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Urquhart R, Kendell C, Pfaff K, Stajduhar K, Patrick L, Dujela C, Scruton S, Fauteux F, Warner G. How do navigation programs address the needs of those living in the community with advanced, life-limiting Illness? A realist evaluation of programs in Canada. BMC Palliat Care 2023; 22:179. [PMID: 37964238 PMCID: PMC10647106 DOI: 10.1186/s12904-023-01304-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/06/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND We sought to identify innovative navigation programs across Canadian jurisdictions that target their services to individuals affected by life-limiting illness and their families, and articulate the principal components of these programs that enable them to address the needs of their clients who are living in the community. METHODS This realist evaluation used a two-phased approach. First, we conducted a horizon scan of innovative community-based navigation programs across Canadian jurisdictions to identify innovative community-based navigation programs that aim to address the needs of community-dwelling individuals affected by life-limiting illness. Second, we conducted semi-structured interviews with key informants from each of the selected programs. Informants included individuals responsible for managing and delivering the program and decision-makers with responsibility and/or oversight of the program. Analyses proceeded in an iterative manner, consistent with realist evaluation methods. This included iteratively developing and refining Context-Mechanism-Outcome (CMO) configurations, and developing the final program theory. RESULTS Twenty-seven navigation programs were identified from the horizon scan. Using specific eligibility criteria, 11 programs were selected for subsequent interviews and in-depth examination. Twenty-three participants were interviewed from these programs, which operated in five Canadian provinces. The programs represented a mixture of community (non-profit or volunteer), research-initiated, and health system programs. The final program theory was articulated as: navigation programs can improve client outcomes if they have supported and empowered staff who have the time and flexibility to personalize care to the needs of their clients. CONCLUSIONS The findings highlight key principles (contexts and mechanisms) that enable navigation programs to develop client relationships, personalize care to client needs, and improve client outcomes. These principles include staff (or volunteer) knowledge and experience to coordinate health and social services, having a point of contact after hours, and providing staff (and volunteers) time and flexibility to develop relationships and respond to individualized client needs. These findings may be used by healthcare organizations - outside of navigation programs - to work towards more person-centred care.
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Affiliation(s)
- Robin Urquhart
- Department of Community Health and Epidemiology, Dalhousie University, Room 413, Halifax, NS, Canada.
| | - Cynthia Kendell
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kathryn Pfaff
- Faculty of Nursing, University of Windsor, Windsor, ON, Canada
| | - Kelli Stajduhar
- School of Nursing, University of Victoria, Victoria, BC, Canada
| | - Linda Patrick
- Faculty of Nursing, University of Windsor, Windsor, ON, Canada
| | - Carren Dujela
- School of Nursing, University of Victoria, Victoria, BC, Canada
| | - Sarah Scruton
- Department of Community Health and Epidemiology, Dalhousie University, Room 413, Halifax, NS, Canada
| | - Faith Fauteux
- Faculty of Nursing, University of Windsor, Windsor, ON, Canada
| | - Grace Warner
- School of Occupational Therapy, Dalhousie University, Halifax, NS, Canada
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Edward H, Smith-Turchyn J. Clinician's Commentary on Nicoll et al. 1. Physiother Can 2023; 75:348-349. [PMID: 38037574 PMCID: PMC10686308 DOI: 10.3138/ptc-2021-0084-cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Holly Edward
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada;
| | - Jenna Smith-Turchyn
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada;
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Paget S, Ostojic K, Goldsmith S, Nassar N, McIntyre S. Determinants of hospital-based health service utilisation in cerebral palsy: a systematic review. Arch Phys Med Rehabil 2021; 103:1628-1637. [PMID: 34968439 DOI: 10.1016/j.apmr.2021.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/25/2021] [Accepted: 12/01/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To systematically review and synthesize evidence of determinants associated with hospital-based health service utilisation among individuals with cerebral palsy (CP). DATA SOURCES Electronic databases MEDLINE, Embase, APA Psycinfo were searched from January 2000 to April 2020. STUDY SELECTION Observational studies were included that described people with CP, reported quantitative measures of hospital-based health service utilisation (inpatient, outpatient, emergency department), and based in high-income countries. We excluded studies that included only subsets of people with CP, or those that only reported therapy service utilisation. DATA EXTRACTION After initial screen, two reviewers reviewed full texts for inclusion and performed data extraction and risk of bias assessment using the Newcastle Ottawa scale. Determinants of health service utilisation were identified and categorised using the Andersen Behavioural Model. DATA SYNTHESIS Seventeen studies met inclusion criteria. Study quality was high. Twenty-six determinants were reported across eight Andersen Model characteristics. Individual predisposing factors such as sex showed no difference in health service utilisation; inpatient admissions decreased with increasing age during childhood and was lower in adults. Increased health service utilisation was associated with "individual need" including severe gross motor disability, epilepsy, developmental/ intellectual disability and gastrostomy-use across inpatient, outpatient and emergency department settings. There was little information reported on socio-demographic and health system contextual determinants. CONCLUSIONS CP health service utilisation was associated with age, severity and comorbidities. Improved understanding of determinants of health service utilisation can support health service access for people with CP.
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Affiliation(s)
- Simon Paget
- The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Kids Rehab, the Children's Hospital at Westmead, Westmead NSW Australia.
| | - Katarina Ostojic
- Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
| | - Shona Goldsmith
- Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
| | - Natasha Nassar
- Child Population and Translational Health, The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Sarah McIntyre
- Cerebral Palsy Alliance, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
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Mona H, Andersson LMC, Hjern A, Ascher H. Barriers to accessing health care among undocumented migrants in Sweden - a principal component analysis. BMC Health Serv Res 2021; 21:830. [PMID: 34404416 PMCID: PMC8369752 DOI: 10.1186/s12913-021-06837-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 07/30/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Undocumented migrants face many hardships in their everyday life such as poor living conditions, discrimination, and lack of access to healthcare. Previous studies have demonstrated considerable health care needs for psychiatric disorders as well as physical diseases. The aim of this paper was to find out the main barriers that undocumented migrants experience in accessing the Swedish healthcare system and to explore their relation with socioeconomic factors. METHODS A cross-sectional study with adult undocumented migrants was performed in the three largest cities of Sweden in 2014-2016. Sampling was done via informal networks. A socioeconomic questionnaire was constructed including 22 barriers to health care. Trained field workers conducted the interviews. A principal component analysis was conducted of all barriers to reveal central components. Then, Pearson's chi-squared test was used to explore the characteristics of undocumented migrants experiencing barriers to care. RESULTS Two main components/barriers were extracted: "Fear of being taken by police/authorities", which was related to fear of disclosure by or in relation to seeking health care, and "Structural and psychosocial factors" which was related to practical obstacles or shame of being ill. Lower age (74.1 % vs 56.0 %), lower level of education (75.0 % vs. 45.1 %), and having no children (70.3 % vs. 48.1 %) were significantly related to a higher likelihood of experiencing a barrier. CONCLUSION Fear of deportation and practical and psychosocial factors constitute hinderance of access to healthcare for undocumented migrants in Sweden. This highlights the importance of clear instructions, both to undocumented migrants and health professionals about the right to health care according to the international law on human rights as well as the law of confidentiality.
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Affiliation(s)
- Hatem Mona
- School of Public Health and Community Medicine, The Institute of Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
| | - Lena M C Andersson
- Department of Social Work, University of Gothenburg, Sprängkullsgatan 23, PO Box 720, SE- 405 30, Gothenburg, Sweden.
| | - Anders Hjern
- Clinical Epidemiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden
- Centre of Health Equity Studies (CHESS), Karolinska Institute, and Stockholm University, Stockholm, Sweden
| | - Henry Ascher
- School of Public Health and Community Medicine, The Institute of Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
- Research Department, Angered Hospital, Gothenburg, Sweden
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Woodford J, Farrand P, Hagström J, Hedenmalm L, von Essen L. Internet-Administered Cognitive Behavioral Therapy for Common Mental Health Difficulties in Parents of Children Treated for Cancer: Intervention Development and Description Study. JMIR Form Res 2021; 5:e22709. [PMID: 34142662 PMCID: PMC8367173 DOI: 10.2196/22709] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/08/2021] [Accepted: 06/17/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Following the end of a child's treatment for cancer, parents may report psychological distress. However, there is a lack of evidence-based interventions that are tailored to the population, and psychological support needs are commonly unmet. An internet-administered low-intensity cognitive behavioral therapy (LICBT)-based intervention (EJDeR [internetbaserad självhjälp för föräldrar till barn som avslutat en behandling mot cancer]) may provide a solution. OBJECTIVE The first objective is to provide an overview of a multimethod approach that was used to inform the development of the EJDeR intervention. The second objective is to provide a detailed description of the EJDeR intervention in accordance with the Template for Intervention Description and Replication (TIDieR) checklist. METHODS EJDeR was developed through a multimethod approach, which included the use of existing evidence, the conceptualization of distress, participatory action research, a cross-sectional survey, and professional and public involvement. Depending on the main presenting difficulty identified during assessment, LICBT behavioral activation or worry management treatment protocols are adopted for the treatment of depression or generalized anxiety disorder when experienced individually or when comorbid. EJDeR is delivered via the Uppsala University Psychosocial Care Programme (U-CARE) portal, a web-based platform that is designed to deliver internet-administered LICBT interventions and includes secure videoconferencing. To guide parents in the use of EJDeR, weekly written messages via the portal are provided by e-therapists comprising final year psychology program students with training in cognitive behavioral therapy. RESULTS An overview of the development process and a description of EJDeR, which was informed by the TIDieR checklist, are presented. Adaptations that were made in response to public involvement are highlighted. CONCLUSIONS EJDeR represents a novel, guided, internet-administered LICBT intervention for supporting parents of children treated for cancer. Adopting the TIDieR checklist offers the potential to enhance fidelity to the intervention protocol and facilitate later implementation. The intervention is currently being tested in a feasibility study (the ENGAGE study). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1136/bmjopen-2018-023708.
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Affiliation(s)
- Joanne Woodford
- Uppsala University, Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala, Sweden
| | - Paul Farrand
- Clinical Education, Development, and Research (CEDAR), Psychology, College of Life and Environmental Sciences, University of Exeter, Exeter, United Kingdom
| | - Josefin Hagström
- Uppsala University, Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala, Sweden
| | - Li Hedenmalm
- Uppsala University, Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala, Sweden
| | - Louise von Essen
- Uppsala University, Healthcare Sciences and e-Health, Department of Women's and Children's Health, Uppsala, Sweden
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Bhambhvani HP, Greenberg DR, Kasman AM, DeRouen MC, Cheng I, Eisenberg ML, Shah SA. Racial and socioeconomic disparities in retroperitoneal lymph node dissection and survival in nonseminomatous germ cell tumor: A population-based study. Urol Oncol 2021; 39:197.e1-197.e8. [PMID: 33423934 DOI: 10.1016/j.urolonc.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Though testicular cancer is the most common cancer in young men, there is a paucity of epidemiologic studies examining sociodemographic disparities in adjuvant therapy and outcomes. We examined the associations of sociodemographic factors with retroperitoneal lymph node dissection (RPLND) and survival among patients with nonseminomatous germ cell tumors (NSGCTs). METHODS Within the Surveillance Epidemiology and End Results database (2005-2015), we identified 8,573 patients with nonseminomatous germ cell tumors. Multivariable logistic regression and Fine-Gray competing-risks regression models were constructed to examine the association of sociodemographic factors (neighborhood SES (nSES), race, and insurance) with, respectively, adjuvant RPLND within 1 year of diagnosis and cancer-specific mortality. RESULTS Patients in the lowest nSES quintile (OR 0.59, 95% CI = 0.40-0.88, P = 0.01) and Black patients (OR 0.41, 95% CI = 0.15-1.00, P= 0.058) with stage II disease were less likely to receive RPLND compared to those in the highest quintile and White patients, respectively. Stage III patients with Medicaid (OR 0.64, 95% CI = 0.46-0.89, P= 0.009) or without insurance (OR 0.46, 95% CI = 0.27-0.76, P= 0.003) were less likely to receive RPLND compared to patients with private insurance. Lowest quintile nSES patients of all disease stages and Black patients with stage I disease (HR = 2.64, 95% CI = 1.12-6.20, P = 0.026) or stage II disease (HR=4.93, 95% CI = 1.48-16.44, P = 0.009) had higher risks of cancer-specific mortality compared to highest quintile nSES and White patients, respectively. CONCLUSIONS This national study found multilevel, stage-specific sociodemographic disparities in receipt of RPLND and survival.
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Affiliation(s)
| | | | - Alex M Kasman
- Department of Urology, Stanford University Medical Center, Stanford, CA
| | - Mindy C DeRouen
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA; UCSF Department of Epidemiology and Biostatistics, San Francisco, CA
| | - Iona Cheng
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA; UCSF Department of Epidemiology and Biostatistics, San Francisco, CA
| | | | - Sumit A Shah
- Division of Oncology, Stanford University Medical Center, Stanford, CA
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Bhambhvani HP, Rodrigues AJ, Medress ZA, Hayden Gephart M. Racial and socioeconomic correlates of treatment and survival among patients with meningioma: a population-based study. J Neurooncol 2020; 147:495-501. [PMID: 32193691 DOI: 10.1007/s11060-020-03455-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/07/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Though meningioma is the most common primary brain tumor, there is a paucity of epidemiologic studies investigating disparities in treatment and patient outcomes. Therefore, we sought to explore how sociodemographic factors are associated with rates of gross total resection (GTR) and radiotherapy as well as survival. METHODS The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database was queried to identify adult patients with meningioma diagnosed between 2005 and 2015. Socioeconomic status (SES) was determined using a validated composite index in which patients were stratified into tertiles and quintiles. Multivariable logistic regression and Cox proportional hazards analyses were used to identify predictors of treatment and survival, respectively. RESULTS 71,098 patients met our inclusion criteria. Low SES quintile was associated with reduced odds of receiving GTR (OR 0.76, 95% CI 0.69-0.83, p < 0.0001) and radiotherapy (OR 0.83, 95% CI 0.76-0.91, p < 0.0001) as well as worse survival (HR 1.48, 95% CI 1.41-1.56) as compared to the highest SES quintile. Black patients had reduced odds of GTR (OR 0.74, 95% CI 0.67-0.71, p < 0.0001) and worse survival (HR 1.23, 95% CI 1.18-1.29, p < 0.0001) as compared to white patients. CONCLUSIONS This national study of patients with meningioma found socioeconomic status and race to be independent inverse correlates of likelihood of GTR, radiotherapy, and survival. Limited access to care may underlie these disparities in part, and future studies are warranted to identify specific causes for these findings.
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Kaur Khakh A, Fast V, Shahid R. Spatial Accessibility to Primary Healthcare Services by Multimodal Means of Travel: Synthesis and Case Study in the City of Calgary. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E170. [PMID: 30634454 PMCID: PMC6351935 DOI: 10.3390/ijerph16020170] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/25/2018] [Accepted: 01/03/2019] [Indexed: 11/16/2022]
Abstract
Universal access to primary healthcare facilities is a driving goal of healthcare organizations. Despite Canada's universal access to primary healthcare status, spatial accessibility to healthcare facilities is still an issue of concern due to the non-uniform distribution of primary healthcare facilities and population over space-leading to spatial inequity in the healthcare sector. Spatial inequity is further magnified when health-related accessibility studies are analyzed on the assumption of universal car access. To overcome car-centric studies of healthcare access, this study compares different travel modes-driving, public transit, and walking-to simulate the multi-modal access to primary healthcare services in the City of Calgary, Canada. Improving on floating catchment area methods, spatial accessibility was calculated based on the Spatial Access Ratio method, which takes into consideration the provider-to-population status of the region. The analysis revealed that, in the City of Calgary, spatial accessibility to the primary healthcare services is the highest for the people with an access to a car, and is significantly lower with multimodal (bus transit and train) means despite being a large urban centre. The social inequity issue raised from this analysis can be resolved by improving the city's pedestrian infrastructure, public transportation, and construction of new clinics in regions of low accessibility.
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Affiliation(s)
- Amritpal Kaur Khakh
- Department of Geography, University of Calgary, Calgary, AB T2N 1N4, Canada.
| | - Victoria Fast
- Department of Geography, University of Calgary, Calgary, AB T2N 1N4, Canada.
| | - Rizwan Shahid
- Primary Health Care, Alberta Health Services, Calgary, AB T2W 3N2, Canada.
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Al-Jazaeri A, Alshwairikh L, Aljebreen MA, AlSwaidan N, Al-Obaidan T, Alzahem A. Variation in access to pediatric surgical care among coexisting public and private providers: inguinal hernia as a model. Ann Saudi Med 2017; 37:290-296. [PMID: 28761028 PMCID: PMC6150598 DOI: 10.5144/0256-4947.2017.290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Faced with growing healthcare demand, the Saudi government is increasingly relying on privatization as a tool to improve patient access to care. Variation in children's access to surgical care between public (PB) and private providers (PV) has not been previously analyzed. OBJECTIVES To compare access to pediatric surgical services between two coexisting PB and PV. DESIGN Retrospective comparative study. SETTINGS A major teaching hospital and the largest PV group in Saudi Arabia. PATIENTS AND METHODS The outcomes for children who underwent inguinal herniotomy (IH) between May 2010 and December 2014 at both providers were with IH serving as the model. Data collected included patient demographics, insurance coverage, referral pattern and access parameters including time-to-surgery (TTS), surgery wait time (SWT) and duration of symptoms (DOS). MAIN OUTCOME MEASURE(S) TTS, SWT and DOS. RESULTS Of 574 IH cases, 56 cases of in-hospital referrals were excluded leaving 290 PB and 228 PV cases. PV patients were younger (12.0 vs 16.4 months, P=.043) and more likely to be male (81.6% vs 72.8%, P=.019), expatriates (18% vs 3.4%, P < .001) and insured (47.4% vs 0%, P < .001). The emergency department was more frequently the source for PB referrals (35.2% vs 12.7%, P < .001) while most PV patients were self-referred (72.8% vs 16.7%, P < .001). Access parameters were remarkably better at PV: TTS (21 vs 66 days, P < .001), SWT (4 vs 31 days, P < .001) and DOS (33 vs 114 days, P < .001). CONCLUSION When coexisting, PV offers significantly better access to pediatric surgical services compared to PB. Diverting public funds to expand children's access to PV can be a valid choice to improve access to care in case when outcomes with the two providers are similar. LIMITATIONS Although it is the first and largest comparison in the pediatric population, the sample may not represent the whole population since it is confined to a single selected surgical condition.
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Affiliation(s)
- Ayman Al-Jazaeri
- Dr. Ayman Al-Jazaeri, Division of Pediatrc Surgery,, Department of Surgery,, King Saud University,, Riyadh 1355, Saudi Arabia, , ORCID: http://orcid.org/0000-0002-6853-0935
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Simoes E, Sokolov AN, Kronenthaler A, Hiltner H, Schaeffeler N, Rall K, Ueding E, Rieger MA, Wagner A, Poesch LS, Baur MC, Kittel J, Brucker SY. Information ranks highest: Expectations of female adolescents with a rare genital malformation towards health care services. PLoS One 2017; 12:e0174031. [PMID: 28426677 PMCID: PMC5398506 DOI: 10.1371/journal.pone.0174031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/02/2017] [Indexed: 11/27/2022] Open
Abstract
Background Access to highly specialized health care services and support to meet the patient’s specific needs is critical for health outcome, especially during age-related transitions within the health care system such as with adolescents entering adult medicine. Being affected by an orphan disease complicates the situation in several important respects. Long distances to dedicated institutions and scarcity of knowledge, even among medical doctors, may present major obstacles for proper access to health care services and health chances. This study is part of the BMBF funded TransCareO project examining in a mixed-method design health care provisional deficits, preferences, and barriers in health care access as perceived by female adolescents affected by the Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS), a rare (orphan) genital malformation. Methods Prior to a communicative validation workshop, critical elements of MRKHS related care and support (items) were identified in interviews with MRKHS patients. During the subsequent workshop, 87 persons involved in health care and support for MRKHS were asked to rate the items using a 7-point Likert scale (7, strongly agree; 1, strongly disagree) as to 1) the elements’ potential importance (i.e., health care expected to be “best practice”, or priority) and 2) the presently experienced care. A gap score between the two was computed highlighting fields of action. Items were arranged into ten separate questionnaires representing domains of care and support (e.g., online-portal, patient participation). Within each domain, several items addressed various aspects of “information” and “access”. Here, we present the outcome of items’ evaluation by patients (attended, NPAT = 35; respondents, NRESP = 19). Results Highest priority scores occurred for domains “Online-Portal”, “Patient participation”, and “Tailored informational offers”, characterizing them as extremely important for the perception as best practice. Highest gap scores yielded domains “Tailored informational offers”, reflecting perceived lack of disease-related information for affected persons, medical experts, and health insurance companies, “Online-Portal” (with limited information available on specialist clinics and specialized doctors), and regarding insufficient support offers (e.g., in school and occupational settings). Conversely, lowest gap scores were found with group offers for MRKHS patients (“Transition programs”) and MRKHS self-help days (“Patient participation”), suggesting satisfaction or good solutions in place. Discussion The importance assigned to disease-related information indicates that informational deficits are perceived by patients as barriers, hindering proper access to health care, especially in an orphan disease. Access to health-related information plays a role for all persons seeking help and care. However, the overwhelmingly high scores attributed to these elements in the context of an orphan disease reveal that here improved information policies are crucial, demanding for institutionalized solutions supported by the health care system. Implications for practice The disparity between experience of care and attribution as best practice detected describes areas of action in all domains involved, highlighting information related fields. New concepts and structures for health care in orphan diseases could draw upon these patient-oriented results a) regarding orphan-disease specific elements demanding institutionalized reimbursement, b) essential elements for center care and corresponding networks, and c) elements reflecting patients´ participation in the conception of centers for rare diseases.
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Affiliation(s)
- Elisabeth Simoes
- Women’s Health Research Institute, Department of Women’s Health, University Hospital Tübingen, Tübingen, Germany
- Staff Unit of Social Medicine, Eberhard Karls University of Tübingen Medical School and University Hospital Tübingen, Tübingen, Germany
- * E-mail: (ES); (ANS)
| | - Alexander N. Sokolov
- Women’s Health Research Institute, Department of Women’s Health, University Hospital Tübingen, Tübingen, Germany
- * E-mail: (ES); (ANS)
| | - Andrea Kronenthaler
- Institute of Sociology, Faculty of Economics and Social Sciences Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Hanna Hiltner
- Institute of Sociology, Faculty of Economics and Social Sciences Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Norbert Schaeffeler
- Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Katharina Rall
- Women’s Health Research Institute, Department of Women’s Health, University Hospital Tübingen, Tübingen, Germany
| | - Esther Ueding
- Women’s Health Research Institute, Department of Women’s Health, University Hospital Tübingen, Tübingen, Germany
| | - Monika A. Rieger
- Institute of Occupational and Social Medicine, and Health Services Research, University Hospital Tübingen, Tübingen, Germany
| | - Anke Wagner
- Institute of Occupational and Social Medicine, and Health Services Research, University Hospital Tübingen, Tübingen, Germany
| | - Leonie S. Poesch
- Women’s Health Research Institute, Department of Women’s Health, University Hospital Tübingen, Tübingen, Germany
| | - Marie-Christin Baur
- Women’s Health Research Institute, Department of Women’s Health, University Hospital Tübingen, Tübingen, Germany
| | - Judith Kittel
- Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Sara Y. Brucker
- Women’s Health Research Institute, Department of Women’s Health, University Hospital Tübingen, Tübingen, Germany
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Frost L, Jenkins LS, Emmink B. Improving access to health care in a rural regional hospital in South Africa: Why do patients miss their appointments? Afr J Prim Health Care Fam Med 2017; 9:e1-e5. [PMID: 28397521 PMCID: PMC5387369 DOI: 10.4102/phcfm.v9i1.1255] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/30/2016] [Accepted: 11/18/2016] [Indexed: 11/24/2022] Open
Abstract
Background Access to health services is one of the Batho Pele (‘people first’) values and principles of the South African government since 1997. This necessitated some changes around public service systems, procedures, attitudes and behaviour. The challenges of providing health care to rural geographically spread populations include variations in socio-economic status, transport opportunities, access to appointment information and patient perceptions of costs and benefits of seeking health care. George hospital, situated in a rural area, serves 5000 outpatient visits monthly, with non-attendance rates of up to 40%. Objectives The aim of this research was to gain a greater understanding of the reasons behind non-attendance of outpatient department clinics to allow locally driven, targeted interventions. Methods This was a descriptive study. We attempted to phone all patients who missed appointments over a 1-month period (n = 574). Only 20% were contactable with one person declining consent. Twenty-nine percent had no telephone number on hospital systems, 7% had incorrect numbers, 2% had died and 42% did not respond to three attempts. Results The main reasons for non-attendance included unaware of appointment date (16%), out of area (11%), confusion over date (11%), sick or admitted to hospital (10%), family member sick or died (7%), appointment should have been cancelled by clerical staff (6%) and transport (6%). Only 9% chose to miss their appointment. The other 24% had various reasons. Conclusions Improved patient awareness of appointments, adjustments in referral systems and enabling appointment cancellation if indicated would directly improve over two-thirds of reasons for non-attendance. Understanding the underlying causes will help appointment planning, reduce wasted costs and have a significant impact on patient care.
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Affiliation(s)
| | - Louis S Jenkins
- George Regional Hospital, Western Cape Government, South Africa and Division of Family Medicine and Primary Care, Stellenbosch University.
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Gea-Sánchez M, Gastaldo D, Molina-Luque F, Otero-García L. Access and utilisation of social and health services as a social determinant of health: the case of undocumented Latin American immigrant women working in Lleida (Catalonia, Spain). HEALTH & SOCIAL CARE IN THE COMMUNITY 2017; 25:424-434. [PMID: 26732249 DOI: 10.1111/hsc.12322] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/23/2015] [Indexed: 06/05/2023]
Abstract
Although Spain has social and healthcare systems based on universal coverage, little is known about how undocumented immigrant women access and utilise them. This is particularly true in the case of Latin Americans who are overrepresented in the informal labour market, taking on traditionally female roles of caregivers and cleaners in private homes. This study describes access and utilisation of social and healthcare services by undocumented Latin American women working and living in rural and urban areas, and the barriers these women may face. An exploratory qualitative study was designed with 12 in-depth interviews with Latin American women living and working in three different settings: an urban city, a rural city and rural villages in the Pyrenees. Interviews were recorded, transcribed and analysed, yielding four key themes: health is a tool for work which worsens due to precarious working conditions; lack of legal status traps Latin American women in precarious jobs; lack of access to and use of social services; and limited access to and use of healthcare services. While residing and working in different areas of the province impacted the utilisation of services, working conditions was the main barrier experienced by the participants. In conclusion, decent working conditions are the key to ensuring undocumented immigrant women's right to social and healthcare. To create a pathway to immigrant women's health promotion, the 'trap of illegality' should be challenged and the impact of being considered 'illegal' should be considered as a social determinant of health, even where the right to access services is legal.
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Affiliation(s)
- Montserrat Gea-Sánchez
- Nursing Department, GESEC, Lleida University, Spain
- Health Care Research Group (GRECS), IRB Lleida, Spain
| | - Denise Gastaldo
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada
| | | | - Laura Otero-García
- Nursing Department, GESEC, Lleida University, Spain
- National School of Public Health, Institute of Health Carlos III, Spain
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13
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Sundaresan P, Stockler MR, Milross CG. What is access to radiation therapy? A conceptual framework and review of influencing factors. AUST HEALTH REV 2016; 40:11-18. [PMID: 26072910 DOI: 10.1071/ah14262] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 04/22/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Optimal radiation therapy (RT) utilisation rates (RURs) have been defined for various cancer indications through extensive work in Australia and overseas. These benchmarks remain unrealised. The gap between optimal RUR and actual RUR has been attributed to inadequacies in 'RT access'. We aimed to develop a conceptual framework for the consideration of 'RT access' by examining the literature for existing constructs and translating it to the context of RT services. We further aimed to use this framework to identify and examine factors influencing 'RT access'. METHODS Existing models of health care access were reviewed and used to develop a multi-dimensional conceptual framework for 'RT access'. A review of the literature was then conducted to identify factors reported to affect RT access and utilisation. The electronic databases searched, the host platform and date range of the databases searched were Ovid MEDLINE, 1946 to October 2014 and PsycINFO via OvidSP,1806 to October 2014. RESULTS The framework developed demonstrates that 'RT access' encompasses opportunity for RT as well as the translation of this opportunity to RT utilisation. Opportunity for RT includes availability, affordability, adequacy (quality) and acceptability of RT services. Several factors at the consumer, referrer and RT service levels affect the translation of this opportunity for RT to actual RT utilisation. CONCLUSION 'Access' is a term that is widely used in the context of health service related research, planning and political discussions. It is a multi-faceted concept with many descriptions. We propose a conceptual framework for the consideration of 'RT access' so that factors affecting RT access and utilisation may be identified and examined. Understanding these factors, and quantifying them where possible, will allow objective evaluation of their impact on RT utilisation and guide implementation of strategies to modify their effects.
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Affiliation(s)
- Puma Sundaresan
- The Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia. Email
| | - Martin R Stockler
- The Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia. Email
| | - Christopher G Milross
- The Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia. Email
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Exploring interprofessional collaboration during the integration of diabetes teams into primary care. BMC FAMILY PRACTICE 2016; 17:12. [PMID: 26831500 PMCID: PMC4736701 DOI: 10.1186/s12875-016-0407-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 01/21/2016] [Indexed: 11/26/2022]
Abstract
Background Specialised diabetes teams, specifically certified nurse and dietitian diabetes educator teams, are being integrated part-time into primary care to provide better care and support for Canadians living with diabetes. This practice model is being implemented throughout Canada in an effort to increase patient access to diabetes education, self-management training, and support. Interprofessional collaboration can have positive effects on both health processes and patient health outcomes, but few studies have explored how health professionals are introduced to and transition into this kind of interprofessional work. Method Data from 18 interviews with diabetes educators, 16 primary care physicians, 23 educators’ reflective journals, and 10 quarterly debriefing sessions were coded and analysed using a directed content analysis approach, facilitated by NVIVO software. Results Four major themes emerged related to challenges faced, strategies adopted, and benefits observed during this transition into interprofessional collaboration between diabetes educators and primary care physicians: (a) negotiating space, place, and role; (b) fostering working relationships; (c) performing collectively; and (d) enhancing knowledge exchange. Conclusions Our findings provide insight into how healthcare professionals who have not traditionally worked together in primary care are collaborating to integrate health services essential for diabetes management. Based on the experiences and personal reflections of participants, establishing new ways of working requires negotiating space and place to practice, role clarification, and frequent and effective modes of formal and informal communication to nurture the development of trust and mutual respect, which are vital to success.
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Nancarrow SA. Six principles to enhance health workforce flexibility. HUMAN RESOURCES FOR HEALTH 2015; 13:9. [PMID: 26264184 PMCID: PMC4532254 DOI: 10.1186/1478-4491-13-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 01/22/2015] [Indexed: 05/29/2023]
Abstract
UNLABELLED This paper proposes approaches to break down the boundaries that reduce the ability of the health workforce to respond to population needs, or workforce flexibility. Accessible health services require sufficient numbers and types of skilled workers to meet population needs. However, there are several reasons that the health workforce cannot or does not meet population needs. These primarily stem from workforce shortages. However, the health workforce can also be prevented from responding appropriately and efficiently because of restrictions imposed by professional boundaries, funding models or therapeutic partitions. These boundaries limit the ability of practitioners to effectively diagnose and treat patients by restricting access to specific skills, technologies and services. In some cases, these boundaries not only reduce workforce flexibility, but they introduce inefficiencies in the form of additional clinical transactions and costs, further detracting from workforce responsiveness. Several new models of care are being developed to enhance workforce flexibility by enabling existing staff to work to their full scope of practice, extend their roles or by introducing new workers. Expanding on these concepts, this theoretical paper proposes six principles that have the potential to enhance health workforce flexibility, specifically: 1. Measure health system performance from the perspective of the patient. 2. Minimise training times. 3. Regulate tasks (competencies), not professions. 4. Match rewards and indemnity to the levels of skill and risk required to perform a particular task, not professional title. 5. Ensure that practitioners have all the skills they need to perform the tasks required to work in the environment in which they work 6. Enable practitioners to work to their full scope of practice delegate tasks where required These proposed principles will challenge some of the existing social norms around health-care delivery; however, many of these principles are already being applied, albeit on a small scale. This paper discusses the implications of these reforms. PROPOSED DISCUSSION POINTS 1. Is person-centred care at odds with professional monopolies? 2. Should the state regulate professions and, by doing so, protect professional monopolies or, instead, regulate tasks or competencies? 3. Can health-care efficiency be enhanced by reducing the number of clinical transactions required to meet patient needs?
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Affiliation(s)
- Susan A Nancarrow
- School of Health and Human Sciences, Southern Cross University, East Lismore, NSW, 2480, Australia.
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Norman AH, Tesser CD. Acesso ao cuidado na Estratégia Saúde da Família: equilíbrio entre demanda espontânea e prevenção/promoção da saúde. SAUDE E SOCIEDADE 2015. [DOI: 10.1590/s0104-12902015000100013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Este artigo propõe algumas diretrizes para a organização do trabalho na Atenção Primária à Saúde (APS) e na Estratégia Saúde da Família (ESF), relacionadas aos desafios de prover acesso e equilibrar no cotidiano dos serviços ações de prevenção de agravos e promoção da saúde com o cuidado ao adoecimento. Primeiramente, apresenta algumas ideias específicas sobre a importância do acesso para a qualidade dos serviços de saúde, seguidas de uma crítica sintética - fundamentada nos conceitos de Geoffrey Rose - à estratégia preventiva de alto risco, que tem tido alto impacto na organização das rotinas assistenciais. A seguir, contextualiza a promoção da saúde relacionada ao cuidado individual na APS/ESF, discutindo o potencial sinérgico do cuidado e da promoção da saúde, em suas dimensões individuais e coletivas, para transcender o modelo biomédico/mecanicista. Finalmente, apoiado nos tópicos anteriores, no que tange aos seus desdobramentos operacionais e utilizando um exemplo concreto, propõe algumas diretrizes para a organização do trabalho e das agendas de médicos e enfermeiros da ESF, de modo a viabilizar equilíbrio e sinergia entre acesso ao cuidado e prevenção/promoção, com vistas ao fortalecimento da ESF como coordenadora local do cuidado e principal porta de entrada do Sistema Único de Saúde.
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Russell DJ, Humphreys JS, Ward B, Chisholm M, Buykx P, McGrail M, Wakerman J. Helping policy-makers address rural health access problems. Aust J Rural Health 2014; 21:61-71. [PMID: 23586567 DOI: 10.1111/ajr.12023] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2012] [Indexed: 11/28/2022] Open
Abstract
This paper provides a comprehensive review of the key dimensions of access and their significance for the provision of primary health care and a framework that assists policy-makers to evaluate how well policy targets the dimensions of access. Access to health care can be conceptualised as the potential ease with which consumers can obtain health care at times of need. Disaggregation of the concept of access into the dimensions of availability, geography, affordability, accommodation, timeliness, acceptability and awareness allows policy-makers to identify key questions which must be addressed to ensure reasonable primary health care access for rural and remote Australians. Evaluating how well national primary health care policies target these dimensions of access helps identify policy gaps and potential inequities in ensuring access to primary health care. Effective policies must incorporate the multiple dimensions of access if they are to comprehensively and effectively address unacceptable inequities in health status and access to basic health services experienced by rural and remote Australians.
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Affiliation(s)
- Deborah J Russell
- School of Rural Health, Monash University, Centre of Research Excellence in Rural and Remote Primary Health Care, Bendigo, Victoria, Australia.
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MacKinney AC, Mueller KJ, Vaughn T, Zhu X. From health care volume to health care value--success strategies for rural health care providers. J Rural Health 2013; 30:221-5. [PMID: 24112136 DOI: 10.1111/jrh.12047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- A Clinton MacKinney
- RUPRI Center for Rural Health Policy Analysis, Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, Iowa
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Rennie L, Porteous T, Ryan M. Preferences for managing symptoms of differing severity: a discrete choice experiment. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:1069-76. [PMID: 23244809 DOI: 10.1016/j.jval.2012.06.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 06/15/2012] [Accepted: 06/22/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND To design cost-effective health services it is important to understand why people adopt particular symptom management strategies. AIM To establish the relative importance of factors that influence decision making when managing symptoms of differing severity, to establish how people trade between these factors, and to estimate the monetary value placed on different management types. DESIGN Discrete choice experiment. SETTING UK online research panel. METHOD Successive members of an online panel were invited to participate until 480 discrete choice experiment questionnaires were completed. Relative preferences for managing three symptom scenarios of varying severity were measured. Symptom management was described by three characteristics (management type, availability, and cost). Preferences for ways of managing symptoms were measured by using conditional logit analysis. RESULTS A total of 98.5% of the completed questionnaires were valid (473 of 480 respondents). People preferred to manage minor symptoms by self-care or by visiting a pharmacy and were willing to pay £21.58 and £19.06, respectively, to do so. For managing moderately severe symptoms, people preferred to consult a general practitioner and were willing to pay £34.86 for this option. People preferred to manage potentially very severe symptoms by consulting a general practitioner and were willing to pay £73.08 to do so. Respondents were willing to trade between management types; options less preferred became more attractive when waiting time and cost were reduced. CONCLUSION People value self-care, supported self-care, and general practitioner consultation differently depending on the type of symptoms. Manipulating costs to users and waiting times for different services could allow policymakers to influence the services people choose when managing symptoms.
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Affiliation(s)
- Lisa Rennie
- University of Aberdeen Academic Primary Care, Aberdeen, UK.
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20
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McGrail MR. Spatial accessibility of primary health care utilising the two step floating catchment area method: an assessment of recent improvements. Int J Health Geogr 2012; 11:50. [PMID: 23153335 PMCID: PMC3520708 DOI: 10.1186/1476-072x-11-50] [Citation(s) in RCA: 147] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 11/06/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The two step floating catchment area (2SFCA) method has emerged in the last decade as a key measure of spatial accessibility, particularly in its application to primary health care access. Many recent 'improvements' to the original 2SFCA method have been developed, which generally either account for distance-decay within a catchment or enable the usage of variable catchment sizes. This paper evaluates the effectiveness of various proposed methods within these two improvement groups. Moreover, its assessment focuses on how well these improvements operate within and between rural and metropolitan populations over large geographical regions. RESULTS Demonstrating these improvements to the whole state of Victoria, Australia, this paper presents the first comparison between continuous and zonal (step) decay functions and specifically their effect within both rural and metropolitan populations. Especially in metropolitan populations, the application of either type of distance-decay function is shown to be problematic by itself. Its inclusion necessitates the addition of a variable catchment size function which can enable the 2SFCA method to dynamically define more appropriate catchments which align with actual health service supply and utilisation. CONCLUSION This study assesses recent 'improvements' to the 2SFCA when applied over large geographic regions of both large and small populations. Its findings demonstrate the necessary combination of both a distance-decay function and variable catchment size function in order for the 2SFCA to appropriately measure healthcare access across all geographical regions.
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Affiliation(s)
- Matthew R McGrail
- Gippsland Medical School, Monash University, Northways Road, Churchill, VIC 3842, Australia.
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Harris MF, Furler JS, Mercer SW, Willems SJ. Equity of access to quality of care in family medicine. INTERNATIONAL JOURNAL OF FAMILY MEDICINE 2012; 2011:858131. [PMID: 22518305 PMCID: PMC3296147 DOI: 10.1155/2011/858131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 11/17/2011] [Indexed: 05/31/2023]
Affiliation(s)
- M. F. Harris
- Centre for Primary Health Care and Equity, Faculty of Medicine, UNSW, Sydney, NSW 2052, Australia
| | - J. S. Furler
- Department of General Practice, The University of Melbourne, Parkville, VIC 3052, Australia
| | - S. W. Mercer
- Section of General Practice and Primary Care, University of Glasgow, Glasgow G12 8QQ, UK
| | - S. J. Willems
- Department of General Practice and Primary Health Care, Ghent University, De Pintelaan 185 1K3, 9000 Gent, Belgium
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Bower P, Kennedy A, Reeves D, Rogers A, Blakeman T, Chew-Graham C, Bowen R, Eden M, Gardner C, Hann M, Lee V, Morris R, Protheroe J, Richardson G, Sanders C, Swallow A, Thompson D. A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol. Implement Sci 2012; 7:7. [PMID: 22280501 PMCID: PMC3274470 DOI: 10.1186/1748-5908-7-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/26/2012] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation. There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient populations, but little consensus concerning the optimal model that would best provide such support. We describe the implementation and evaluation of self-management support through an evidence-based 'whole systems' model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care. METHODS The evaluation involves a large-scale, multi-site study of the implementation, effectiveness, and cost-effectiveness of this model of self-management support using a cluster randomised controlled trial in patients with three long-term conditions of diabetes, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). The outcome measures include healthcare utilisation and quality of life. We describe the methods of the cluster randomised trial. DISCUSSION If the 'whole systems' model proves effective and cost-effective, it will provide decision-makers with a model for the delivery of self-management support for populations with long-term conditions that can be implemented widely to maximise 'reach' across the wider patient population. TRIAL REGISTRATION NUMBER ISRCTN: ISRCTN90940049.
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Affiliation(s)
- Peter Bower
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Anne Kennedy
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - David Reeves
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Anne Rogers
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Tom Blakeman
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Carolyn Chew-Graham
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Robert Bowen
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Martin Eden
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Caroline Gardner
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Mark Hann
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Victoria Lee
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Rebecca Morris
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Joanne Protheroe
- Institute of Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Keele University, UK
| | - Gerry Richardson
- Centre for Health Economics, University of York, York YO10 5DD, UK
| | - Caroline Sanders
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Angela Swallow
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - David Thompson
- Section GI Science, School of Translational Medicine- Hope, Clinical Sciences Building, Hope Hospital, Salford M6 8HD, UK
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Gauld R, Al-wahaibi S, Chisholm J, Crabbe R, Kwon B, Oh T, Palepu R, Rawcliffe N, Sohn S. Scorecards for health system performance assessment: the New Zealand example. Health Policy 2011; 103:200-8. [PMID: 21723641 DOI: 10.1016/j.healthpol.2011.05.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2011] [Revised: 04/14/2011] [Accepted: 05/31/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To develop a national scorecard for assessing health system performance derived from routine data. METHODS We drew upon national and international data to develop benchmarks for health system performance, then applied basic ratio scores to compare New Zealand performances to the benchmark. 64 indicators were included in four assessment categories: healthy lives, quality, access, and efficiency. In a fifth category, 27 of these indicators were used to score health system equity. Indicator scores in each category were then averaged to give a health system score out of 100. RESULTS New Zealand's health system achieved an overall score of 71 out of 100. The system scored relatively well on quality and efficiency, but poorly on equity despite considerable government investment in reducing inequalities. CONCLUSIONS The scorecard offers a useful method for combining a range of data to give an overall picture of health system performance, highlighting strengths, weaknesses and areas for improvement. This initial study provides a baseline for assessing New Zealand's performance over time and, where data permit, a template for other countries to follow.
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Affiliation(s)
- Robin Gauld
- Centre for Health Systems, Department of Preventive and Social Medicine, University of Otago, Adams Building, Frederick Street, PO Box 913, Dunedin 9054, New Zealand.
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Ryan B, White S, Wild J, Court H, Margrain TH. The newly established primary care based Welsh Low Vision Service is effective and has improved access to low vision services in Wales. Ophthalmic Physiol Opt 2010; 30:358-64. [PMID: 20492541 DOI: 10.1111/j.1475-1313.2010.00729.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM The aim of this study was to determine whether the new, primary care based, Welsh Low Vision Service (WLVS) improved access to low vision services in Wales and was effective. METHOD The impact of the WLVS was determined by measuring the number of low vision appointments; travel time to the nearest service provider; and waiting times for low vision services for 1 year before, and for 1 year after, its establishment. Change in self-report visual function (using the 7 item NEI-VFQ), near visual acuity, patient satisfaction and use of low vision aids were used to determine the effectiveness of the service. RESULTS Following instigation of the WLVS, the number of low vision assessments increased by 51.7%, the waiting time decreased from more than 6 months to less than 2 months for the majority of people, and journey time to the nearest service provider reduced for 80% of people. Visual disability scores improved significantly (p < 0.001) by 0.79 logits and 97.42% patients found the service helpful. CONCLUSIONS The extension of low vision rehabilitation services into primary care identified a considerable unmet burden of need as evidenced by the substantial increase in the number of low vision assessments provided in Wales. The new service is effective and exhibits improved access.
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Affiliation(s)
- Barbara Ryan
- Cardiff School of Optometry and Vision Sciences, Cardiff University, Maindy Road, Cardiff, UK
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Abstract
Objective There has been growing interest in applying complexity theory to health care systems, both in policy and academic research discourses. However, its application often lacks rigour - authors discuss the properties of complex systems, state that they apply to health care and draw conclusions anchored around the idea of ‘whole system change’. This paper explores the use of whole systems change in a programme to improve the delivery of unscheduled health care in Scotland. Methods Qualitative case-studies of five health boards in Scotland reflecting different demographics, initial performance data and progress towards meeting programme targets. Results The programme's collaborative approach was successful in moving to a culture of mutual understanding and greater awareness of the interdependencies between different functions within the hospitals. There was whole system working at the acute hospital level, leading to improved patient flows. But despite recognizing the need for whole system change overall, it proved hard to address relationships with stakeholders influencing wider out-of-hospital patient flows. This was exacerbated by the structure of the programme, which was designed much more around acute patient flows. Conclusions The programme worked well to improve performance by focusing on interdependencies within a large part of the acute care subsystem but did not have the same impact at the overall health care system level. This has important implications for the design of policy and associated programmes which seek to effect whole system reform, or at least are realistic about the magnitude of change they can achieve.
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Richards D. Self-help: Empowering service users or aiding cash strapped mental health services? J Ment Health 2009. [DOI: 10.1080/09638230410001669246] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
This article examines the policy of using target-setting and measurement to deliver on the United Nations’ (UN) development goals. Using evidence from similar monitoring and management strategies in the United Kingdom (UK), we question the purpose of using process and outcome targets and suggest that this approach can be counter-productive. It can also lead to a situation where maintaining public relations and image is prioritised at the expense of making real impacts on key development issues. While the UN's aims are praiseworthy, we suggest that the somewhat simplistic methodology adopted is damaging to the very people that the UN is seeking to help.
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Affiliation(s)
- Lucy Webb
- Lucy Webb is a Senior Lecturer in mental health nursing, Division of Professional Registration, Elizabeth Gaskell Campus, Manchester Metropolitan University, Hathersage Road, Manchester, United Kingdom.M13 0JA
| | - Tony Ryan
- Tony Ryan is a Research Consultant in health service management, the Tony Ryan Associates, 26 Sergeants Lane, Whitefield Manchester, M45 7TS, United Kingdom
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Abstract
Surgical oncology is one of the most frequently studied surgical specialties with regard to disparities in quality of care. There is variation in the care received according to nonclinical factors such as age, race and ethnicity, education, income, and even geographic region. Differences exist with regard to who gets treatment, what treatment is received, and the outcomes of those treatments. Although the existence of such disparities is no longer in doubt, the etiology is still being investigated. Ongoing research and quality improvement initiatives move beyond the mere description of existing disparities in one of three ways: (1) identifying and understanding the factors that lead to disparities; (2) advancing available methods to measure and track disparities; and (3) developing an approach to improvement. In this article, we start out by offering a framework to describe potential factors that lead to disparities, using examples from surgical oncology. We then describe the approaches to measuring and tracking disparities that are being used in research and quality improvement. Finally, we attempt to illustrate how all of these factors interact and offer some potential strategies to close the gap and alleviate disparities within the discipline.
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Affiliation(s)
- Caprice C Greenberg
- Center for Surgery and Public Health, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115, USA.
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Evangelista PA, Barreto SM, Guerra HL. Central de regulação de leitos do SUS em Belo Horizonte, Minas Gerais, Brasil: avaliação de seu papel pelo estudo das internações por doenças isquêmicas do coração. CAD SAUDE PUBLICA 2008; 24:767-76. [DOI: 10.1590/s0102-311x2008000400006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Accepted: 09/20/2007] [Indexed: 11/22/2022] Open
Abstract
A Central de Internações de Belo Horizonte, Minas Gerais, Brasil, visa tornar ágil o acesso às internações pelo Sistema Único de Saúde (SUS). Entretanto, muitas internações ocorrem diretamente nos hospitais, sem intermediação da Central de Internação. O estudo comparou as características das internações realizadas em 2002, com relação à via de acesso. Foram selecionadas internações com hipótese diagnóstica de infarto agudo do miocárdio e insuficiência coronariana aguda. De 3.705 internações, 24,9% foram realizadas pela Central de Internação e 75,1% por via direta. As proporções de internações via direta foram maiores que pela Central de Internação para pacientes > 70 anos, internados por insuficiência coronariana aguda, na clínica cirúrgica e no fim de semana. Os percentuais das internações via Central de Internação foram maiores que os feitos por via direta para residentes em outros municípios, em hospitais não públicos e com utilização de UTI. O número de dias de internação também foi diferente entre as vias. O estudo mostrou diferenças nas características das internações realizadas pelas duas vias de acesso.
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Affiliation(s)
| | - Sandhi Maria Barreto
- Universidade Federal de Minas Gerais, Brasil; Universidade Federal de Minas Gerais, Brasil
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Farrand P, Duncan F, Byng R. Impact of graduate mental health workers upon primary care mental health: a qualitative study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2007; 15:486-93. [PMID: 17685994 DOI: 10.1111/j.1365-2524.2007.00707.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The role of the primary care graduate mental health worker (GMHW) was developed to improve the availability of mental health services within primary care. However, little is known concerning the impact of the role upon primary care mental health. Semistructured interviews were undertaken with 27 key stakeholders (12 clients, 10 managers/supervisors, 5 general practitioners) who had experience of the GMHW role and activities provided. Thematic analysis of interview transcripts highlighted four main themes: Access to primary care mental health, Inappropriate referrals, GMHW characteristics, and Role developments. All participant groups highlighted a range of ways in which the GMHW role was making significant contributions to primary care mental health. Many of these were associated with increasing access to mental health services afforded by the range of interventions provided. Benefits, however, may exclude working clients who expressed concerns about a lack of flexibility in the appointment times offered. Concerns arise as a consequence of inappropriate referrals made by some general practitioners. Such referrals were, in part, motivated by a belief that developments in primary care mental health should have been directed towards clients with more severe difficulties. In conclusion, this study suggests that the GMHW role is having a significant impact upon primary care mental health. Attempts to improve primary care mental health through the incorporation of the GMHW role within stepped care models of mental health service delivery should be encouraged.
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Affiliation(s)
- Paul Farrand
- School of Applied Psychosocial Studies, Faculty of Health and Social Work, University of Plymouth, Exeter, UK.
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Ryan T, Webb L, Meier PS. A systems approach to care pathways into in-patient alcohol detoxification: outcomes from a retrospective study. Drug Alcohol Depend 2006; 85:28-34. [PMID: 16621338 DOI: 10.1016/j.drugalcdep.2006.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2005] [Revised: 03/13/2006] [Accepted: 03/13/2006] [Indexed: 11/25/2022]
Abstract
This paper describes the effects of the adoption of a systems approach to alcohol service delivery by four previously separate organisations in Manchester, UK that commenced in 1997. The study examined a database of 5542 admissions for in-patient detoxification between 1995 and 2003, which permitted the analysis of changes occurring in the composition of the client group after the adoption of the new model. Findings suggest that working with the systems approach resulted in more effective targeting of people with higher levels of alcohol dependency towards in-patient detoxification. Females and people in stable housing also benefited from increased access in the new system. Increases in planned discharges were observed across all demographic variables, although alcohol-dependent males without stable accommodation found it more difficult to access in-patient detoxification after the new model was introduced. We conclude that in comparison to a loose network of services a co-ordinated and managed service system can improve targeting for in-patient detoxification for most people with severe alcohol dependence but may not do so for all who need access.
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Affiliation(s)
- Tony Ryan
- Department of Mental Health Social Work, University of Manchester and Health and Social Care Advisory Service, UK.
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Christian CK, Niland J, Edge SB, Ottesen RA, Hughes ME, Theriault R, Wilson J, Hergrueter CA, Weeks JC. A multi-institutional analysis of the socioeconomic determinants of breast reconstruction: a study of the National Comprehensive Cancer Network. Ann Surg 2006; 243:241-9. [PMID: 16432358 PMCID: PMC1448910 DOI: 10.1097/01.sla.0000197738.63512.23] [Citation(s) in RCA: 181] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the rate of postmastectomy reconstruction and investigate the impact of socioeconomic status on the receipt of reconstruction. SUMMARY BACKGROUND DATA The National Comprehensive Cancer Network (NCCN) Outcomes Project is a prospective, multi-institutional database that contains data on all newly diagnosed breast cancer patients treated at one of the participating comprehensive cancer centers. METHODS The study cohort consisted of 2174 patients with DCIS and stage I, II, and III invasive breast cancer who underwent mastectomy at one of 8 NCCN centers. Rates of reconstruction were determined. Logistic regression analyses were used to evaluate whether socioeconomic characteristics are associated with breast reconstruction. RESULTS Overall, 42% of patients had breast reconstruction following mastectomy. Patients with Medicaid and Medicare were less likely to undergo reconstruction than those with managed care insurance; however, there was no difference for indemnity versus managed care insurance. Homemakers and retired patients had fewer reconstructions than those employed outside the home. Patients with a high school education or less were less likely to have reconstruction than those with more education. Race and ethnicity were not significant predictors of reconstruction. CONCLUSIONS The reconstruction rate in this study (42%) is markedly higher than those previously reported. The type of insurance, education level, and employment status of a patient, but not her race or ethnicity, appear to influence the use of breast reconstruction. Because all patients were treated at an NCCN institution, these socioeconomic differences cannot be explained by access to care.
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Affiliation(s)
- Caprice K Christian
- Department of Surgery, Brigham and Women's Hospital, Boston, MA 02115, and Department of Breast Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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Jordan H, Roderick P, Martin D, Barnett S. Distance, rurality and the need for care: access to health services in South West England. Int J Health Geogr 2004; 3:21. [PMID: 15456514 PMCID: PMC524184 DOI: 10.1186/1476-072x-3-21] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2004] [Accepted: 09/29/2004] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND: This paper explores the geographical accessibility of health services in urban and rural areas of the South West of England, comparing two measures of geographical access and characterising the areas most remote from hospitals.Straight-line distance and drive-time to the nearest general practice (GP) and acute hospital (DGH) were calculated for postcodes and aggregated to 1991 Census wards. The correlation between the two measures was used to identify wards where straight-line distance was not an accurate predictor of drive-time. Wards over 25 km from a DGH were classified as 'remote', and characterised in terms of rurality, deprivation, age structure and health status of the population. RESULTS: The access measures were highly correlated (r2>0.93). The greatest differences were found in coastal and rural wards of the far South West. Median straight-line distance to GPs was 1 km (IQR = 0.6-2 km) and to DGHs, 12 km (IQR = 5-19 km). Deprivation and rates of premature limiting long term illness were raised in areas most distant from hospitals, but there was no evidence of higher premature mortality rates. Half of the wards remote from a DGH were not classed as rural by the Office for National Statistics. Almost a quarter of households in the wards furthest from hospitals had no car, and the proportion of households with access to two or more cars fell in the most remote areas. CONCLUSION: Drive-time is a more accurate measure of access for peripheral and rural areas. Geographical access to health services, especially GPs, is good, but remoteness affects both rural and urban areas: studies concentrating purely on rural areas may underestimate geographical barriers to accessing health care. A sizeable minority of households still had no car in 1991, and few had more than one car, particularly in areas very close to and very distant from hospitals. Better measures of geographical access, which integrate public and private transport availability with distance and travel time, are required if an accurate reflection of the experience those without their own transport is to be obtained.
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Affiliation(s)
- Hannah Jordan
- Health Care Research Unit, CCS Division, School of Medicine, University of Southampton, UK
| | - Paul Roderick
- Health Care Research Unit, CCS Division, School of Medicine, University of Southampton, UK
| | - David Martin
- School of Geography, University of Southampton, UK
| | - Sarah Barnett
- International Perinatal Care Unit, Institute of Child Health, London, UK
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Chapman JL, Zechel A, Carter YH, Abbott S. Systematic review of recent innovations in service provision to improve access to primary care. Br J Gen Pract 2004; 54:374-81. [PMID: 15113523 PMCID: PMC1266174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND In England, there are particularly pressing problems concerning access to adequate primary care services. Consequently, innovative ways of delivering primary care have been introduced to facilitate and broaden access. AIMS The aim of this study was to review the evidence of seven recent innovations in service provision to improve access or equity in access to primary care, by performing a systematic review of the literature. DESIGN OF STUDY Systematic review. SETTING Primary care in the United Kingdom (UK). METHOD Seven electronic databases were searched and key journals were hand-searched. Unpublished and 'grey' literature were sought via the Internet and through professional contacts. Intervention studies addressing one of seven recent innovations and conducted in the UK during the last 20 years were included. Two researchers independently assessed the quality of papers. RESULTS Thirty studies (32 papers and two reports) were identified overall. Variation in study design and outcome measures made comparisons difficult. However, there was some evidence to suggest that access is improved by changing the ways in which primary care is delivered. First-wave personal medical services pilots facilitated improvements in access to primary care in previously under-served areas and/or populations. Walk-in centres and NHS Direct have provided additional access to primary care for white middle-class patients; there is some evidence suggesting that these innovations have increased access inequalities. There is some evidence that telephone consultations with GPs or nurses can safely substitute face-to-face consultations, although it is not clear that this reduces the number of face-to-face consultations over time. Nurse practitioners and community pharmacists can manage common conditions without the patient consulting a general practitioner. CONCLUSION The evidence is insufficient to make clear recommendations regarding ways to improve access to primary care. In the future, it is important that, as new initiatives are planned, well-designed evaluations are commissioned simultaneously.
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Affiliation(s)
- Jenifer L Chapman
- Centre for Infectious Disease, Institute of Cell and Molecular Sciences, Queen Mary's, University of London, London.
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Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. CAD SAUDE PUBLICA 2004; 20 Suppl 2:S190-8. [PMID: 15608933 DOI: 10.1590/s0102-311x2004000800014] [Citation(s) in RCA: 277] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
O objetivo deste artigo é rever os conceitos de acesso e de utilização de serviços de saúde, identificando pontos de distinção e articulação existentes entre ambos. Acesso é um conceito complexo, geralmente empregado de forma imprecisa e que muda ao longo do tempo e de acordo com o contexto. A utilização dos serviços de saúde representa o centro do funcionamento dos sistemas de saúde. Apesar das divergências, predomina a visão de que o acesso relaciona-se a características da oferta de serviços. O uso de serviços é uma expressão do acesso, mas não se explica apenas por ele. Fatores individuais predisponentes e contextuais também influenciam o uso. Observa-se uma tendência de ampliação do escopo do conceito de acesso, com deslocamento do seu eixo da entrada nos serviços (uso) para os resultados dos cuidados recebidos. O acesso é visto pelo seu impacto na saúde e dependerá também da adequação do cuidado prestado. Finalmente, destaca-se que determinantes da saúde diferem daqueles do uso de serviços e que a utilização de serviços impacta diretamente a doença, mas apenas indiretamente a saúde.
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Affiliation(s)
- Claudia Travassos
- Centro de Informação Científica e Tecnológica, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
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Faulkner A, Mills N, Bainton D, Baxter K, Kinnersley P, Peters TJ, Sharp D. A systematic review of the effect of primary care-based service innovations on quality and patterns of referral to specialist secondary care. Br J Gen Pract 2003; 53:878-84. [PMID: 14702909 PMCID: PMC1314732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND Innovations are proliferating at the primary-secondary care interface, affecting referral to secondary care and resource use. Evidence about the range of effects and implications for the healthcare system of different types of innovation have not previously been summarised. AIM To review the available evidence on initiatives affecting primary care referral to specialist secondary care. SETTING Studies of primary-secondary care interface. METHOD Systematic review of trials, using adapted Cochrane Collaboration (effective practice and organisation of care) criteria. Studies from 1980 to 2001 were identified from a wide range of sources. Strict inclusion criteria were applied, and relevant clinical, service and cost data extracted using an agreed protocol. The main outcome measures were referral rates to specialist secondary care. RESULTS Of the 139 studies initially identified. 34 met the review criteria. An updated search added a further 10 studies. Two studies provided economic analysis only. Referral was not the primary outcome of interest in the majority of included studies. Professional interventions generally had an impact on referral rates consistent with the intended change in clinician behaviour. Similarly, specialist 'outreach' or other primary care-based specialist provider schemes had at least a small effect upon referral rates to secondary care with the direction of effect being that intended or rational from a clinical and sociological perspective. Of the financial interventions, one was aimed primarily at changing the numbers or proportion of referrals from primary to specialist secondary care, and the direction of change was as expected in all cases. The quality of the reporting of the economic components of the 14 studies giving economic data was poor in many cases. When grouped by intervention type, no overall pattern of change in referral costs or total costs emerged. CONCLUSION The studies identified were extremely diverse in methodology, clinical subject, organisational form, and quality of evidence. The number of good quality evaluations of innovative schemes to enhance the existing capacity of primary care was small, but increasing. Well-evaluated service initiatives in this area should be supported. Organisational innovations in the structure of service provision need not increase total costs to the National Health Service (NHS), even though costs associated with referral may increase. This review provides limited, partial, and conditional support for current primary care-oriented NHS policy developments in the United Kingdom.
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Affiliation(s)
- Alex Faulkner
- Cardiff University School of Social Sciences, Glamorgan Building, King Edward VII Avenue, Cardiff CF10 3WT.
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George A, Rubin G. Non-attendance in general practice: a systematic review and its implications for access to primary health care. Fam Pract 2003; 20:178-84. [PMID: 12651793 DOI: 10.1093/fampra/20.2.178] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Non-attendance in general practice has received increasing attention over the past few years. Its relationship with access to health care has been recognized and is of particular relevance in light of the access targets set out in the NHS Plan. METHODS The literature was searched for articles relating to non-attendance. Titles and abstracts were examined, and relevant articles obtained. Bibliographies were examined for further references. Articles that described interventions for reducing non-attendance that were comparative studies and that examined general appointments, as opposed to appointments for screening purposes for example, were of particular interest. RESULTS AND CONCLUSIONS The epidemiology of non-attendance has been well described, but there is little work on the reasons for non-attendance. Evidence for effective interventions to improve attendance in primary care is lacking, and this may prove to be an area of research interest in the future. As well as specific interventions to reduce non-attendance, new approaches to health care access are required in order to tackle this issue.
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Affiliation(s)
- Ajay George
- Centre for Primary and Community Care, University of Sunderland, Benedict Building, St George's Way, UK.
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Richards DA, Lovell K, McEvoy P. Access and effectiveness in psychological therapies: self-help as a routine health technology. HEALTH & SOCIAL CARE IN THE COMMUNITY 2003; 11:175-182. [PMID: 14629220 DOI: 10.1046/j.1365-2524.2003.00417.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The ability of psychological treatment services to deliver effective and accessible mental healthcare, as demanded by the National Service Framework for mental health, is compromised by the traditional configuration of psychological therapy services, powerful gatekeeping by these services and the difficulties which exist in engaging primary care in mental healthcare. Although a number of service models have been suggested, most address access from the perspective of secondary care service providers. In particular, self-help, a powerful ideology and a clinically effective health technology, is given insufficient prominence in psychological therapy services. Self-help is often only considered for mild problems or as an adjunct to therapy, and it is assumed that mental health professionals with traditional therapeutic skills are needed to support self-help. Following a review of access and self-help in psychological therapies, the present authors propose criteria against which services could be designed in order to fully utilise self-help as a powerful health technology in psychological therapies. Accompanying these criteria is a research framework drawn from recent work on access and illness self-management that can be used to evaluate the performance of services attempting to improve access to psychological therapies.
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Affiliation(s)
- David A Richards
- School of Nursing Midwifery and Health Visiting, University of Manchester, Manchester, UK.
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Iliffe S, Lenihan P, Wallace P, Drennan V, Blanchard M, Harris A. Applying community-oriented primary care methods in British general practice: a case study. Br J Gen Pract 2002; 52:646-51. [PMID: 12171223 PMCID: PMC1314383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND The '75 and over' assessments built into the 1990 contract for general practice have failed to enthuse primary care teams or make a significant impact on the health of older people. Alternative methods for improving the health of older people living at home are being sought. AIM To test the feasibility of applying community-oriented primary care methodology to a relatively deprived sub-population of older people in a relatively deprived area. DESIGN OF STUDY A combination of developmental and triangulation approaches to data analysis. SETTING Four general practices in an inner London borough. METHOD A community-oriented primary care approach was used to initiate innovative care for older people, supported financially by the health authority and practically by primary care academics. RESULTS All four practices identified problems needing attention in the older population, developed different projects focused on particular needs among older people, and tested them in practice. Patient and public involvement were central to the design and implementation processes in only one practice. Innovations were sustained in only one practice, but some were adopted by a primary care group and others extended to a wider group of practices by the health authority. CONCLUSION A modified community-oriented primary care approach can be used in British general practice, and changes can be promoted that are perceived as valuable by planning bodies. However, this methodology may have more impact at primary care trust level than at practice level.
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Affiliation(s)
- Steve Iliffe
- Department of Primary Care and Population Sciences, Royal Free and UCL Medical School, London.
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Martin D, Wrigley H, Barnett S, Roderick P. Increasing the sophistication of access measurement in a rural healthcare study. Health Place 2002; 8:3-13. [PMID: 11852259 DOI: 10.1016/s1353-8292(01)00031-4] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This paper considers the problem of deriving realistic access measures between population demand and health service locations, in the context of a rural region of England. The paper reviews approaches used in earlier work by the authors and others, and considers new public transport information systems that are now becoming available. An application is presented which incorporates the modelling of both private and public transportation travel times for access to district general hospitals in Cornwall. This information has been assembled from published timetables in order to evaluate the use of more sophisticated access measures that might be used when such data becomes more generally available. The work is set within the context of an ongoing substantive research programme concerned with health outcomes in the rural South West of England.
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Affiliation(s)
- D Martin
- Department of Geography, University of Southampton, Southampton SO17 1BJ, UK.
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Anderson R, Thomas DW. Out-of-hours dental services: a survey of current provision in the United Kingdom. Br Dent J 2000; 188:269-74. [PMID: 10758690 DOI: 10.1038/sj.bdj.4800452] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the variety of arrangements for providing out-of-hours dental care in the UK. DESIGN A telephone interview survey of health authorities and health boards. SETTING United Kingdom. SUBJECTS 104 health authority contacts, usually consultants in dental public health, dental advisers or others in a position to describe the local dental service arrangements. RESULTS At weekends, 25 authorities have no formal dental care arrangements for unregistered patients, 55 have separate arrangements for registered and unregistered patients, and 44 have 'universal access' arrangements--for anyone in an area, regardless of their registration status. On weekday nights over two-thirds (82/124) of UK health authorities have no formal arrangements for unregistered patients. Where there are separate 'safety-net' services intended for unregistered patients only they are usually (in 48 of 55 authorities) emergency treatment sessions. A fifth of authorities reported planned changes to their local out-of-hours arrangements, including the introduction of telephone triage, and moves to make care available at more times, to more people or from centralised premises. CONCLUSIONS There is extremely wide geographical variation in the organisation of out-of-hours dental services provided in the United Kingdom. In many parts of the UK there are no formal out-of-hours care arrangements for unregistered patients, even at weekends. This unequal provision will mean inequitable access for many unregistered patients. With increasing demands from a growing unregistered population, and various government initiatives to make primary care services more integrated and accessible, the highly fragmented pattern of provision in many areas may no longer be acceptable.
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Affiliation(s)
- R Anderson
- Department of Oral Surgery, Medicine and Pathology, University of Wales College of Medicine, Health Park, Cardiff.
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Reynolds M. Improving access to medical care. General practice cooperatives are coping well. BMJ (CLINICAL RESEARCH ED.) 1999; 319:1496. [PMID: 10582942 PMCID: PMC1117213 DOI: 10.1136/bmj.319.7223.1496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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