Patterns of patient experience with primary care access in Australia, Canada, New Zealand and Switzerland: a comparative study

Has the NHS national extended access scheme delivered its policy aims? A case study of two large scale extended access providers

OBJECTIVES

In 2018, NHS England mandated that all patients in England should be able to access general practice services outside of ordinary hours. While some patients would access additional hours at their own practice, others would need supra-practice level provision - that is, they would be seen in a different location and by a different care team. The policy aim was to enhance patient access to care, with a particular focus on those who work during the day. This study examines (a) how supra-practice level provision of extended access appointments for general medical problems are operationalised and (b) whether the aims of the policy are being met.

METHODS

This study presents qualitative comparative case studies of two contrasting service providers offering extended access. The data collected included 30 hours of clinician-patient observations, 25 interviews with staff, managers, and commissioners, 20 interviews with patients, organisational protocols/documentation, and routinely collected appointment data. Thematic analysis ran concurrently with data gathering and facilitated the iterative adaptation of data collection.

RESULTS

Three cross-cutting themes were identified: extended access is being used to bolster a struggling primary care system, extended access provides a different service to in-hours general practice, and it is difficult for extended access to provide seamless care.

CONCLUSIONS

Supra-practice access models can provide effective care for most patients with straightforward issues. When ongoing management of complex problems is required, this model of patient care can be problematic.

Taxonomy of advanced access practice profiles among family physicians, nurse practitioners and nurses in university-affiliated team-based primary healthcare clinics in Quebec

OBJECTIVES

The advanced access model is highly recommended to improve timely access to primary healthcare (PHC). However, its adoption varies among PHC providers. We aim to identify the advanced access profiles of PHC providers.

DESIGN

A cross-sectional study was conducted between October 2019 and March 2020. Latent class analysis (LCA) measures were used to identify PHC provider profiles based on 14 variables, 2 organisational context characteristics (clinical size and geographical area) and 12 advanced access strategies.

SETTING AND PARTICIPANTS

All family physicians, nurse practitioners and nurses working in the 49 university-affiliated team-based PHC clinics in Quebec, Canada, were invited, of which 35 participated.

PRIMARY OUTCOME MEASURE

The LCA was based on 335 respondents. We determined the optimal number of profiles using statistical criteria (Akaike information criterion, Bayesian information criterion) and qualitatively named each of the six advanced access profiles.

RESULTS

(1) Low supply and demand planification (25%) was characterised by the smallest proportion of strategies used to balance supply and demand. (2) Reactive interprofessional collaboration (25%) was characterised by high collaboration and long opening periods for appointment scheduling. (3) Structured interprofessional collaboration (19%) was characterised by high use of interprofessional team meetings. (4) Small urban delegating practices (13%) was exclusively composed of family physicians and characterised by task delegation to other PHC providers on the team. (5) Comprehensive practices in urban settings (13%) was characterised by including as many services as possible on each visit. (6) Rural agility (4%) was characterised by the highest uptake of advanced access strategies based on flexibility, including adjusting the schedule to demand and having a large number of open-slot appointments available in the next 48 hours.

CONCLUSION

The different patterns of advanced access strategy adoption confirm the need for training to be tailored to individuals, categories of PHC providers and contexts.

Using days alive and out of hospital to measure surgical outcomes in New Zealand: a cross-sectional study

OBJECTIVES

To measure differences at various deciles in days alive and out of hospital to 90 days (DAOH₉₀) and explore its utility for identifying outliers of performance among district health boards (DHBs).

METHODS

Days in hospital and mortality within 90 days of surgery were extracted by linking data from the New Zealand National Minimum Data Set and the births and deaths registry between 1 January 2011 and 31 December 2021 for all adults in New Zealand undergoing acute laparotomy (AL-a relatively high-risk group), elective total hip replacement (THR-a medium risk group) or lower segment caesarean section (LSCS-a low-risk group). DAOH₉₀ was calculated without censoring to zero in cases of mortality. For each DHB, direct risk standardisation was used to adjust for potential confounders and presented in deciles according to baseline patient risk. The Mann-Whitney U test assessed overall DAOH₉₀ differences between DHBs, and comparisons are presented between selected deciles of DAOH₉₀ for each operation.

RESULTS

We obtained national data for 35 175, 52 032 and 117 695 patients undergoing AL, THR and LSCS procedures, respectively. We have demonstrated that calculating DAOH without censoring zero allows for differences between procedures and DHBs to be identified. Risk-adjusted national mean DAOH₉₀ Scores were 64.0 days, 79.0 days and 82.0 days at the 0.1 decile and 75.0 days, 82.0 days and 84.0 days at the 0.2 decile for AL, THR and LSCS, respectively, matching to their expected risk profiles. Differences between procedures and DHBs were most marked at lower deciles of the DAOH₉₀ distribution, and outlier DHBs were detectable. Corresponding 90-day mortality rates were 5.45%, 0.78% and 0.01%.

CONCLUSION

In New Zealand after direct risk adjustment, differences in DAOH₉₀ between three types of surgical procedure reflected their respective risk levels and associated mortality rates. Outlier DHBs were identified for each procedure. Thus, our approach to analysing DAOH₉₀ appears to have considerable face validity and potential utility for contributing to the measurement of perioperative outcomes in an audit or quality improvement setting.

A cross-sectional health literacy profile of Australian regional adults using the Health Literacy Questionnaire©

OBJECTIVE

Health literacy is the resources and abilities required to make and enact health decisions. This study aimed to describe the health literacy of a diverse cross-section of adults in regional Victoria.

METHODS

Participants were recruited from two primary care clinics differing in socioeconomic scope and through non-clinical recruitment via the town's largest football club. Health Literacy Questionnaire© measured nine distinct scales, and comprehensive demographic data were also collected. Effect-sizes and regression were used for health literacy comparison between groups.

RESULTS

In this sample of 351 adults, health literacy strengths were observed in Scale 1: 'Feeling understood and supported by healthcare providers' (mean 3.29/4 ±0.5) and Scale 9: 'Understanding health information well enough to know what to do' (mean 4.10/5 ±0.6). Challenging areas were Scale 5: 'Appraising health information' (mean 2.88/4 ±0.5) and Scale 7: 'Navigating the healthcare system' (mean 3.84/5 ±0.6). After adjustment, living alone predicted lower scores across most scales.

CONCLUSIONS

This study showed greater health literacy barriers experienced by certain groups, particularly those who live alone and those who weren't clinically recruited.

IMPLICATIONS FOR PUBLIC HEALTH

These findings have implications for further research into addressing health literacy barriers in marginalised individuals and non-clinical settings. Results from this study may inform interventions which address identified barriers.

Profiles, Correlates and Outcomes Among Patients Experiencing an Onset of Mental Disorder Based on Outpatient Care Received Following Index Emergency Department Visits

OBJECTIVE

This 5-year longitudinal study evaluated patients with an onset of mental disorder (MD) following index emergency department (ED) visits, in terms of (1) patient profiles based on 12-month outpatient follow-up care received, (2) sociodemographic and clinical correlates, and (3) adverse health outcomes for the subsequent 2 years.

METHODS

Data from administrative databases were collected for 2541 patients with an onset of MD, following discharge from Quebec ED. Latent class analysis was performed to identify patient profiles based on the adequacy of follow-up care after ED discharge. Bivariate analyses examined associations between class membership and sociodemographic and clinical correlates, high ED use (3 + visits/yearly), hospitalizations, and suicidal behaviors.

RESULTS

Five classes of patients were identified. Class 1, the smallest, labeled "patient psychiatrist only," included mainly young patients with serious MD. Classes 2 and 3, roughly 20%, were labeled "high use of patient general practitioner (GP) and psychiatrist" and "low use of patient GP and psychiatrist," respectively. Both included patients with complex MD, but Class 2 had more women and older patients with chronic physical illnesses. The 2 largest classes were labeled "no usual patient service provider" (Class 5) and "patient GP only" (Class 4). Class 5 included more younger men with substance-related disorders, while Class 4 had the older patients living in rural areas, many with common MD and chronic physical illnesses. Class 3 patients had the poorest outcomes, followed by Classes 1 and 2, while Classes 4 and 5 had the best outcomes.

CONCLUSIONS

Results revealed that nearly 40% of patients experiencing an onset of MD received little or no outpatient care following ED discharge. Higher severity or complexity of MD and, to a lesser extent, no or low GP follow-up may explain these adverse outcomes. More adequate, continuous care, including collaborative care, is needed for these vulnerable, high-needs patients.

Translating Planetary Health Principles Into Sustainable Primary Care Services

Global anthropogenic environmental degradations such as climate change are increasingly recognized as critical public health issues, on which human beings should urgently act in order to preserve sustainable conditions of living on Earth. "Planetary Health" is a breakthrough concept and emerging research field based on the recognition of the interdependent relationships between living organisms-both human and non-human-and their ecosystems. In that regards, there have been numerous calls by healthcare professionals for a greater recognition and adoption of Planetary Health perspective. At the same time, current Western healthcare systems are facing their limits when it comes to providing affordable, equitable and sustainable healthcare services. Furthermore, while hospital-centrism remains the dominant model of Western health systems, primary care and public health continue to be largely undervalued by policy makers. While healthcare services will have to adapt to the sanitary impacts of environmental degradations, they should also ambition to accompany and accelerate the societal transformations required to re-inscribe the functioning of human societies within planetary boundaries. The entire health system requires profound transformations to achieve this, with obviously a key role for public health. But we argue that the first line of care represented by primary care might also have an important role to play, with its holistic, interdisciplinary, and longitudinal approach to patients, strongly grounded in their living environments and communities. This will require however to redefine the roles, activities and organization of primary care actors to better integrate socio-environmental determinants of health, strengthen interprofessional collaborations, including non-medical collaborations and more generally develop new, environmentally-centered models of care. Furthermore, a planetary health perspective translated in primary care will require the strengthening of synergies between institutions and actors in the field of health and sustainability.

Rural–Urban Disparities in Realized Spatial Access to General Practitioners, Orthopedic Surgeons, and Physiotherapists among People with Osteoarthritis in Alberta, Canada

Rural Canadians have high health care needs due to high prevalence of osteoarthritis (OA) but lack access to care. Examining realized access to three types of providers (general practitioners (GPs), orthopedic surgeons (Ortho), and physiotherapists (PTs)) simultaneously helps identify gaps in access to needed OA care, inform accessibility assessment, and support health care resource allocation. Travel time from a patient’s postal code to the physician’s postal code was calculated using origin–destination network analysis. We applied descriptive statistics to summarize differences in travel time, hotspot analysis to explore geospatial patterns, and distance decay function to examine the travel pattern of health care utilization by urbanicity. The median travel time in Alberta was 11.6 min (IQR = 4.3–25.7) to GPs, 28.9 (IQR = 14.8–65.0) to Ortho, and 33.7 (IQR = 23.1–47.3) to PTs. We observed significant rural–urban disparities in realized access to GPs (2.9 and IQR = 0.0–92.1 in rural remote areas vs. 12.6 and IQR = 6.4–21.0 in metropolitan areas), Ortho (233.3 and IQR = 171.3–363.7 in rural remote areas vs. 21.3 and IQR = 14.0–29.3 in metropolitan areas), and PTs (62.4 and IQR = 0.0–232.1 in rural remote areas vs. 32.1 and IQR = 25.2–39.9 in metropolitan areas). We identified hotspots of realized access to all three types of providers in rural remote areas, where patients with OA tend to travel longer for health care. This study may provide insight on the choice of catchment size and the distance decay pattern of health care utilization for further studies on spatial accessibility.

Qualitative evaluation of primary care providers' experiences caring for frequent users of the emergency department

OBJECTIVES

Many interventions have been developed over the years to offer frequent users of the emergency department (FUEDs) better access to quality coordinated healthcare. Despite recognising the role primary care physicians (PCPs) play in FUEDs' care, to date their perceptions of case management, the most studied intervention, have rarely been assessed. Furthermore, a gap regarding PCPs' experience of caring for FUEDs persists. Thus, this study aimed to explore PCPs' perceptions of the care provided to FUEDs in emergency and primary care settings, their views on the local case management team (CMT), and their suggestions to improve FUEDs' care.

DESIGN

Qualitative study using in-depth semistructured interviews and inductive thematic analysis.

SETTING

Canton of Vaud, Switzerland.

PARTICIPANTS

Thirty PCPs participated, 16 in private practice (PP-PCPs) and 14 based at the Lausanne University Centre of General Medicine and Public Health (Unisanté-U-PCPs).

RESULTS

U-PCPs and PP-PCPs thought that most FUEDs' emergency department (ED) visits were legitimate, but questioned ED adequacy to meet FUEDs' needs. Yet, both PCP groups reported encountering many challenges in FUEDs' care themselves. In this context, PP-PCPs seemed more satisfied of the care they provided to FUEDs than U-PCPs. Generally, U-PCPs seemed to find more value in the CMT to help them care for FUEDs than PP-PCPs. To enhance FUEDs' care, U-PCPs and PP-PCPs suggested enhancing collaboration with other healthcare providers. U-PCPs also wished to increase their availability, and some PP-PCPs considered outpatient clinics, larger group practices or medical centres most appropriate to handle FUEDs' needs.

CONCLUSIONS

This study highlights the many challenges PCPs face in caring for FUEDs, that a CM intervention has the potential to mitigate, and provides ways forward in improving FUEDs' care, including reinforced communication with the CMT and ED physicians, and structural changes to their own way of delivering care to FUEDs.

Deployment of the consultation-liaison model in adult and child-adolescent psychiatry and its impact on improving mental health treatment

Background

Little information exists on the perceptions of psychiatrists regarding the implementation and various impacts of the consultation-liaison model. This model has been used in Quebec (Canada) through the function of specialist respondent-psychiatrists (SRP) since 2009. This study assessed the main activities, barriers or facilitators, and impact of SRP in adult and child-adolescent psychiatry on the capacity of service providers in primary care and youth centers to treat patients with mental health disorders (MHD).

Methods

Data included 126 self-administered questionnaires from SRP and semi-structured interviews from 48 SRP managers. Mixed methods were used, with qualitative findings from managers complementing the SRP survey. Comparative analyses of SRP responses in adult versus child-adolescent psychiatry were also conducted.

Results

Psychiatrists dedicated a median 24.12 h/month to the SRP function, mainly involving case discussions with primary care teams or youth centers. They were confident about the level of support they provided and satisfied with their influence in clinical decision-making, but less satisfied with the support provided by their organizations. SRP evaluated their impacts on clinical practice as moderate, particularly among general practitioners (GP). SRP working in child-adolescent psychiatry were more comfortable, motivated, and positive about their overall performance and impact than in adult psychiatry. Organizational barriers (e.g. team instability) were most prevalent, followed by system-level factors (e.g. network size and complexity, lack of resources, model inflexibility) and individual factors (e.g. GP reluctance to treat patients with MHD). Organizational facilitators included support from family medicine group directors, collaboration with university family medicine groups and coordination by liaison nurses; at the system level, pre-existing relationships and working in the same institution; while individual-level facilitators included SRP personality and strong organizational support.

Conclusion

Quebec SRP were implemented sparingly in family medicine groups and youth centers, while SRP viewed their overall impact as moderate. Results were more positive in child-adolescent psychiatry than in adult psychiatry. Increased support for the SRP function, adapting the model to GP in need of more direct support, and resolving key system issues may improve SRP effectiveness in terms of team stability, coordination among providers, access to MH services and readiness to implement innovations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01437-5.

Predictors of Recurrent High Emergency Department Use among Patients with Mental Disorders

Few studies have examined predictors of recurrent high ED use. This study assessed predictors of recurrent high ED use over two and three consecutive years, compared with high one-year ED use. This five-year longitudinal study is based on a cohort of 3121 patients who visited one of six Quebec (Canada) ED at least three times in 2014–2015. Multinomial logistic regression was performed. Clinical, sociodemographic and service use variables were identified based on data extracted from health administrative databases for 2012–2013 to 2014–2015. Of the 3121 high ED users, 15% (n = 468) were recurrent high ED users for a two-year period and 12% (n = 364) over three years. Patients with three consecutive years of high ED use had more personality disorders, anxiety disorders, alcohol or drug related disorders, chronic physical illnesses, suicidal behaviors and violence or social issues. More resided in areas with high social deprivation, consulted frequently with psychiatrists, had more interventions in local community health service centers, more prior hospitalizations and lower continuity of medical care. Three consecutive years of high ED use may be a benchmark for identifying high users needing better ambulatory care. As most have multiple and complex health problems, higher continuity and adequacy of medical care should be prioritized.

Does healthcare inequity reflect variations in peoples' abilities to access healthcare? Results from a multi-jurisdictional interventional study in two high-income countries

Background

Primary healthcare services must respond to the healthcare-seeking needs of persons with a wide range of personal and social characteristics. In this study, examined whether socially vulnerable persons exhibit lower abilities to access healthcare. First, we examined how personal and social characteristics are associated with the abilities to access healthcare described in the patient-centered accessibility framework and with the likelihood of reporting problematic access. We then examined whether higher abilities to access healthcare are protective against problematic access. Finally, we explored whether social vulnerabilities predict problematic access after accounting for abilities to access healthcare.

Methods

This is an exploratory analysis of pooled data collected in the Innovative Models Promoting Access-To-Care Transformation (IMPACT) study, a Canadian-Australian research program that aimed to improve access to primary healthcare for vulnerable populations. This specific analysis is based on 284 participants in four study regions who completed a baseline access survey. Hierarchical linear regression models were used to explore the effects of personal or social characteristics on the abilities to access care; logistic regression models, to determine the increased or decreased likelihood of problematic access.

Results

The likelihood of problematic access varies by personal and social characteristics. Those reporting at least two social vulnerabilities are more likely to experience all indicators of problematic access except hospitalizations. Perceived financial status and accumulated vulnerabilities were also associated with lower abilities to access care. Higher scores on abilities to access healthcare are protective against most indicators of problematic access except hospitalizations. Logistic regression models showed that ability to access is more predictive of problematic access than social vulnerability.

Conclusions

We showed that those at higher risk of social vulnerability are more likely to report problematic access and also have low scores on ability to seek, reach, pay, and engage with healthcare. Equity-oriented healthcare interventions should pay particular attention to enhancing people’s abilities to access care in addition to modifying organizational processes and structures that reinforce social systems of discrimination or exclusion.