Pay-for-virtue: an option to improve pay-for-performance?

Compounding inequity: a qualitative study of gout management in an urban marae clinic in Auckland

INTRODUCTION Gout remains a health equity issue; Māori and Pacific peoples are disproportionately afflicted, with increased burden and loss of quality of life, yet are less likely to receive appropriate management, which mainly occurs in primary care. AIM This study aims to understand the perspectives of the mainly Māori and Pacific clinicians and staff at an urban marae practice about barriers and challenges to delivering effective care to a Māori and Pacific community with high burden of gout. METHODS Semi-structured interviews were conducted with 10 staff members delivering health care to a mostly Indigenous community. Interviews sought to ascertain staff views of enablers and barriers to optimal gout management and analyse them thematically. RESULTS Three themes were identified: community disadvantage; demands unique to Indigenous providers; and challenges and opportunities for optimising gout management. High prevalence and heavy impact of gout on wellbeing in the community was intertwined with socioeconomic disadvantage, precariousness of employment and entrenched inaccurate (yet pliable) patient views on gout, to the detriment of focused, effective care. Structural and funding demands on providers inhibited staff focus on the clear community need. Providers saw the culturally safe and competent approach necessary for improvement as requiring community empowerment with appropriate clinical tools and adequate resourcing. DISCUSSION Despite provider intent to deliver culturally appropriate and safe care and equitable health outcomes for patients suffering from gout, general practice initiatives without aligned resourcing or incentives are inhibited when inequity is pervasive. Simply asking Māori providers to do more for the same amount of resource may not be effective.

"I'm Dr Jekyll and Mr Hyde": are GPs' antibiotic prescribing patterns contextually dependent? A qualitative focus group study

OBJECTIVE

To explore factors and circumstances contributing to prudent antibiotic prescribing for respiratory tract infections in primary care.

DESIGN

Two focus groups representing rural and urban areas. A semi-structured interview guide with open-ended questions and an editing analysis style was used. They were examined to identify meaning units that were sorted into categories in an iterative process throughout the analysis.

SETTING

Primary health care in two counties in southern Sweden.

SUBJECTS

Two groups including seven and six general practitioners (GPs) respectively, men and women of different ages with different professional experiences.

MAIN OUTCOME MEASURES

Exploration of categories, determination of themes, construction of models.

RESULTS

The decision to prescribe antibiotics takes place in the encounter between GP and patient, initially characterized by harmony or fight and the subsequent process by collaboration or negotiation, resulting in agreement, compromise, or disagreement. Several factors influence the meeting and contribute to enhancing the conditions for rational prescribing. These conditions are connected to the GP, the relationship, and the setting; organization as well as professional culture. The findings indicate synergies between the factors, and that one factor can sometimes compensate for lack of another. Continuity and mutual trust can make a brief consultation successful, but lack of continuity can eliminate the effects of knowledge and professional skills.

CONCLUSIONS

The findings emphasize the importance of the encounter between the GP and the patient for prudent antibiotic prescribing. Furthermore, the importance of an appropriate organization of primary care, which promotes continuity and encourages professional autonomy, is demonstrated.