their degree-of-worry (DOW) in a telephone contact with OOH services, but its impact on triage response is undetermined. The aim of this study was to investigate the association between call-handlers’ awareness of the caller’s DOW and the telephone triage response. Methods A randomized controlled trial at a Danish OOH service using telephone triage with quantitative analyses and qualitative process evaluation. Prior to contact with a call-handler, callers were asked to rate their DOW on a five-point scale. Calls were randomized to show or not show DOW on the call-handlers’ screens. Triage response (telephone consultation or face-to-face consultation) was analysed using Chi-square tests. Process evaluation incorporated a quantitative and qualitative assessment of intervention implementation and fidelity. Results Of 11,413 calls, 5705 were allocated to the intervention and 5708 to the control group. No difference in number of face-to-face consultations was detected between the two groups (OR 1.05, 95% CI 0.98 to 1.14, p = 0.17). The process evaluation showed that call-handlers did not use the DOW systematically and were reluctant to use DOW. Conclusion Awareness of DOW did not affect the triage response, but this finding could reflect a weak implementation strategy. Future studies should emphasise the implementation strategy to determine the effect of DOW on triage response. Trial registration Registration number, Clinicaltrials.gov NCT02979457. Electronic supplementary material The online version of this article (10.1186/s13049-019-0618-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hejdi Gamst-Jensen
- Emergency Medical Services Copenhagen, Copenhagen University, Copenhagen, Denmark.
| | - Erika Frishknecht Christensen
- Center for Prehospital and Emergency Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Clinic of Emergency Medicine and Department of Anaesthesiology and Intensive Care, Aalborg University Hospital South, Aalborg, Denmark
| | - Freddy Lippert
- Emergency Medical Services Copenhagen, Copenhagen University, Copenhagen, Denmark
| | - Fredrik Folke
- Emergency Medical Services Copenhagen, Copenhagen University, Copenhagen, Denmark.,Department of Cardiology, Copenhagen University Hospital, Gentofte, Denmark
| | - Ingrid Egerod
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark.,Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark
| | | | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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21
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Noels EC, Wakkee M, van den Bos RR, Bindels PJE, Nijsten T, Lugtenberg M. Substitution of low-risk skin cancer hospital care towards primary care: A qualitative study on views of general practitioners and dermatologists. PLoS One 2019; 14:e0213595. [PMID: 30889211 PMCID: PMC6424446 DOI: 10.1371/journal.pone.0213595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/25/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Rising healthcare expenditures places the potential for substitution of hospital care towards primary care high on the political agenda. As low-risk basal cell carcinoma (BCC) care is one of the potential targets for substitution of hospital care towards primary care the objective of this study is to gain insight in the views of healthcare professionals regarding substitution of skin cancer care, and to identify perceived barriers and potential strategies to facilitate substitution. METHODS A qualitative study was conducted consisting of 40 interviews with dermatologists and GPs and three focus groups with 18 selected GPs with noted willingness regarding substitution of skin cancer care. The interviews and focus groups focused on general views, perceived barriers and potential strategies to facilitate substitution of skin cancer care, using predefined topic lists. All sessions were audio-taped, transcribed verbatim and analyzed using the program AtlasTi. RESULTS GPs were generally positive regarding substitution of skin care whereas dermatologists expressed more concerns. Lack of trust in GPs to adequately perform skin cancer care and a preference of patients for dermatologists are reported as barriers by dermatologists. The main barriers reported by GPs were a lack of confidence in own skills to perform skin cancer care, a lack of trust from both patients and dermatologists and limited time and financial compensation. Facilitating strategies suggested by both groups mainly focused on improving GPs' education and improving the collaboration between primary and secondary care. GPs additionally suggested efforts from dermatologists to increase their own and patients' trust in GPs, and time and financial compensation. The selected group of GPs suggested practical solutions to facilitate substitution focusing on changes in organizational structure including horizontal referring, outreach models and practice size reduction. CONCLUSIONS GPs and, to lesser extent, dermatologists are positive regarding substitution of low-risk BCC care, though report substantial barriers that need to be addressed before substitution can be further implemented. Aside from essential strategies such as improving GPs' skin cancer education and time and financial compensation, rearranging the organizational structure in primary care and between primary and secondary care may facilitate effective and safe substitution of low-risk BCC care.
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Affiliation(s)
- E. C. Noels
- Department of Dermatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M. Wakkee
- Department of Dermatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - R. R. van den Bos
- Department of Dermatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - P. J. E. Bindels
- Department of General Practice, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - T. Nijsten
- Department of Dermatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - M. Lugtenberg
- Department of Dermatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
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León-Cortés JL, Leal Fernández G, Sánchez-Pérez HJ. Health reform in Mexico: governance and potential outcomes. Int J Equity Health 2019; 18:30. [PMID: 30732653 PMCID: PMC6367748 DOI: 10.1186/s12939-019-0929-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/24/2019] [Indexed: 01/26/2023] Open
Abstract
Adopting key mechanisms to restructure public policy in developing countries is a crucial political task. The strengthening of infrastructure of health services, care quality, monitoring and population health; all might contribute to assuring the functionality of a national system for health monitoring and care. Over the last decades, the Mexican government has launched wide-ranging political reforms aiming to overcome socioeconomic and environmental problems, namely health, education, finances, energy and pension. The proposed (but yet not implemented) health reform in Mexico during E. Peña Nieto’s administration (2012–2018) pretended an adjustment in Article 4 of the Mexican Constitution to compact medical care and reduce the State’s responsibility to a provision of minimum health packages for the population. Here we use a simple analytical model to describe and interprete the concepts of context, process, actors and content and the outcome of three of the most important resulting components of this intended reform i.e. universality, basic packages, and ‘outsourcing’. In light of the start of the Mexico’s new federal administration, we argue that, if not properly defined by all actors, the implementation of such structural health reform in Mexico would precipitate a model of private/public association exacerbating a crisis of political representation, human rights, justice and governance.
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Affiliation(s)
- Jorge L León-Cortés
- Departamento de Conservación de la Biodiversidad, El Colegio de la Frontera Sur, Carretera Panamericana & Av. Periférico Sur S/N, 29290, San Cristóbal de Las Casas, Chiapas, Mexico. .,Network GRAAL (Research Groups for America and Africa Latins), San Cristóbal de Las Casas, Chiapas, Mexico.
| | - Gustavo Leal Fernández
- Unidad Xochimilco, División de Ciencias Biológicas y de la Salud, Universidad Autónoma Metropolitana, Calzada del Hueso 1100, Col. Villa Quietud, Delegación Coyoacán, 04960, Mexico City, Mexico
| | - Héctor J Sánchez-Pérez
- Network GRAAL (Research Groups for America and Africa Latins), San Cristóbal de Las Casas, Chiapas, Mexico.,Departamento de Salud, El Colegio de la Frontera Sur, Carretera Panamericana & Av. Periférico Sur S/N, 29290, San Cristóbal de las Casas, Chiapas, Mexico
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Mira JJ, Carrillo I, Silvestre C, Pérez-Pérez P, Nebot C, Olivera G, González de Dios J, Aranaz Andrés JM. Drivers and strategies for avoiding overuse. A cross-sectional study to explore the experience of Spanish primary care providers handling uncertainty and patients' requests. BMJ Open 2018; 8:e021339. [PMID: 29909371 PMCID: PMC6009548 DOI: 10.1136/bmjopen-2017-021339] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Identify the sources of overuse from the point of view of the Spanish primary care professionals, and analyse the frequency of overuse due to pressure from patients in addition to the responses when professionals face these demands. DESIGN A cross-sectional study. SETTING Primary care in Spain. PARTICIPANTS A non-randomised sample of 2201 providers (general practitioners, paediatricians and nurses) was recruited during the survey. PRIMARY AND SECONDARY OUTCOME MEASURES The frequency, causes and responsibility for overuse, the frequency that patients demand unnecessary tests or procedures, the profile of the most demanding patients, and arguments for dissuading the patient. RESULTS In all, 936 general practitioners, 682 paediatricians and 286 nurses replied (response rate 18.6%). Patient requests (67%) and defensive medicine (40%) were the most cited causes of overuse. Five hundred and twenty-two (27%) received requests from their patients almost every day for unnecessary tests or procedures, and 132 (7%) recognised granting the requests. The lack of time in consultation, and information about new medical advances and treatments that patients could find on printed and digital media, contributed to the professional's inability to adequately counter this pressure by patients. Clinical safety (49.9%) and evidence (39.4%) were the arguments that dissuaded patients from their requests the most. Cost savings was not a convincing argument (6.8%), above all for paediatricians (4.3%). General practitioners resisted more pressure from their patients (x2=88.8, P<0.001, percentage difference (PD)=17.0), while nurses admitted to carrying out more unnecessary procedures (x2=175.7, P<0.001, PD=12.3). CONCLUSION Satisfying the patient and patient uncertainty about what should be done and defensive medicine practices explains some of the frequent causes of overuse. Safety arguments are useful to dissuade patients from their requests.
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Affiliation(s)
- José Joaquín Mira
- Alicante-Sant Joan Health District, Conselleria de Sanidad, Alicante, Spain
- Health Psychology Department, Universidad Miguel Hernández de Elche, Alicante, Spain
- REDISSEC, Red de Servicios de Salud Orientados a Enfermedades Crónicas, Valencia, Spain
| | - Irene Carrillo
- Health Psychology Department, Universidad Miguel Hernández de Elche, Alicante, Spain
| | - Carmen Silvestre
- Servicio de Efectividad y Seguridad Asistencial, Servicio Navarro de Salud-Osasunbidea, Pamplona, Spain
| | - Pastora Pérez-Pérez
- Observatorio para la Seguridad del Paciente, Agencia de Calidad Sanitaria de Andalucía, Sevilla, Spain
| | - Cristina Nebot
- Centro de Salud Fuente de San Luis, Dr. Peset Health District, Conselleria de Sanidad, Valencia, Spain
| | - Guadalupe Olivera
- Hospital Clínico San Carlos, Servicio Madrileño de Salud, Madrid, Spain
| | - Javier González de Dios
- Hospital General Universitario de Alicante, Conselleria de Sanidad, Alicante, Spain
- CIBER de Enfermedades Raras, Alicante, Spain
| | - Jesús María Aranaz Andrés
- Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Servicio Madrileño de Salud, Madrid, Spain
- Centro de Investigación Biomédica en Red en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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Trevena LJ, Harrison C, Britt HC. Administrative encounters in general practice: low value or hidden value care? Med J Aust 2018; 208:114-118. [PMID: 29438646 DOI: 10.5694/mja17.00225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 09/14/2017] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To determine the frequency of general practice administrative encounters, and to determine whether they represent low value care. DESIGN Secondary analysis of data from the Bettering Evaluation and Care of Health (BEACH) dataset. SETTING 1 568 100 GP-patient encounters in Australia, 2000-01 to 2015-16. PARTICIPANTS An annual nationally representative random sample of about 1000 GPs, who each recorded the details of 100 consecutive encounters with patients. MAIN OUTCOME MEASURES Proportions of general practice encounters that were potentially low value care encounters (among the patient's reasons for the encounter was at least one administrative, medication, or referral request) and potentially low value care only encounters (such reasons were the sole reason for the encounter). For 2015-16, we also examined other health care provided by GPs at these encounters. RESULTS During 2015-16, 18.5% (95% CI, 17.7-19.3%) of 97 398 GP-patient encounters were potentially low value care request encounters; 7.4% (95% CI, 7.0-7.9%) were potentially low value care only encounters. Administrative work was requested at 3.8% (95% CI, 3.5-4.0%) of GP visits, 35.4% of which were for care planning and coordination, 33.5% for certification, and 31.2% for other reasons. Medication requests were made at 13.1% (95% CI, 12.4-13.7%) of encounters; other health care was provided at 57.9% of medication request encounters, counselling, advice or education at 23.4%, and pathology testing was ordered at 16.7%. Referrals were requested at 2.8% (95% CI, 1.7-3.0%) of visits, at 69.4% of which additional health care was provided. The problems managed most frequently at potentially low value care only encounters were chronic diseases. CONCLUSION Most patients requested certificates, medications and referrals in the context of seeking help for other health needs. Additional health care, particularly for chronic diseases, was provided at most GP administrative encounters. The MBS Review should consider the hidden value of these encounters.
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Affiliation(s)
- Lyndal J Trevena
- Sydney School of Public Health, University of Sydney, Sydney, NSW
| | | | - Helena C Britt
- Sydney School of Public Health, University of Sydney, Sydney, NSW
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25
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Alber K, Kuehlein T, Schedlbauer A, Schaffer S. Medical overuse and quaternary prevention in primary care - A qualitative study with general practitioners. BMC FAMILY PRACTICE 2017; 18:99. [PMID: 29216841 PMCID: PMC5721694 DOI: 10.1186/s12875-017-0667-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 11/16/2017] [Indexed: 11/16/2022]
Abstract
Background Medical overuse is a topic of growing interest in health care systems and especially in primary care. It comprises both over investigation and overtreatment. Quaternary prevention strategies aim at protecting patients from unnecessary or harmful medicine. The objective of this study was to gain a deeper understanding of relevant aspects of medical overuse in primary care from the perspective of German general practitioners (GPs). We focused on the scope, consequences and drivers of medical overuse and strategies to reduce it (=quaternary prevention). Methods We used the qualitative Grounded Theory approach. Theoretical sampling was carried out to recruit GPs in Bavaria, Germany. We accessed the field of research through GPs with academic affiliation, recommendations by interview partners and personal contacts. They differed in terms of primary care experience, gender, region, work experience abroad, academic affiliation, type of specialist training, practice organisation and position. Qualitative in-depth face-to-face interviews with a semi-structured interview guide were conducted (n = 13). The interviews were audiotaped and transcribed verbatim. Data analysis was carried out using open and axial coding. Results GPs defined medical overuse as unnecessary investigations and treatment that lack patient benefit or bear the potential to cause harm. They observed that medical overuse takes place in all three German reimbursement categories: statutory health insurance, private insurance and individual health services (direct payment). GPs criticised the poor acceptance of gate-keeping in German primary care. They referred to a low-threshold referral policy and direct patient access to outpatient secondary care, leading to specialist treatment without clear medical indication. The GPs described various direct drivers of medical overuse within their direct area of influence. They also emphasised indirect drivers related to system or societal processes. The proposed strategies for reducing medical overuse included a well-founded wait-and-see approach, medical education, a trustful doctor-patient relationship, the improvement of primary/health care structures and the involvement of patients and society. Conclusions GPs are frequently located at the starting point of the diagnostic and treatment process. They have the potential to play a vital role in quaternary prevention. This requires a debate going beyond the medical profession and involving society as a whole. Electronic supplementary material The online version of this article (10.1186/s12875-017-0667-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kathrin Alber
- Institute of General Practice, Friedrich-Alexander-University Erlangen-Nuernberg (FAU), Universitaetsstr. 29, 91054, Erlangen, Germany.
| | - Thomas Kuehlein
- Institute of General Practice, Friedrich-Alexander-University Erlangen-Nuernberg (FAU), Universitaetsstr. 29, 91054, Erlangen, Germany
| | - Angela Schedlbauer
- Institute of General Practice, Friedrich-Alexander-University Erlangen-Nuernberg (FAU), Universitaetsstr. 29, 91054, Erlangen, Germany
| | - Susann Schaffer
- Institute of General Practice, Friedrich-Alexander-University Erlangen-Nuernberg (FAU), Universitaetsstr. 29, 91054, Erlangen, Germany
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26
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van der Wees PJ, Wammes JJG, Jeurissen PPT, Westert GP. The role of physicians and their professional bodies in containing health care costs. Fam Pract 2017; 34:637-638. [PMID: 28968742 DOI: 10.1093/fampra/cmx079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Philip J van der Wees
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Joost J G Wammes
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Patrick P T Jeurissen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Gert P Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
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27
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Dündar C. Health-seeking behavior and medical facility choice in Samsun, Turkey. Health Policy 2017; 121:1015-1019. [PMID: 28734683 DOI: 10.1016/j.healthpol.2017.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 06/26/2017] [Accepted: 07/02/2017] [Indexed: 10/19/2022]
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28
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Andersen MK, Pedersen LB, Dupont M, Pedersen KM, Munck A, Nexøe J. General practitioners' attitudes towards and experiences with referrals due to supplemental health insurance. Fam Pract 2017; 34:581-586. [PMID: 28472286 DOI: 10.1093/fampra/cmx035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Supplemental health insurances (SHI) cover 38% of the Danish population. SHI can give faster access to, and additional treatment from, private health providers. However, this is contingent on a referral from the general practitioner (GP), further complicating clinical decision-making. OBJECTIVES To describe GPs' attitudes to SHI and their experiences with patients holding SHI. Moreover, we analysed associations between different GP characteristics; e.g. gender, age, practice type, own SHI status and their attitudes to and experiences with SHI. METHODS A questionnaire was mailed to 3321 GPs focusing on three issues: (i) Attitudes towards the public health care system. (ii) Perceptions of the impact of SHI. (iii) Experiences with patients holding SHIs. RESULTS The response rate was 64%. Overall, GPs found that SHIs contribute to inequality (83%) and overtreatment (90%). However, 46% often feel under pressure to refer SHI patients to specialist care, even though not medically indicated, while 11% always or often refer SHI patients unconditionally. Both groups perceive SHI patients more insistent on getting referrals than patients without SHI. CONCLUSION Even though a majority of GPs associate SHI with overtreatment and inequality in health, many GPs feel under pressure to refer patients holding SHI for treatments or examinations that are not medically warranted. Some GPs even refer these patients without further examination or questioning. Insistent SHI patients may partly explain this paradox. Future research should illuminate SHI patients' courses in the private as well as the public healthcare system with regards to medical indications and health outcome measures focusing on inequality and overtreatment.
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Affiliation(s)
- Merethe K Andersen
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, 5000 Odense C, Denmark
| | - Line B Pedersen
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, 5000 Odense C, Denmark.,COHERE - Centre of Health Economic Research, Department of Business and Economics, University of Southern Denmark, Campusvej 55, 5000 Odense C, Denmark
| | - Michael Dupont
- Attestudvalget, Danish Medical Association, Kristianiagade 12, 2100 København Ø, Denmark
| | - Kjeld Møller Pedersen
- COHERE - Centre of Health Economic Research, Department of Business and Economics, University of Southern Denmark, Campusvej 55, 5000 Odense C, Denmark
| | - Anders Munck
- Audit Projekt Odense, Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, 5000 Odense C, Denmark
| | - Jørgen Nexøe
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, 5000 Odense C, Denmark
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29
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Xu J, Mills A. Challenges for gatekeeping: a qualitative systems analysis of a pilot in rural China. Int J Equity Health 2017; 16:106. [PMID: 28666445 PMCID: PMC5493841 DOI: 10.1186/s12939-017-0593-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 05/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gatekeeping involves a generalist doctor who controls patients' access to specialist care, and has been discussed as an important policy option to rebalance the primary care and hospital sectors in low- and middle-income countries, despite thin evidence. A gatekeeping pilot in a Chinese rural setting launched in 2013 has offered an opportunity to study the functioning of gatekeeping under such conditions. METHODS In this qualitative study within a mixed-method evaluation of the gatekeeping pilot, we developed an innovative systems analysis method, combining the World Health Organisation categorisation of health system building blocks, the "Framework" approach of policy analysis and causal loop analysis. We conducted in-depth interviews with 20 stakeholders from 4 groups (patients, doctors, health facility managers and government administrators) in the pilot area over two years. Based on information extracted from the interviews, we drew a causal loop diagram which highlighted the feedback loops within the system that had self-reinforcing or self-balancing characteristics, and used the diagram to examine systematically the mechanisms of intended and actual functioning of gatekeeping and analyse the systems level challenges that affected the effectiveness of gatekeeping. RESULTS Had the gatekeeping pilot programme worked as intended, it would incentivize both providers and patients to increase service utilization at primary care level, as well as establish and enhance two reinforcing feedback loops to shift balance towards primary care. However, a performance-based salary policy undermined the motivation for clinical primary care. Furthermore, the primary care providers suffered from three reinforcing feedback loops (related to primary care capacity, human resource sustainability, patients' faith) that trapped primary care development in vicious cycles. At the interface between hospitals and primary care providers, there were also feedback loops exacerbating the existing hospital dominance. These feedback loops were intensified by the unintended consequences of concurrent policies (restrictions on technologies and medicines) and delayed reform in hospitals. Furthermore, the gatekeeping policy itself faced resistance to further development, due to the prevailing ineffective and ritualistic nature of gatekeeping, which formed a balancing loop. CONCLUSIONS The study shows that the intended benefits of gatekeeping were illusionary largely due to weak and worsening primary care conditions, and delay, ineffectiveness or unintended consequences of several other ongoing reforms. One particularly dangerous development of the system, which deserves urgent attention, is the harming of the professional prospects of primary care doctors. Our findings highlight the need for coordination and prioritization in designing policies related to primary care and managing changes with multiple on-going reforms. The approach used here facilitates comprehensive study of intended and actual mechanisms, and demonstrates the challenges of a complex health system intervention in a dynamic environment.
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Affiliation(s)
- Jin Xu
- China Center for Health Development Studies, Peking University, Beijing, 100191 China
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Anne Mills
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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30
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Rutten M, Vrielink F, Smits M, Giesen P. Patient and care characteristics of self-referrals treated by the general practitioner cooperative at emergency-care-access-points in the Netherlands. BMC FAMILY PRACTICE 2017; 18:62. [PMID: 28499354 PMCID: PMC5429563 DOI: 10.1186/s12875-017-0633-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 05/02/2017] [Indexed: 11/10/2022]
Abstract
Background In the Netherlands, out-of-hours primary care is provided in general practitioner-cooperatives (GPCs). These are increasingly located on site and in collaboration with emergency departments of hospitals (ED). At such sites, also called emergency-care-access-points (ECAP), the GPC is generally responsible for the triage and treatment of self-referrals who used to attend the ED. To evaluate the effects and safety of this novel organisation, we studied the characteristics and the quality of care given by GPCs to self-referrals at ECAPs. Methods Retrospective analysis (August 2011–January 2012) of 783 records of self-referred patients at three Dutch GPCs in an ECAP. This was supplemented with a retrospective analysis of patient records during a follow-up period of three-months to asses safety. Results Patient-characteristics: 59% was male, 46% aged between 16–45 years and 59% trauma-related. Most cases (95%) were triaged low-urgent. None received the highest urgency-category. Quality: The triage outcome was correct in 79%, underestimated in 12% and overestimated in 9%. After GP consultation 20% were referred to the ED, mostly for radio-diagnostics. Of the referrals to secondary care, 98% were according to common medical practice. Thirty percent had a follow-up contact, mostly with their own general practitioner, seldom with the ED. Complications, all non-severe, were registered in 3.2%; 0.4% were possibly preventable. Conclusions Self-referred patients at an ECAP are mostly trauma related, low-urgent and male patients. The majority could be treated by the GPC without subsequent referral to the ED. Care given at the GPC is reasonably efficient and safe. Triage and treatment of self-referrals by the GPC at ECAPs might offer opportunities for other countries facing problems with inappropriate emergency department visits.
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Affiliation(s)
- Martijn Rutten
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands.
| | - Fieke Vrielink
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Marleen Smits
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
| | - Paul Giesen
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
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31
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Carroll N, Richardson I. Mapping a Careflow Network to assess the connectedness of Connected Health. Health Informatics J 2017; 25:106-125. [PMID: 28438102 DOI: 10.1177/1460458217702943] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Connected Health is an emerging and rapidly developing field which has the potential to transform healthcare service systems by increasing its safety, quality and overall efficiency. From a healthcare perspective, process improvement models have mainly focused on the static workflow viewpoint. The objective of this article is to study and model the dynamic nature of healthcare delivery, allowing us to identify where potential issues exist within the service system and to examine how Connected Health technological solutions may support service efficiencies. We explore the application of social network analysis (SNA) as a modelling technique which captures the dynamic nature of a healthcare service. We demonstrate how it can be used to map the 'Careflow Network' and guide Connected Health innovators to examine specific opportunities within the healthcare service. Our results indicate that healthcare technology must be correctly identified and implemented within the Careflow Network to enjoy improvements in service delivery. Oftentimes, prior to making the transformation to Connected Health, researchers use various modelling techniques that fail to identify where Connected Health innovation is best placed in a healthcare service network. Using SNA allows us to develop an understanding of the current operation of healthcare system within which they can effect change. It is important to identify and model the resource exchanges to ensure that the quality and safety of care are enhanced, efficiencies are increased and the overall healthcare service system is improved. We have shown that dynamic models allow us to study the exchange of resources. These are often intertwined within a socio-technical context in an informal manner and not accounted for in static models, yet capture a truer insight on the operations of a Careflow Network.
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Keizer E, Maassen I, Smits M, Wensing M, Giesen P. Reducing the use of out-of-hours primary care services: A survey among Dutch general practitioners. Eur J Gen Pract 2016; 22:189-95. [PMID: 27248713 DOI: 10.1080/13814788.2016.1178718] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Out-of-hours primary care services have a high general practitioner (GP) workload with increasing costs, while half of all contacts are non-urgent. OBJECTIVES To identify views of GPs to influence the use of the out-of-hours GP cooperatives. METHODS Cross-sectional survey study among a random sample of 800 GPs in the Netherlands. RESULTS Of the 428 respondents (53.5% response rate), 86.5% confirmed an increase in their workload and 91.8% felt that the number of patient contacts could be reduced. A total of 75.4% GP respondents reported that the 24-h service society was a 'very important' reason why patients with non-urgent problems attended the GP cooperative; the equivalent for worry or anxiety was 65.8%, and for easy accessibility, 60.1%. Many GPs (83.9%) believed that the way telephone triage is currently performed contributes to the high use of GP cooperatives. Measures that GPs believed were both desirable and effective in reducing the use of GP cooperatives included co-payment for patients, stricter triage, and a larger role for the telephone consultation doctor. GPs considered patient education, improved telephone accessibility of daytime general practices, more possibilities for same-day appointments, as well as feedback concerning the use of GP cooperatives to practices and triage nurses also desirable, but less effective. CONCLUSION This study provides several clues for influencing the use of GP cooperatives. Further research is needed to examine the impact and safety of these strategies. [Box: see text].
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Affiliation(s)
- Ellen Keizer
- a Radboud University Medical Center, Radboud Institute for Health Sciences , IQ Healthcare , Nijmegen , The Netherlands
| | - Irene Maassen
- a Radboud University Medical Center, Radboud Institute for Health Sciences , IQ Healthcare , Nijmegen , The Netherlands
| | - Marleen Smits
- a Radboud University Medical Center, Radboud Institute for Health Sciences , IQ Healthcare , Nijmegen , The Netherlands
| | - Michel Wensing
- a Radboud University Medical Center, Radboud Institute for Health Sciences , IQ Healthcare , Nijmegen , The Netherlands
| | - Paul Giesen
- a Radboud University Medical Center, Radboud Institute for Health Sciences , IQ Healthcare , Nijmegen , The Netherlands
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Peeters JM, Krijgsman JW, Brabers AE, Jong JDD, Friele RD. Use and Uptake of eHealth in General Practice: A Cross-Sectional Survey and Focus Group Study Among Health Care Users and General Practitioners. JMIR Med Inform 2016; 4:e11. [PMID: 27052805 PMCID: PMC4838754 DOI: 10.2196/medinform.4515] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 09/21/2015] [Accepted: 01/21/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Policy makers promote the use of eHealth to widen access to health care services and to improve the quality and safety of care. Nevertheless, the enthusiasm among policy makers for eHealth does not match its uptake and use. eHealth is defined in this study as "health services delivered or enhanced through the Internet and related information and communication technologies." OBJECTIVE The objective of this study was to investigate (1) the current use of eHealth in the Netherlands by general practitioners (GPs) and health care users, (2) the future plans of GPs to provide eHealth and the willingness of health care users to use eHealth services, and (3) the perceived positive effects and barriers from the perspective of GPs and health care users. METHODS A cross-sectional survey of a sample of Dutch GPs and members of the Dutch Health Care Consumer Panel was conducted in April 2014. A pre-structured questionnaire was completed by 171 GPs (12% response) and by 754 health care users (50% response). In addition, two focus groups were conducted in June 2014: one group with GPs (8 participants) and one with health care users (10 participants). RESULTS Three-quarters of Dutch GPs that responded to the questionnaire (67.3%, 115/171) offered patients the possibility of requesting a prescription via the Internet, and half of them offered patients the possibility of asking a question via the Internet (49.1%, 84/171). In general, they did intend to provide future eHealth services. Nonetheless, many of the GPs perceived barriers, especially concerning its innovation (eg, insufficient reliable, secure systems) and the sociopolitical context (eg, lack of financial compensation for the time spent on implementation). By contrast, health care users were generally not aware of existing eHealth services offered by their GPs. Nevertheless, half of them were willing to use eHealth services when offered by their GP. In general, health care users have positive attitudes regarding eHealth. One in five (20.6%, 148/718) health care users perceived barriers to the use of eHealth. These included concerns about the safety of health information obtained via the Internet (66.7%, 96/144) and privacy aspects (55.6%, 80/144). CONCLUSIONS GPs and health care users have generally positive attitudes towards eHealth, which is a prerequisite for the uptake of eHealth. But, general practitioners in particular perceive barriers to using eHealth and consider the implementation of eHealth to be complex. This study shows that there is room for improving awareness of eHealth services in primary care. It will take some time before these issues are resolved and eHealth can be fully adopted.
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Keizer E, Smits M, Peters Y, Huibers L, Giesen P, Wensing M. Contacts with out-of-hours primary care for nonurgent problems: patients' beliefs or deficiencies in healthcare? BMC FAMILY PRACTICE 2015; 16:157. [PMID: 26510620 PMCID: PMC4625560 DOI: 10.1186/s12875-015-0376-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/21/2015] [Indexed: 12/04/2022]
Abstract
Background In the Netherlands, about half of the patient contacts with a general practitioner (GP) cooperative are nonurgent from a medical perspective. A part of these problems can wait until office hours or can be managed by the patient himself without further professional care. However, from the patient’s perspective, there may be a need to contact a physician immediately. Our objective was to determine whether contacts with out-of-hours primary care made by patients with nonurgent problems are the result of patients’ beliefs or of deficiencies in the healthcare system. Methods We performed a survey among 2000 patients with nonurgent health problems in four GP cooperatives in the Netherlands. Two GPs independently judged the medical necessity of the contacts of all patients in this study. We examined characteristics, views and motives of patients with medically necessary contacts and those without medically necessary contacts. Descriptive statistics were used to describe the characteristics, views and reasons of the patients with medically unnecessary contacts and medically necessary contacts. Differences between these groups were tested with chi-square tests. Results The response rate was 32.3 % (N = 646). Of the nonurgent contacts 30.4 % were judged as medically necessary (95 % CI 27.0-34.2). Compared to patients with nonurgent but medically necessary contacts, patients with medically unnecessary contacts were younger and were more often frequent attenders. They had longer-existing problems, lower self-assessed urgency, and more often believed GP cooperatives are intended for all help requests. Worry was the most frequently mentioned motive for contacting a GP cooperative for patients with a medically unnecessary contact (45.3 %) and a perceived need to see a GP for patients with a medically necessary contact (44.2 %). Perceived availability (5.8 %) and accessibility (8.3 %) of a patient’s own GP played a role for some patients. Conclusion Motives for contacting a GP cooperative are mostly patient-related, but also deficiencies in access to general practice may partly explain medically unnecessary use. Efforts to change the use of GP cooperatives should focus on education of subgroups with an increased likelihood of contact for medically unnecessary problems. Improvement of access to daytime primary care may also decrease use of the GP cooperative.
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Affiliation(s)
- Ellen Keizer
- Radboud University Medical Center, Radboud Institute for Health Sciences, 114 IQ Healthcare, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands.
| | - Marleen Smits
- Radboud University Medical Center, Radboud Institute for Health Sciences, 114 IQ Healthcare, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands.
| | - Yvonne Peters
- Radboud University Medical Center, Radboud Institute for Health Sciences, 114 IQ Healthcare, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands.
| | - Linda Huibers
- Radboud University Medical Center, Radboud Institute for Health Sciences, 114 IQ Healthcare, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands. .,Aarhus University, Research Unit for General Practice, Aarhus, Denmark.
| | - Paul Giesen
- Radboud University Medical Center, Radboud Institute for Health Sciences, 114 IQ Healthcare, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands.
| | - Michel Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, 114 IQ Healthcare, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands.
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de Vries C, Doggen C, Hilbers E, Verheij R, IJzerman M, Geertsma R, Kusters R. Results of a survey among GP practices on how they manage patient safety aspects related to point-of-care testing in every day practice. BMC FAMILY PRACTICE 2015; 16:9. [PMID: 25648985 PMCID: PMC4332919 DOI: 10.1186/s12875-014-0217-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 12/16/2014] [Indexed: 11/23/2022]
Abstract
Background Point-of-care (POC) tests are devices or test strips that can be used near or at the site where care is delivered to patients, enabling a relatively fast diagnosis. Although many general practitioners (GPs) in the Netherlands are using POC tests in their practice, little is known on how they manage the corresponding patient safety aspects. Methods To obtain information on this aspect, an invitation to participate in a web-based questionnaire was sent to a random sample of 750 GP practices. Of this sample 111 GP practices returned a complete questionnaire. Data was analysed by using descriptive statistics. Results Results show that there is not always attention for quality control measures such as checking storage conditions, executing calibration, and maintenance. In addition, universal hygienic measures, such as washing hands before taking a blood sample, are not always followed. Refresher courses on the use of POC tests are hardly organized. Only a few of the GPs contact the manufacturer of the device when a device failure occurs. Well-controlled aspects include patient identification and actions taken when ambiguous test results are obtained. Conclusions We observed a number of risks for errors with POC tests in GP practices that may be reduced by proper training of personnel, introduction of standard operating procedures and measures for quality control and improved hygiene. To encourage proper use of POCT in general practices, a national POCT guideline, dedicated to primary care and in line with ISO standards, should be introduced. Electronic supplementary material The online version of this article (doi:10.1186/s12875-014-0217-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claudette de Vries
- Centre for Health Protection, National Institute for Public Health and the Environment (RIVM), P.O. Box 1, NL-3720 BA, Bilthoven, The Netherlands.
| | - Carine Doggen
- Health Technology and Services Research, MIRA institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands.
| | - Ellen Hilbers
- Centre for Health Protection, National Institute for Public Health and the Environment (RIVM), P.O. Box 1, NL-3720 BA, Bilthoven, The Netherlands.
| | - Robert Verheij
- Netherlands institute for health services research, Utrecht, The Netherlands.
| | - Maarten IJzerman
- Health Technology and Services Research, MIRA institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands.
| | - Robert Geertsma
- Centre for Health Protection, National Institute for Public Health and the Environment (RIVM), P.O. Box 1, NL-3720 BA, Bilthoven, The Netherlands.
| | - Ron Kusters
- Health Technology and Services Research, MIRA institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands. .,Clinical Chemistry and Haematology laboratory, Jeroen Bosch Ziekenhuis, Utrecht, The Netherlands.
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