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Marco-Ibáñez A, Aguilar-Palacio I, Gamba-Cabezas A, Compés-Dea ML, Aibar Remón C. [How the individual characteristics and area of residence influence the request for virtual consultations?]. Semergen 2024; 50:102296. [PMID: 39208518 DOI: 10.1016/j.semerg.2024.102296] [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: 01/31/2024] [Revised: 04/04/2024] [Accepted: 05/13/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION The foundation of virtual consultation is to improve the cooperation and the coordination between Primary Care and other specialties. However, in its use inequities related to socioeconomic determinants have been described. The aim of this study was to identify individual and geographical factors affecting the likelihood of accessing this resource. MATERIAL AND METHODS Descriptive study of virtual and non-virtual consultations requested by Primary Care doctors from other specialists doctors in Aragon between 1 January 2020 and 31 December 2022. Characteristics of the interconsultations and variables specific to the patient treated were recorded and analyzed; and the request rate for virtual consultations by specialty and the standardized rates by age by Basic Health Zone and stratified by sex were calculated. RESULTS Progressive increase in the number of virtual consultations for the study period, being Traumatology, Neurology, Urology, General Surgery and Dermatology the specialties that received the most. The standardized rates by age and stratified by sex were higher in women and the Health Areas of Huesca, Calatayud and Alcañiz. The request was higher in 2022 and the specialized referral was the main type of response. Regarding variables of the patients treated, virtual consultations were requested more in urban and less dispersed areas, women, patients with lower adjusted morbidity and with free pharmacy, pensioners and active users with income less than €18,000/year. CONCLUSIONS Despite the rise of telemedicine and its potential advantages, it is necessary to adapt it to the needs of the local population, to mitigate inequalities in access, and to integrate it with face-to-face care.
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Affiliation(s)
- A Marco-Ibáñez
- Centro de Salud Casablanca, Servicio Aragonés de Salud, Grupo de Investigación en Servicios Sanitarios (GRISSA), Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, España.
| | - I Aguilar-Palacio
- Universidad de Zaragoza, Grupo de Investigación en Servicios Sanitarios (GRISSA), Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, España
| | - A Gamba-Cabezas
- Grupo de Investigación en Servicios Sanitarios (GRISSA), Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, España
| | - M L Compés-Dea
- Dirección General de Asistencia Sanitaria y Planificación del Departamento de Sanidad del Gobierno de Aragón. Grupo de Investigación en Servicios Sanitarios (GRISSA), Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, España
| | - C Aibar Remón
- Universidad de Zaragoza, Grupo de Investigación en Servicios Sanitarios (GRISSA), Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, España
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Craven EM, Luck G, Whitney D, Dodhia H, Foster S, Stanke C, Seed PT, Crompton J, Brown KA. Why do children under 5 years go to the GP in Lambeth: a cross-sectional study. BMJ Open 2024; 14:e082253. [PMID: 38803264 PMCID: PMC11328670 DOI: 10.1136/bmjopen-2023-082253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVES This study identifies the most common recorded reason for attendance to primary care for children under 5 years old, including a breakdown via age, ethnicity, deprivation quintile and sex. DESIGN Cross-sectional. SETTING 39 of 40 general practices in Lambeth, London, UK. PARTICIPANTS 22 189 children under 5 years who had attended primary care between the 1 April 2017 and 31 March 2020 and had not opted out of anonymous data sharing within Lambeth DataNet. OUTCOME MEASURE The primary objective was to identify the most frequently recorded complaint in general practice for children under 5 years old. The secondary objective was to understand how presenting complaint differs by age, ethnicity, sex and deprivation level. The third objective was to create a multivariate logistic regression with frequent attendance as the outcome variable. RESULTS Nine conditions formed over 50% of all patient interactions: the most common reason was upper respiratory tract infections (14%), followed by eczema (8%) and cough (7%). While there was some variation by ethnicity and age, these nine conditions remained dominant. Children living in the most deprived area are more likely to be frequent attenders than children living in the least deprived area (adjusted OR (AOR) 1.27 (95% CI 1.14 to 1.41)). Children of Indian (AOR 1.47 (1.04 to 2.08)), Bangladeshi (AOR 2.70 (1.95 to 3.74)) and other white (AOR 1.18 (1.04 to 1.34)) ethnicities were more likely to be frequent attenders, compared with those of white British ethnicity. CONCLUSIONS Most reasons for attendance for children under 5 years to primary care are for acute, self-limiting conditions. Some of these could potentially be managed by increasing access to community care services, such as pharmacies. By focusing on the influence of the broader determinants of health as to why particular groups are more likely to attend, health promotion efforts have the opportunity to reduce barriers to healthcare and improve outcomes.
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Affiliation(s)
| | | | - David Whitney
- Department of Population Health Sciences, School of Life Course & Population Sciences, King's College London, London, UK
| | - Hiten Dodhia
- Public Health, London Borough of Lambeth, London, UK
| | | | | | - Paul T Seed
- Department of Women & Children's Health, School of Life Course & Population Sciences, Kings College London, London, UK
| | | | - Kerry Ann Brown
- University of Exeter Medical School, University of Exeter, Exeter, UK
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Aljerian N, Alharbi A. Assessing Medical Emergency E-referral Request Acceptance Patterns and Trends: A Comprehensive Analysis of Secondary Data From the Kingdom of Saudi Arabia. Cureus 2024; 16:e53511. [PMID: 38314384 PMCID: PMC10838169 DOI: 10.7759/cureus.53511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 02/06/2024] Open
Abstract
Introduction Patient transfers in emergencies have been linked to reduced mortality rates and enhanced quality of care. The Saudi Medical Appointments and Referrals Centre (SMARC), an e-referral system in the Kingdom of Saudi Arabia (KSA) since 2019, plays a crucial role in ensuring quality and continuity of care. The findings of this study can provide valuable insights into the effectiveness of the e-referral system and identify potential areas for improvement in the management of emergency cases. Objective This study aims to examine e-referral patterns for emergency medical cases throughout all 13 administrative regions of KSA. Concurrently, it estimates the acceptance rate of medical emergency referrals and investigates associated factors among KSA hospitals. Methods This retrospective study utilized secondary data from the SMARC e-referral system, specifically focusing on medical emergency e-referral requests in the entire KSA during 2021. Descriptive univariate analyses were conducted to characterize the referral requests, followed by bivariate analyses to explore associations between factors and referral acceptance. Adjusted multiple logistic regression analyses were then performed to calculate adjusted odds ratios (ORs) and corresponding 95% confidence intervals, controlling for potential confounding variables. Results A total of 29,660 medical emergency referral requests were initiated across all regions of KSA during the study time frame, and, of these, 20,523 (69.19%) were accepted. The average age of patients with a medical emergency referral was 52 years old, and referral requests were higher among Saudis (13,781; 54.18%), males (13,781; 54.18%), and those from the Western region (10,560; 35.60%). Nearly 20,854 (70%) were due to the unavailability of specialized doctors or specialties in facilities. Based on multi-logistic regression, referral request acceptance was high in some factors as follows: compared to the Central region, requests from the Northern, Southern, Eastern, and Western regions had higher acceptance rates at 123%, 64%, 54%, and 46%, respectively. In addition, referral requests that were due to the unavailability of a specialized doctor or medical equipment had higher acceptance rates (19% and 16%), respectively, than those due to the unavailability of a specific specialty. Conclusion This study provides valuable insights into regional variations, sociodemographic factors, and referral reasons within the medical emergency e-referral system in the KSA. By estimating the acceptance rate of medical emergency referrals and investigating associated factors, this analysis confirms the effectiveness of the e-referral system in facilitating access to quality care, particularly for marginalized patients. The study highlights the need for health policy improvements to ensure equitable resource allocation and reduce disparities in healthcare access.
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Affiliation(s)
- Nawfal Aljerian
- Emergency Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Emergency Medicine, Medical Referrals Centre, Ministry of Health, Riyadh, SAU
| | - Abdullah Alharbi
- Family and Community Medicine, Faculty of Medicine, Jazan University, Jazan, SAU
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Aboelkhir HAB, Elomri A, ElMekkawy TY, Kerbache L, Elakkad MS, Al-Ansari A, Aboumarzouk OM, El Omri A. A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16952. [PMID: 36554837 PMCID: PMC9778793 DOI: 10.3390/ijerph192416952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/24/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process. METHODS A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis. RESULTS A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified. CONCLUSIONS Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.
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Affiliation(s)
| | - Adel Elomri
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Tarek Y. ElMekkawy
- Department of Mechanical and Industrial Engineering, College of Engineering, Qatar University, Doha 2713, Qatar
| | - Laoucine Kerbache
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Mohamed S. Elakkad
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Abdulla Al-Ansari
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Omar M. Aboumarzouk
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- College of Medicine, QU-Health, Qatar University, Doha 2713, Qatar
- School of Medicine, Dentistry and Nursing, The University of Glasgow, Glasgow G12 8QQ, UK
| | - Abdelfatteh El Omri
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
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Parkinson B, McManus E, Sutton M, Meacock R. Does recruiting patients to diabetes prevention programmes via primary care reinforce existing inequalities in care provision between general practices? A retrospective observational study. BMJ Qual Saf 2022; 32:274-285. [PMID: 36597995 DOI: 10.1136/bmjqs-2022-014983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/24/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary care plays a crucial role in identifying patients' needs and referring at-risk individuals to preventive services. However, well-established variations in care delivery may be replicated in this prevention activity. OBJECTIVE To examine whether recruiting patients to the English NHS Diabetes Prevention Programme via primary care reinforces existing inequalities in care provision between practices, in terms of clinical quality, accessibility and resources. METHODS We generated annual practice-level counts of referrals across the first 4 years of the programme (June 2016 to March 2020). These were linked to 15 indicators of practice clinical quality, access and resources measured during 2018/19. We used random effects Poisson regressions to examine associations between referrals and these indicators, controlling for practice and population characteristics, for 6871 practices in England. RESULTS On average, practices made 3.72 referrals per 1000 population annually and rates varied substantially between practices. Referral rates were positively associated with the quality of clinical care provided. A 1 SD higher level of achievement on Quality and Outcomes Framework diabetes indicators was associated with an 11% (95% CI: 8% to 14%) higher referral rate. This positive association was consistent across all five clinical quality indicators. There was no association between referral rates and accessibility, overall payments or staffing. Associations between referrals and receiving different supplementary payments over the core contract were mixed, with 8%-11% lower referral rates for some payments but not for others. CONCLUSION Recruiting patients to diabetes prevention programmes via primary care reinforces existing inequalities between general practices in the clinical quality of care they provide. This leaves patients registered with practices providing lower quality clinical care even more disadvantaged. Providing additional support to lower quality practices or using alternative recruitment methods may be necessary to avoid differential engagement in prevention programmes from widening these variations and potential health inequalities further.
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Affiliation(s)
- Beth Parkinson
- Health, Organisation, Policy and Economics Research Group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Emma McManus
- Health, Organisation, Policy and Economics Research Group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Matt Sutton
- Health, Organisation, Policy and Economics Research Group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK.,Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rachel Meacock
- Health, Organisation, Policy and Economics Research Group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
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Fooken J, Jeet V. Using Australian panel data to account for unobserved factors in measuring inequities for different channels of healthcare utilization. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:717-728. [PMID: 34661794 DOI: 10.1007/s10198-021-01391-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 10/06/2021] [Indexed: 06/13/2023]
Abstract
Inequity in healthcare utilization is typically measured as the unequal distribution of services by observable non-need indicators, such as income, after controlling for observable need indicators. However, important sources of unequal healthcare utilization are often unobserved. The unobserved element may reflect need factors, such as imperfectly measured severity of illness, that would predict greater utilization across different healthcare channels, but also based on choice, such as patient preferences to use a particular healthcare channel over an alternative one, which may differ in its effect between channels. Accounting for unobserved sources of utilization may, therefore, help to understand contradictory inequalities between different healthcare channels, such as pro-poor inequalities for general practitioner use and pro-rich inequalities for specialist visits. This paper uses survey data from the Household Income and Labour Dynamics in Australia and panel data methods to investigate if seemingly contradictory inequalities between different healthcare channels are explained by latent individual-level heterogeneity. Results show that unobserved individual-level heterogeneity affects inequities across different healthcare channels, providing indications that the unobserved element may primarily represent unobserved need.
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Affiliation(s)
- Jonas Fooken
- Centre for the Business and Economics of Health, The University of Queensland, Sir Llew Edwards Building (#14), Cnr University Drive and Campbell Road, St Lucia, QLD, 4067, Australia.
| | - Varinder Jeet
- Macquarie University Centre for the Health Economy, Level 1 EMC2 Building, 3 Innovation Rd, Macquarie Park, NSW, 2109, Australia
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7
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Svedahl ER, Pape K, Austad B, Vie GÅ, Anthun KS, Carlsen F, Bjørngaard JH. Effects of GP characteristics on unplanned hospital admissions and patient safety. A 9-year follow-up of all Norwegian out-of-hours contacts. Fam Pract 2022; 39:381-388. [PMID: 34694363 PMCID: PMC9155163 DOI: 10.1093/fampra/cmab120] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There are substantial differences in hospital referrals between general practitioners (GPs); however, there is little research on the consequences for patient safety and further healthcare use. OBJECTIVE To investigate associations between out-of-hours GP characteristics, unplanned hospital admissions, and patient safety. METHODS This cohort study included all Norwegian out-of-hours services contacts from 2008 to 2016, linked to registry data on patient characteristics, healthcare use and death, and GP age, sex, specialist status, out-of-hours service experience, and prior admission proportion. We estimated the impact from GP characteristics on (i) immediate unplanned hospital admissions for "all conditions," (ii) immediate unplanned hospital admissions for "critical conditions," (iii) 30-day unplanned hospital admissions, (iv) 30-day hospital costs, and (v) 30-day risk of death. To limit confounding, we matched patients in groups by age, time, and location, with an assumption of random assignment of GPs to patients with this design. RESULTS Patients under the care of older and male GPs had fewer immediate unplanned hospital admissions, but the effects on cumulative 30-day unplanned hospital admissions and costs were small. The GPs' prior admission proportion was strongly associated with both immediate and 30-day unplanned hospital admissions. Higher prior admission proportion was also associated with admitting more patients with critical conditions. There was little evidence of any associations between GP characteristics and 30-day risk of death. CONCLUSIONS GPs' prior admission proportion was strongly associated with unplanned hospital admissions. We found little effects on 30-day mortality, but more restrictive referral practices may threaten patient safety through missing out on critical cases.
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Affiliation(s)
- Ellen Rabben Svedahl
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kristine Pape
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjarne Austad
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Gunnhild Åberge Vie
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjartan Sarheim Anthun
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Health Research, SINTEF Digital, Trondheim, Norway
| | - Fredrik Carlsen
- Department of Economics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Johan Håkon Bjørngaard
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
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8
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Osadchuk MA, Svistunov AA, Balashov DV, Osadchuk MM. Functional dyspepsia: a multifaceted problem in gastroenterology. TERAPEVT ARKH 2022; 93:1539-1544. [DOI: 10.26442/00403660.2021.12.201190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 01/16/2022] [Indexed: 11/22/2022]
Abstract
The article presents the views on dyspepsia in world practice, data on the difficulties of diagnosis and the problem of the effectiveness of various therapy regimens. Particular attention is paid to the use of fixed forms of drugs for functional dyspepsia, in particular Omez DSR.
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9
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Moore FR, Williams L, Dunbar M. Sociodemographic predictors of attendance at a Scottish pain management programme. Br J Pain 2021; 15:393-400. [PMID: 34840787 PMCID: PMC8611294 DOI: 10.1177/2049463720970579] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
We examined relationships between various sociodemographic factors and attendance at the Glasgow Pain Management Programme (n = 2899 from 2011 to 2019). We tested for associations between gender, age and socioeconomic deprivation of patients who were invited to attend, and uptake to a programme when invited, attendance at screening assessment, eligibility, adherence and attendance at 3- and 6-month reviews. Uptake was significantly higher for patients from more affluent areas (95% confidence interval (CI) = 0.93–0.99, p = 0.002) and for older patients (95% CI = 0.98–0.99, p = 0.006), although effect sizes were very small. Patients were significantly more likely to be assessed as suitable if they were younger (95% CI = 0.98–0.99, p = 0.013) or female (95% CI = 0.55–0.84, p < 0.001). Attendance at sessions and at 3- and 6-month reviews was higher for patients from more affluent areas (95% CI = 1–1.09, p = 0.001, and 95% CI = 1–1.1, p = 0.044 respectively). We argue that there are multiple potential explanations for these findings and that future work should attempt to determine whether these patterns replicate in other populations and to determine any modifiable causes.
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Affiliation(s)
- F R Moore
- Phoenix Centre, Raigmore Hospital, Inverness, UK
| | | | - M Dunbar
- New Victoria Hospital, Glasgow, UK
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10
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Cancer detection via primary care urgent referral and association with practice characteristics: a retrospective cross-sectional study in England from 2009/2010 to 2018/2019. Br J Gen Pract 2021; 71:e826-e835. [PMID: 34544690 PMCID: PMC8463132 DOI: 10.3399/bjgp.2020.1030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background There is substantial variation in the use of urgent suspected cancer referral (2-week wait [2WW]) between practices. Aim To examine the change in use of 2WW referrals in England over 10 years (2009/2010 to 2018/2019) and the practice and population factors associated with cancer detection. Design and setting Retrospective cross-sectional study of English general practices and their 2WW referral and Cancer Waiting Times database detection data (all cancers other than non-melanoma skin cancers) from 2009/2010 to 2018/2019. Method A retrospective study conducted using descriptive statistics of changes over 10 years in 2WW referral data. Yearly linear regression models were used to determine the association between cancer detection rates and quintiles of practice and population characteristics. Predicted cancer detection rates were calculated, as well as the difference between lowest to highest quintiles. Results Over the 10 years studied there were 14.89 million 2WW referrals (2.24 million in 2018/2019), and 2.68 million new cancer diagnoses, of which 1.26 million were detected following 2WW. The detection rate increased from 41% to 52% over the time period. In 2018/2019 an additional 66 172 cancers were detected via 2WW compared with 2009/2010. Higher cancer detection via 2WW referrals was associated with larger practices and those with younger GPs. From 2016/2017 onwards more deprived practice populations were associated with decreased cancer detection. Conclusion From 2009/2010 to 2018/2019 2WW referrals increased on average by 10% year on year. The most consistent association with higher cancer detection was found for larger practices and those with younger GPs, though these differences became attenuated over time. The more recent association between increased practice deprivation and lower cancer detection is a cause for concern. The COVID-19 pandemic has led to significant impacts on 2WW referral activity and the impact on patient outcomes will need to be studied.
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Abstract
Functional dyspepsia is a common functional gastrointestinal (GI) disorder of gastroduodenal origin, diagnosed clinically in the presence of prototypical symptoms of epigastric pain and meal-related symptoms, and without structural explanation. The most recent diagnostic criteria provide for two functional dyspepsia subtypes, epigastric pain syndrome (EPS) and post-prandial distress syndrome (PDS) based on the predominant symptom pattern. The evaluation of dyspepsia should keep laboratory, imaging, and invasive testing to a minimum, as extensive or repetitive investigations are of rather low diagnostic yield in the absence of localizing symptoms or alarm features. Factors with etiopathologic relationships to functional dyspepsia include micro-inflammation, GI infections, abnormalities of gastroduodenal motility, visceral hypersensitivity, disturbances along the brain-gut axis, and psychological factors; all of these causative mechanisms have potential to partially explain symptoms in some functional dyspepsia patients, thus providing a rationale for the efficacy of a diversity of therapeutic approaches to functional dyspepsia. Management of dyspepsia symptoms relies upon both pharmacologic treatments and non-pharmacologic approaches, including psychological and complementary interventions. The evidence in support of established functional dyspepsia therapies is reviewed, and forms the basis for an effective functional dyspepsia treatment strategy emphasizing the patient's current symptom severity, pattern, and impact on the function and quality of life of the individual.
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12
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Knuutila M, Lehti TE, Karppinen H, Kautiainen H, Strandberg TE, Pitkala KH. Associations of perceived poor societal treatment among the oldest-old. Arch Gerontol Geriatr 2020; 93:104318. [PMID: 33310658 DOI: 10.1016/j.archger.2020.104318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies of perceived ageism among older people have focused on younger age groups with the respondents' mean age far below 80. OBJECTIVE To explore the perceptions of poor societal treatment of older people among home-dwelling people aged 75-100+ and how their perceptions are associated with demographic characteristics, health, functioning, and wellbeing. METHODS In the Helsinki Aging Study, a random sample of 2,917 home-dwelling people aged 75-104 received a postal questionnaire inquiring about their health, wellbeing and experiences. The response rate was 74%. We asked: 'How in your opinion are older people treated in Finland?' (well/moderately/poorly) and categorized the respondents according to their responses. A multivariable forward stepwise ordered logistic regression model was used to determine the independent associations of the variables on the ordinal level of perceptions of treatment. RESULTS Of the participants, 1,653 responded to the index item. Of these, only 13% thought that older people are treated well in society, and 66% and 21% were of the opinion that older people are treated moderately or poorly in society, respectively. Perceived poor societal treatment was more common among women, the younger respondents, and those with lower incomes, as well as family caregivers and those with lower self-rated health and lower psychological wellbeing. Those who were able to walk outside unassisted and those with a regular hobby perceived poor societal treatment more often. CONCLUSIONS Several demographic factors, self-rated health, psychological wellbeing and better functioning were associated with perceptions of poor treatment among the oldest-old.
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Affiliation(s)
- M Knuutila
- Social Services and Health Care, City of Helsinki, Helsinki, Finland; Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland.
| | - T E Lehti
- Social Services and Health Care, City of Helsinki, Helsinki, Finland; Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - H Karppinen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - H Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - T E Strandberg
- Clinics of Internal Medicine and Geriatrics, Helsinki University Hospital, Helsinki, Finland; Department of Internal Medicine and Geriatrics, University of Helsinki, Helsinki, Finland
| | - K H Pitkala
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland; Unit of Primary Health Care, Helsinki University Hospital, Helsinki, Finland
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13
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de Lusignan S, Alexander H, Broderick C, Dennis J, McGovern A, Feeney C, Flohr C. Patterns and trends in eczema management in UK primary care (2009-2018): A population-based cohort study. Clin Exp Allergy 2020; 51:483-494. [PMID: 33176023 PMCID: PMC7984383 DOI: 10.1111/cea.13783] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/07/2020] [Accepted: 10/28/2020] [Indexed: 12/11/2022]
Abstract
Background Despite the high disease burden of eczema, a contemporary overview of the patterns and trends in primary care healthcare utilization and treatment is lacking. Objective To quantify primary care consultations, specialist referrals, prescribing, and treatment escalation, in children and adults with eczema in England. Methods A large primary care research database was used to examine healthcare and treatment utilization in people with active eczema (n = 411,931). Management trends and variations by age, sex, socioeconomic status, and ethnicity were described from 2009 to 2018 inclusive. Results Primary care consultation rates increased from 87.8 (95% confidence interval [95% CI] 87.3–88.3) to 112.0 (95% CI 111.5–112.6) per 100 person‐years over 2009 to 2018. Specialist referral rates also increased from 3.8 (95% CI 3.7–3.9) to 5.0 (95% CI 4.9–5.1) per 100 person‐years over the same period. Consultation rates were highest in infants. Specialist referrals were greatest in the over 50s and lowest in people of lower socioeconomic status, despite a higher rate of primary care consultations. There were small changes in prescribing over time; emollients increased (prescribed to 48.5% of people with active eczema in 2009 compared to 51.4% in 2018) and topical corticosteroids decreased (57.3%–52.0%). Prescribing disparities were observed, including less prescribing of potent and very potent topical corticosteroids in non‐white ethnicities and people of lower socioeconomic status. Treatment escalation was more common with increasing age and in children of non‐white ethnicity. Conclusion and clinical relevance The management of eczema varies by sociodemographic status in England, with lower rates of specialist referral in people from more‐deprived backgrounds. There are different patterns of healthcare utilization, treatment, and treatment escalation in people of non‐white ethnicity and of more‐deprived backgrounds.
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Affiliation(s)
- Simon de Lusignan
- Nuffield Department of Primary Care health Sciences, University of Oxford, Oxford, UK.,Royal College of General Practitioners, Research and Surveillance Centre, London, UK
| | - Helen Alexander
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Conor Broderick
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - John Dennis
- Momentum Data, Pendragon House, St. Albans, UK
| | | | | | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
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14
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Butterworth J, Richards S, Warren F, Pitchforth E, Campbell J. Randomised feasibility trial and embedded qualitative process evaluation of a new intervention to facilitate the involvement of older patients with multimorbidity in decision-making about their healthcare during general practice consultations: the VOLITION study protocol. Pilot Feasibility Stud 2020; 6:161. [PMID: 33117558 PMCID: PMC7586675 DOI: 10.1186/s40814-020-00699-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 09/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The number of older people with multiple health problems is increasing worldwide. This creates a strain on clinicians and the health service when delivering clinical care to this patient group, who themselves carry a large treatment burden. Despite shared decision-making being acknowledged by healthcare organisations as a priority feature of clinical care, older patients with multimorbidity are less often involved in decision-making when compared with younger patients, with some evidence suggesting associated health inequalities. Interventions aimed at facilitating shared decision-making between doctors and patients are outdated in their assessments of today's older patient population who need support in prioritising complex care needs in order to maximise quality of life and day-to-day function. AIMS To undertake feasibility testing of an intervention ('VOLITION') aimed at facilitating the involvement of older patients with more than one long-term health problem in shared decision-making about their healthcare during GP consultations.To inform the design of a fully powered trial to assess intervention effectiveness. METHODS This study is a cluster randomised controlled feasibility trial with qualitative process evaluation interviews. Participants are patients, aged 65 years and above with more than one long-term health problem (multimorbidity), and the GPs that they consult with. This study aims to recruit 6 GP practices, 18 GPs and 180 patients. The intervention comprises two components: (i) a half-day training workshop for GPs in shared decision-making; and (ii) a leaflet for patients that facilitate their engagement with shared decision-making. Intervention implementation will take 2 weeks (to complete delivery of both patient and GP components), and follow-up duration will be 12 weeks (from index consultation and commencement of data collection to final case note review and process evaluation interview). The trial will run from 01/01/20 to 31/01/21; 1 year 31 days. DISCUSSION Shared decision-making for older people with multimorbidity in general practice is under-researched. Emerging clinical guidelines advise a patient-centred approach, to reduce treatment burden and focus on quality of life alongside disease control. The systematic development, testing and evaluation of an intervention is warranted and timely. This study will test the feasibility of implementing a new intervention in UK general practice for future evaluation as a part of routine care. TRIAL REGISTRATION CLINICAL TRIALS.GOV registration number NCT03786315, registered 24/12/18.
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Affiliation(s)
- Joanne Butterworth
- Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, Room 110, Smeall building, St Luke’s campus, Magdalen Road, Exeter, EX1 2LU UK
| | - Suzanne Richards
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Fiona Warren
- Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, Room 110, Smeall building, St Luke’s campus, Magdalen Road, Exeter, EX1 2LU UK
| | - Emma Pitchforth
- Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, Room 110, Smeall building, St Luke’s campus, Magdalen Road, Exeter, EX1 2LU UK
| | - John Campbell
- Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, Room 110, Smeall building, St Luke’s campus, Magdalen Road, Exeter, EX1 2LU UK
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15
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van den Bogaart EHA, Spreeuwenberg MD, Kroese MEAL, van den Boogaart MW, Boymans TAEJ, Ruwaard D. Referral decisions and its predictors related to orthopaedic care. A retrospective study in a novel primary care setting. PLoS One 2020; 15:e0227863. [PMID: 31971964 PMCID: PMC6977750 DOI: 10.1371/journal.pone.0227863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 12/31/2019] [Indexed: 12/05/2022] Open
Abstract
Due to the ageing population, the prevalence of musculoskeletal disorders will continue to rise, as well as healthcare expenditure. To overcome these increasing expenditures, integration of orthopaedic care should be stimulated. The Primary Care Plus (PC+) intervention aimed to achieve this by facilitating collaboration between primary care and the hospital, in which specialised medical care is shifted to a primary care setting. The present study aims to evaluate the referral decision following orthopaedic care in PC+ and in particular to evaluate the influence of diagnostic tests on this decision. Therefore, retrospective monitoring data of patients visiting PC+ for orthopaedic care was used. Data was divided into two periods; P1 and P2. During P2, specialists in PC+ were able to request additional diagnostic tests (such as ultrasounds and MRIs). A total of 2,438 patients visiting PC+ for orthopaedic care were included in the analysis. The primary outcome was the referral decision following PC+ (back to the general practitioner (GP) or referral to outpatient hospital care). Independent variables were consultation- and patient-related predictors. To describe variations in the referral decision, logistic regression modelling was used. Results show that during P2, significantly more patients were referred back to their GP. Moreover, the multivariable analysis show a significant effect of patient age on the referral decision (OR 0.86, 95% CI = 0.81-0.91) and a significant interaction was found between the treating specialist and the period (p = 0.015) and between patient's diagnosis and the period (p ≤ 0.001). Despite the significant impact of the possibility of requesting additional diagnostic tests in PC+, it is important to discuss the extent to which the availability of diagnostic tests fits within the vision of PC+. In addition, selecting appropriate profiles for specialists and patients for PC+ are necessary to further optimise the effectiveness and cost of care.
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Affiliation(s)
- Esther H. A. van den Bogaart
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Marieke D. Spreeuwenberg
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Research Centre for Technology in Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Mariëlle E. A. L. Kroese
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Mark W. van den Boogaart
- Department of Orthopaedic Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Tim A. E. J. Boymans
- Department of Orthopaedic Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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16
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Jansson MM, Harjumaa M, Puhto A, Pikkarainen M. Patients’ satisfaction and experiences during elective primary fast‐track total hip and knee arthroplasty journey: A qualitative study. J Clin Nurs 2019; 29:567-582. [DOI: 10.1111/jocn.15121] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 10/04/2019] [Accepted: 11/19/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Miia Marika Jansson
- Research Group of Medical Imaging Physics and Technology University of Oulu Oulu Finland
- Oulu University Hospital Oulu Finland
| | | | - Ari‐Pekka Puhto
- Division of Operative Care Department of Orthopaedic and Trauma Surgery Oulu University Hospital Oulu Finland
| | - Minna Pikkarainen
- Research Group of Medical Imaging Physics and Technology University of Oulu Oulu Finland
- VTT Technical Research Centre of Finland Oulu Finland
- Martti Ahtisaari Institute Oulu Business School Oulu University Oulu Finland
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17
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Butterworth JE, Hays R, McDonagh STJ, Richards SH, Bower P, Campbell J. Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations. Cochrane Database Syst Rev 2019; 2019:CD013124. [PMID: 31684697 PMCID: PMC6815935 DOI: 10.1002/14651858.cd013124.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Older patients with multiple health problems (multi-morbidity) value being involved in decision-making about their health care. However, they are less frequently involved than younger patients. To maximise quality of life, day-to-day function, and patient safety, older patients require support to identify unmet healthcare needs and to prioritise treatment options. OBJECTIVES To assess the effects of interventions for older patients with multi-morbidity aiming to involve them in decision-making about their health care during primary care consultations. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; all years to August 2018), in the Cochrane Library; MEDLINE (OvidSP) (1966 to August 2018); Embase (OvidSP) (1988 to August 2018); PsycINFO (OvidSP) (1806 to August 2018); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Ovid) (1982 to September 2008), then in Ebsco (2009 to August 2018); Centre for Reviews and Dissemination Databases (Database of Abstracts and Reviews of Effects (DARE)) (all years to August 2018); the Health Technology Assessment (HTA) Database (all years to August 2018); the Ongoing Reviews Database (all years to August 2018); and Dissertation Abstracts International (1861 to August 2018). SELECTION CRITERIA We sought randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs of interventions to involve patients in decision-making about their health care versus usual care/control/another intervention, for patients aged 65 years and older with multi-morbidity in primary care. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. Meta-analysis was not possible; therefore we prepared a narrative synthesis. MAIN RESULTS We included three studies involving 1879 participants: two RCTs and one cluster-RCT. Interventions consisted of: · patient workshop and individual coaching using behaviour change techniques; · individual patient coaching utilising cognitive-behavioural therapy and motivational interviewing; and · holistic patient review, multi-disciplinary practitioner training, and organisational change. No studies reported the primary outcome 'patient involvement in decision-making' or the primary adverse outcome 'less patient involvement as a result of the intervention'. Comparing interventions (patient workshop and individual coaching, holistic patient review plus practitioner training, and organisational change) to usual care: we are uncertain whether interventions had any effect on patient reports of high self-rated health (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.36 to 5.49; very low-certainty evidence) or on patient enablement (mean difference (MD) 0.60, 95% CI -9.23 to 10.43; very low-certainty evidence) compared with usual care. Interventions probably had no effect on health-related quality of life (adjusted difference in means 0.00, 95% CI -0.02 to 0.02; moderate-certainty evidence) or on medication adherence (MD 0.06, 95% CI -0.05 to 0.17; moderate-certainty evidence) but probably improved the number of patients discussing their priorities (adjusted odds ratio 1.85, 95% CI 1.44 to 2.38; moderate-certainty evidence) and probably increased the number of nurse consultations (incident rate ratio from adjusted multi-level Poisson model 1.37, 95% CI 1.17 to 1.61; moderate-certainty evidence) compared with usual care. Practitioner outcomes were not measured. Interventions were not reported to adversely affect rates of participant death or anxiety, emergency department attendance, or hospital admission compared with usual care. Comparing interventions (patient workshop and coaching, individual patient coaching) to attention-control conditions: we are uncertain whether interventions affect patient-reported high self-rated health (RR 0.38, 95% CI 0.15 to 1.00, favouring attention control, with very low-certainty evidence; RR 2.17, 95% CI 0.85 to 5.52, favouring the intervention, with very low-certainty evidence). We are uncertain whether interventions affect patient enablement and engagement by increasing either patient activation (MD 1.20, 95% CI -8.21 to 10.61; very low-certainty evidence) or self-efficacy (MD 0.29, 95% CI -0.21 to 0.79; very low-certainty evidence); or whether interventions affect the number of general practice visits (MD 0.51, 95% CI -0.34 to 1.36; very low-certainty evidence), compared to attention-control conditions. The intervention may however lead to more patient-reported changes in management of their health conditions (RR 1.82, 95% CI 1.35 to 2.44; low-certainty evidence). Practitioner outcomes were not measured. Interventions were not reported to adversely affect emergency department attendance nor hospital admission when compared with attention control. Comparing one form of intervention with another: not measured. There was 'unclear' risk across studies for performance bias, detection bias, and reporting bias; however, no aspects were 'high' risk. Evidence was downgraded via GRADE, most often because of 'small sample size' and 'evidence from a single study'. AUTHORS' CONCLUSIONS Limited available evidence does not allow a robust conclusion regarding the objectives of this review. Whilst patient involvement in decision-making is seen as a key mechanism for improving care, it is rarely examined as an intervention and was not measured by included studies. Consistency in design, analysis, and evaluation of interventions would enable a greater likelihood of robust conclusions in future reviews.
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Affiliation(s)
- Joanne E Butterworth
- University of Exeter Medical SchoolUniversity of Exeter Collaboration for Academic Primary Care (APEx)Smeall BuildingSt Luke's CampusExeterDevonUKEX1 2LU
| | - Rebecca Hays
- University of ManchesterNIHR School for Primary Care Research, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care5th Floor, Williamson BuildingOxford RoadManchesterUKM13 9PL
| | - Sinead TJ McDonagh
- University of Exeter Medical SchoolUniversity of Exeter Collaboration for Academic Primary Care (APEx)Smeall BuildingSt Luke's CampusExeterDevonUKEX1 2LU
| | - Suzanne H Richards
- University of LeedsLeeds Institute of Health SciencesCharles Thackrah Building101 Clarendon RoadLeedsUKLS2 9LJ
| | - Peter Bower
- University of ManchesterNIHR School for Primary Care Research, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care5th Floor, Williamson BuildingOxford RoadManchesterUKM13 9PL
| | - John Campbell
- University of Exeter Medical SchoolUniversity of Exeter Collaboration for Academic Primary Care (APEx)Smeall BuildingSt Luke's CampusExeterDevonUKEX1 2LU
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18
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Jansson MM, Harjumaa M, Puhto AP, Pikkarainen M. Healthcare professionals' proposed eHealth needs in elective primary fast-track hip and knee arthroplasty journey: A qualitative interview study. J Clin Nurs 2019; 28:4434-4446. [PMID: 31408555 DOI: 10.1111/jocn.15028] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/17/2019] [Accepted: 08/04/2019] [Indexed: 01/09/2023]
Abstract
AIMS AND OBJECTIVES To examine the lived experience of healthcare professionals providing care for patients with total hip and knee arthroplasty and to understand healthcare professionals' proposed eHealth needs in elective primary fast-track hip and knee arthroplasty journey. BACKGROUND There is little evidence in nursing literature to indicate how to develop new eHealth services to support surgical care journeys. Evidence is particularly lacking regarding the development of eHealth solutions. DESIGN This was a qualitative interview study. METHODS Semi-structured interviews were conducted with four surgeons, two anaesthesiologists, ten nurses and four physiotherapists in a single joint replacement centre during autumn 2018. The data were analysed using an inductive content analysis method. NVivo qualitative data analysis software was used. The COREQ checklist for qualitative studies was followed. RESULTS Our research addressed the gap in evidence by focusing on the four main parts of the patient journey in the selected context. Analysis of the data revealed nine main categories for the proposed eHealth needs: eligibility criteria, referrals, meeting the Health Care Guarantee, patient flow, postdischarge care, patient counselling, communication, transparency of the journey and receiving feedback. In addition, the requirements and further development needs for eHealth solutions were generally identified. CONCLUSIONS From the point of view of healthcare professionals, eHealth solutions have huge potential in supporting the elective primary fast-track hip and knee arthroplasty journey. However, it is important to acknowledge that these needs may be very different depending on the technological and organisational environment in question. RELEVANCE TO CLINICAL PRACTICE More effective use of information and communication technologies is needed for organisational optimisation resulting in a streamlined pathway, better access to healthcare services, improved outcomes and an improved patient experience. These results can be used in the development of new eHealth solutions to support surgical care journeys and patient education.
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Affiliation(s)
- Miia Marika Jansson
- Research Group of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland.,Oulu University Hospital, Oulu, Finland
| | | | - Ari-Pekka Puhto
- Division of Operative Care, Department of Orthopaedic and Trauma Surgery, Oulu University Hospital, Oulu, Finland
| | - Minna Pikkarainen
- Research Group of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland.,VTT Technical Research Centre of Finland, Oulu, Finland.,Martti Ahtisaari Institute, Oulu Business School, Oulu University, Oulu, Finland
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Diwakar L, Cummins C, Hackett S, Rees M, Charles L, Kerrigan C, Creed H, Roberts T. Parent experiences with paediatric allergy pathways in the West Midlands: A qualitative study. Clin Exp Allergy 2019; 49:357-365. [PMID: 30609142 PMCID: PMC6446821 DOI: 10.1111/cea.13334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/26/2018] [Accepted: 10/15/2018] [Indexed: 11/28/2022]
Abstract
Background The prevalence, severity and complexity of allergic diseases have been increasing steadily in the United Kingdom over the last few decades. Primary care physicians are often not adequately trained in allergy management while specialist services for allergy are scarce and heterogeneous. Services, therefore, have been unable to meet the rising demand. This is particularly true for paediatric allergy services in the United Kingdom. Objective To understand parent experiences with paediatric allergy pathways in the West Midlands (WM) region of the United Kingdom. Methods Parents of children aged between 0 and 16 years from the WM region were recruited opportunistically until thematic saturation was achieved. Eighteen semi‐structured interviews were carried out and transcribed verbatim. Data were analysed on NVivo software using the framework method. Themes were identified from the transcripts as well as from existing literature. Results Parents highlighted numerous issues related to allergy services in the region including difficulties with being taken seriously by their physicians, problems with accessing health care and issues with information and the need for additional supportive care for allergies. Conclusions and Clinical relevance Primary care for children with allergies in the WM is disparate. Parents experience difficulties in accessing primary and secondary care services and also obtaining timely and appropriate information regarding their child's allergies. Most parents were happy to be reviewed by either specialist nurses or by consultants in the hospital. Improving accessibility and availability of reliable information as well as provision of additional services (such as psychologists and dietetics) were highlighted by parents as being important to allergy services in the region. These findings can help inform future planning and commissioning of allergy services.
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Affiliation(s)
- Lavanya Diwakar
- Department of Health Economics, University of Birmingham, Birmingham, UK.,Department of Immunology, University Hospital of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Carole Cummins
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Scott Hackett
- Department of Paediatric Immunodeficiency and Allergy, Birmingham Heartlands Hospital NHS Trust, Birmingham, UK
| | - Martyn Rees
- Department of Paediatric Respiratory Medicine, Royal Shrewsbury and Telford Hospitals NHS Trust, Shrewsbury, UK
| | - Lynette Charles
- Department of Paediatric Respiratory Medicine, Royal Shrewsbury and Telford Hospitals NHS Trust, Shrewsbury, UK
| | - Caroline Kerrigan
- Department of Paediatric Immunodeficiency and Allergy, Birmingham Heartlands Hospital NHS Trust, Birmingham, UK
| | - Helen Creed
- Department of Paediatric Immunodeficiency and Allergy, Birmingham Heartlands Hospital NHS Trust, Birmingham, UK
| | - Tracy Roberts
- Department of Health Economics, University of Birmingham, Birmingham, UK
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20
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Walton E, Ahmed A, Burton C, Mathers N. Influences of socioeconomic deprivation on GPs' decisions to refer patients to cardiology: a qualitative study. Br J Gen Pract 2018; 68:e826-e834. [PMID: 30348887 PMCID: PMC6255241 DOI: 10.3399/bjgp18x699785] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/14/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Variation in GP referral practice may be a factor contributing to the lower uptake of cardiology specialist services for people living in socioeconomic deprivation. Cardiology referrals were chosen for this study due to higher rates of premature death and emergency admissions resulting from coronary heart disease for patients living in more deprived areas. AIM To find out how socioeconomic deprivation influences GP referral practice. DESIGN AND SETTING A qualitative study of GPs working in affluent and deprived areas of one large city in the UK. METHOD The authors used purposive and snowball sampling to recruit 17 GP participants to interviews and a focus group. Participants were asked to reflect on their own experience of making referrals. The authors used a framework approach to the analysis, with differences in themes for GPs working in least and most deprived areas being highlighted. RESULTS The authors identified four main themes by which socioeconomic deprivation influenced GP referral practice: identifying problems; making decisions about referral; navigating the healthcare system; and external pressures. Using a published framework of consultation complexity, the authors then examined the data in relation to a fifth theme of complexity. Referrals from areas of high socioeconomic deprivation involved greater complexity in the majority of the domains of this framework. CONCLUSION Socioeconomic deprivation influences GP referral decisions and navigation of the healthcare system in multiple ways. Referral practice for GPs working in deprived areas is more complex than for their peers working in more affluent areas.
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Affiliation(s)
- Elizabeth Walton
- Academic Unit of Primary Medical Care, University of Sheffield, and Whitehouse Surgery, Sheffield
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21
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Black CJ, Houghton LA, Ford AC. Insights into the evaluation and management of dyspepsia: recent developments and new guidelines. Therap Adv Gastroenterol 2018; 11:1756284818805597. [PMID: 30397412 PMCID: PMC6207968 DOI: 10.1177/1756284818805597] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 09/17/2018] [Indexed: 02/04/2023] Open
Abstract
Dyspepsia is a very common gastrointestinal (GI) condition worldwide. We critically examine the recommendations of recently published guidelines for the management of dyspepsia, including those produced jointly by the American College of Gastroenterology and the Canadian Association of Gastroenterology, and those published by the UK National Institute for Health and Care Excellence. Dyspepsia is a symptom complex, characterized by a range of upper GI symptoms including epigastric pain or burning, early satiety, and post-prandial fullness. Although alarm features are used to help prioritize access to upper GI endoscopy, they are of limited utility in predicting endoscopic findings, and the majority of patients with dyspepsia will have no organic pathology identified at upper GI endoscopy. These patients are labelled as having functional dyspepsia (FD). The Rome IV criteria, which are used to define FD, further subclassify patients with FD as having either epigastric pain syndrome or post-prandial distress syndrome, depending on their predominant symptoms. Unfortunately, the Rome criteria perform poorly at identifying FD without the need for upper GI endoscopy. This has led to the investigation of alternative diagnostic approaches, including whether a capsaicin pill or combined serum biomarkers can accurately identify patients with FD. However, there is insufficient evidence to support either of these approaches at the present time. Patients with FD should be tested for H. pylori infection and be prescribed eradication therapy if they test positive. If they continue to have symptoms following this, then a trial of treatment with a proton pump inhibitor (PPI) should be given for up to 8 weeks. In cases where symptoms fail to adequately respond to PPI treatment, a tricyclic antidepressant may be of benefit, and should be continued for 6 to 12 months in patients who respond. Prokinetics demonstrate limited efficacy for treating FD, but could be considered if other strategies have failed. However, there are practical difficulties due to their limited availability in some countries and the risk of serious side effects. Patients with FD who fail to respond to drug treatments should be offered psychological therapy, where available. Overall, with the exception of recommendations relating to H. pylori testing and the prescription of PPIs, which are made on the basis of high-quality evidence, the evidence underpinning other elements of dyspepsia management is largely of low-quality. Consequently, there are still many aspects of the evaluation and management of dyspepsia that require further research.
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Affiliation(s)
| | - Lesley A. Houghton
- Leeds Gastroenterology Institute, St. James’s University Hospital, Leeds, UK,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Alexander C. Ford
- Leeds Gastroenterology Institute, St. James’s University Hospital, Leeds, UK,Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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22
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Butterworth JE, Hays R, Richards SH, Bower P, Campbell J. Interventions for involving older patients with multimorbidity in decision-making during primary care consultations. Hippokratia 2018. [DOI: 10.1002/14651858.cd013124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Joanne E Butterworth
- University of Exeter Medical School; Primary Care Research Group; Smeall Building St Luke's Campus Exeter Devon UK EX1 2LU
| | - Rebecca Hays
- University of Manchester; NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care; 5th Floor, Williamson Building Oxford Road Manchester UK M13 9PL
| | - Suzanne H Richards
- University of Leeds; Leeds Institute of Health Sciences; Charles Thackrah Building 101 Clarendon Road Leeds UK LS2 9LJ
| | - Peter Bower
- University of Manchester; NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Division of Population Health, Health Services Research and Primary Care; 5th Floor, Williamson Building Oxford Road Manchester UK M13 9PL
| | - John Campbell
- University of Exeter Medical School; Department of General Practice and Primary Care; Smeall Building St Luke's Campus Exeter UK EX1 2LU
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Kim AM, Cho S, Kim HJ, Jung H, Jo MW, Lee JY, Eun SJ. Primary Care Patients' Preference for Hospitals over Clinics in Korea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15061119. [PMID: 29848995 PMCID: PMC6025534 DOI: 10.3390/ijerph15061119] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/25/2018] [Accepted: 05/26/2018] [Indexed: 01/12/2023]
Abstract
Korea is in a unique condition to observe whether patients, when equal access to the levels of health care facilities is guaranteed by the support of the national health insurance, choose the appropriate levels of health care facilities. This study was performed to investigate the primary care patients’ preference for hospitals over clinics under no restriction for their choice. We used the 2011 National Inpatient Sample database of the Health Insurance Review and Assessment Service in Korea. A primary care patient was defined as a patient who visited as an outpatient in health care facilities with one of the 52 minor conditions defined by the Korean government. We found that approximately 15% of outpatient visits of the patients who were eligible for primary care in Korea happened in hospitals. In terms of cost, the outpatient visits in hospitals accounted for about 29% of total cost of outpatient visits. This arbitrary access to hospitals can lead to an inefficient use of health care resources. In order to ensure that health care facilities are stratified in terms of access as well as size and function, interventions to distribute patients to the appropriate level of care are required.
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Affiliation(s)
- Agnus M Kim
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Seongcheol Cho
- Regional Emergency Care Center, Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Hyun Joo Kim
- Department of Nursing Science, Shinsung University, Dangjin 31801, Korea.
| | - Hyemin Jung
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Min-Woo Jo
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul 05505, Korea.
| | - Jin Yong Lee
- Public Health Medical Service, Boramae Medical Center, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea.
| | - Sang Jun Eun
- Department of Preventive Medicine, Chungnam National University College of Medicine, Daejeon 35015, Korea.
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Vallance AE, van der Meulen J, Kuryba A, Braun M, Jayne DG, Hill J, Cameron IC, Walker K. Socioeconomic differences in selection for liver resection in metastatic colorectal cancer and the impact on survival. Eur J Surg Oncol 2018; 44:1588-1594. [PMID: 29895508 DOI: 10.1016/j.ejso.2018.05.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 05/02/2018] [Accepted: 05/17/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Socioeconomic inequalities in colorectal cancer (CRC) survival are well recognised. The aim of this study was to describe the impact of socioeconomic deprivation on survival in patients with synchronous CRC liver-limited metastases, and to investigate if any survival inequalities are explained by differences in liver resection rates. METHODS Patients in the National Bowel Cancer Audit diagnosed with CRC between 2010 and 2016 in the English National Health Service were included. Linked Hospital Episode Statistics data were used to identify the presence of liver metastases and whether a liver resection had been performed. Multivariable random-effects logistic regression was used to estimate the odds ratio (OR) of liver resection by Index of Multiple Deprivation (IMD) quintile. Cox-proportional hazards model was used to compare 3-year survival. RESULTS 13,656 patients were included, of whom 2213 (16.2%) underwent liver resection. Patients in the least deprived IMD quintile were more likely to undergo liver resection than those in the most deprived quintile (adjusted OR 1.42, 95% confidence interval (CI) 1.18-1.70). Patients in the least deprived quintile had better 3-year survival (least deprived vs. most deprived quintile, 22.3% vs. 17.4%; adjusted hazard ratio (HR) 1.20, 1.11-1.30). Adjusting for liver resection attenuated, but did not remove, this effect. There was no difference in survival between IMD quintile when restricted to patients who underwent liver resection (adjusted HR 0.97, 0.76-1.23). CONCLUSIONS Deprived CRC patients with synchronous liver-limited metastases have worse survival than more affluent patients. Lower rates of liver resection in more deprived patients is a contributory factor.
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Affiliation(s)
- A E Vallance
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
| | - J van der Meulen
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - A Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - M Braun
- Christie NHS Foundation Trust, Manchester, UK
| | - D G Jayne
- The John Goligher Colorectal Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - J Hill
- Department of General Surgery, Manchester Royal Infirmary, Manchester, UK
| | - I C Cameron
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - K Walker
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Funston G, O'Flynn H, Ryan NAJ, Hamilton W, Crosbie EJ. Recognizing Gynecological Cancer in Primary Care: Risk Factors, Red Flags, and Referrals. Adv Ther 2018; 35:577-589. [PMID: 29516408 PMCID: PMC5910472 DOI: 10.1007/s12325-018-0683-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Indexed: 12/11/2022]
Abstract
Early diagnosis of symptomatic gynecological cancer is likely to improve patient outcomes, including survival. The primary care practitioner has a key role to play in this-they must recognize the symptoms and signs of gynecological cancer and make prompt evidence-based decisions regarding further investigation and referral. However, this is often difficult as many of the symptoms of gynecological cancers are nonspecific and are more likely to be caused by benign rather than malignant disease. As primary care is generally the first point of patient contact, those working in this setting usually encounter cancer patients at an earlier, and possibly less symptomatic, stage than practitioners in secondary care. Despite these challenges, research has improved our understanding of the symptoms patients present to primary care with, and a range of tests and referral pathways now exist in the UK and other countries to aid early diagnosis. Primary care practitioners can also play a key role in gynecological cancer prevention. A significant proportion of gynecological cancer is preventable either through lifestyle changes such as weight loss, or, for cervical cancer, vaccination and/or engagement with screening programs. Primary care provides an excellent opportunity to discuss cancer risk with patients and to promote risk reduction strategies and lifestyle change. In this article, the first in a series discussing cancer detection in primary care, we concentrate on gynecological cancer and focus on the three most common forms that a primary care practitioner is likely to encounter: ovarian, endometrial, and cervical cancer. We outline key risk factors, briefly discuss prevention and screening strategies, and offer practical guidance on the recognition of symptoms and signs and the investigation and referral of women with suspected cancer. While this article is written from a UK primary care perspective, much of what is discussed will be of relevance to those working in other healthcare systems.
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Affiliation(s)
- Garth Funston
- Centre for Primary Care, University of Manchester, Manchester, UK.
| | - Helena O'Flynn
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Neil A J Ryan
- Gynaecological Oncology Group, University of Manchester, Manchester, UK
| | | | - Emma J Crosbie
- Gynaecological Oncology Group, University of Manchester, Manchester, UK
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McGeoch G, Holland K, Kerdemelidis M, Elliot N, Shand B, Fink C, Dixon A, Gullery C. Unmet need for referred services as measured by general practice. J Prim Health Care 2018. [PMID: 29530138 DOI: 10.1071/hc17044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Unmet needs are a key indicator of the success of a health system. Clinicians and funders in Christchurch, Canterbury, New Zealand were concerned that unmet health need was hidden. AIM The aim of this survey was to estimate the proportion of patients attending general practice who were unable to access clinically indicated referred services. METHODS The survey used a novel method to estimate unserviced health needs. General practitioners (GPs, n = 54) asked their patients (n = 2135) during a consultation about any health needs requiring a referred service. If both agreed that a service was potentially beneficial and not available, this was documented on an e-referral system for review. The outcomes of actual referrals were also reviewed. RESULTS The patient group was broadly representative of the Canterbury population, but over-sampled female and middle-aged people and under-sampled Māori. Data adjusted to regional demographics showed that 3.6% of patients had a GP-confirmed unserviced health need. Elective orthopaedic surgery, general surgery and mental health were areas of greatest need. Unserviced health needs were significantly (P ≤ 0.05) associated with greater deprivation, middle-age, and receiving high health-use subsidies. DISCUSSION To our knowledge, this is the first survey of GP and patient agreement on unserviced referred health needs. Measuring unserviced health needs in this way is directly relevant to service planning because the gaps identified reflect clinically indicated services that patients want and need. The survey method is an improvement on declined referral rates as a measure of need. Key factors in the method were using a patient-initiated GP consultation and an e-referral system to collect data.
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Affiliation(s)
- Graham McGeoch
- Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Kieran Holland
- Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Melissa Kerdemelidis
- Planning and Funding and Decision Support, Canterbury District Health Board, Christchurch, New Zealand
| | - Nikki Elliot
- Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Brett Shand
- Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Catherine Fink
- Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Anne Dixon
- Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand
| | - Carolyn Gullery
- Planning and Funding and Decision Support, Canterbury District Health Board, Christchurch, New Zealand
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Kiran A, Geary RS, Gurol-Urganci I, Cromwell DA, Bansi-Matharu L, Shakespeare J, Mahmood T, van der Meulen J. Sociodemographic differences in symptom severity and duration among women referred to secondary care for menorrhagia in England and Wales: a cohort study from the National Heavy Menstrual Bleeding Audit. BMJ Open 2018; 8:e018444. [PMID: 29420229 PMCID: PMC5829848 DOI: 10.1136/bmjopen-2017-018444] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To examine symptom severity and duration at time of referral to secondary care for heavy menstrual bleeding (HMB) by socioeconomic deprivation, age and ethnicity DESIGN: Cohort analysis of data from the National HMB Audit linked to Hospital Episode Statistics data. SETTING English and Welsh National Health Services (secondary care): February 2011 to January 2012. PARTICIPANTS 15 325 women aged 18-60 years in England and Wales who had a new referral for HMB to a gynaecology outpatient department METHODS: Multivariable linear regression to calculate adjusted differences in mean symptom severity and quality of life scores at first outpatient visit. Multivariable logistic regression to calculate adjusted ORs. Adjustment for body mass index, parity and comorbidities. PRIMARY OUTCOME MEASURES Mean symptom severity score (0=best, 100=worst), mean condition-specific quality of life score (0=worst, 100=best) and symptom duration (≥1 year). RESULTS Women were on average 42 years old and 12% reported minority ethnic backgrounds. Mean symptom severity and condition-specific quality of life scores were 61.8 and 34.7. Almost three-quarters of women (74%) reported having had symptoms for ≥1 year. Women from more deprived areas had more severe symptoms at their first outpatient visit (difference -6.1; 95% CI-7.2 to -4.9, between least and most deprived quintiles) and worse condition-specific quality of life (difference 6.3; 95% CI 5.1 to 7.5). Symptom severity declined with age while quality of life improved. CONCLUSIONS Women living in more deprived areas reported more severe HMB symptoms and poorer quality of life at the start of treatment in secondary care. Providers should examine referral practices to explore if these differences reflect women's health-seeking behaviour or how providers decide whether or not to refer.
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Affiliation(s)
- Amit Kiran
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Rebecca Sally Geary
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Ipek Gurol-Urganci
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - David A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | | | | | - Tahir Mahmood
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, UK
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Tandjung R, Morell S, Hanhart A, Haefeli A, Valeri F, Rosemann T, Senn O. Referral determinants in Swiss primary care with a special focus on managed care. PLoS One 2017; 12:e0186307. [PMID: 29112975 PMCID: PMC5675398 DOI: 10.1371/journal.pone.0186307] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 09/28/2017] [Indexed: 11/21/2022] Open
Abstract
Studies have shown large variation of referral probabilities in different countries, and many influencing factors have been described. This variation is most likely explained by different healthcare systems, particularly to which extent primary care physicians (PCPs) act as gatekeepers. In Switzerland no mandatory gatekeeping system exists, however insurance companies offer voluntary managed care plans with reduced insurance premiums. We aimed at investigating the role of managed care plans as a potential referral determinant in a non-gatekeeping healthcare system. We conducted a cross-sectional study with 90 PCPs collecting data on consultations and referrals in 2012/2013. During each consultation up to six reasons for encounters (RFE) were documented. For each RFE PCPs indicated whether a referral was initiated. Determinants for referrals were analyzed by hierarchical logistic regression, taking the potential cluster effect of the PCP into account. To further investigate the independent association of the managed care plan with the referral probability, a hierarchical multivariate logistic regression model was applied, taking into account all available data potentially affecting the referring decision. PCPs collected data on 24’774 patients with 42’890 RFE, of which 2427 led to a referral. 37.5% of patients were insured in managed health care plans. Univariate analysis showed significant higher referral rates of patients with managed care plans (10.7% vs. 8.5%). The difference in referral probability remained significant after controlling for other confounders in the hierarchical multivariate regression model (OR 1.355). Patients in managed care plans were more likely to be referred than patients without such a model. These data contradict the argument that patients in managed care plans have limited healthcare access, but underline the central role of PCPs as coordinator of care.
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Affiliation(s)
- Ryan Tandjung
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Seraina Morell
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Andreas Hanhart
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
- Private Primary Care Practice, Wetzikon, Switzerland
| | | | - Fabio Valeri
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
- * E-mail:
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Willis TA, West R, Rushforth B, Stokes T, Glidewell L, Carder P, Faulkner S, Foy R. Variations in achievement of evidence-based, high-impact quality indicators in general practice: An observational study. PLoS One 2017; 12:e0177949. [PMID: 28704407 PMCID: PMC5509104 DOI: 10.1371/journal.pone.0177949] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 05/05/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There are widely recognised variations in the delivery and outcomes of healthcare but an incomplete understanding of their causes. There is a growing interest in using routinely collected 'big data' in the evaluation of healthcare. We developed a set of evidence-based 'high impact' quality indicators (QIs) for primary care and examined variations in achievement of these indicators using routinely collected data in the United Kingdom (UK). METHODS Cross-sectional analysis of routinely collected, electronic primary care data from a sample of general practices in West Yorkshire, UK (n = 89). The QIs covered aspects of care (including processes and intermediate clinical outcomes) in relation to diabetes, hypertension, atrial fibrillation, myocardial infarction, chronic kidney disease (CKD) and 'risky' prescribing combinations. Regression models explored the impact of practice and patient characteristics. Clustering within practice was accounted for by including a random intercept for practice. RESULTS Median practice achievement of the QIs ranged from 43.2% (diabetes control) to 72.2% (blood pressure control in CKD). Considerable between-practice variation existed for all indicators: the difference between the highest and lowest performing practices was 26.3 percentage points for risky prescribing and 100 percentage points for anticoagulation in atrial fibrillation. Odds ratios associated with the random effects for practices emphasised this; there was a greater than ten-fold difference in the likelihood of achieving the hypertension indicator between the lowest and highest performing practices. Patient characteristics, in particular age, gender and comorbidity, were consistently but modestly associated with indicator achievement. Statistically significant practice characteristics were identified less frequently in adjusted models. CONCLUSIONS Despite various policy and improvement initiatives, there are enduring inappropriate variations in the delivery of evidence-based care. Much of this variation is not explained by routinely collected patient or practice variables, and is likely to be attributable to differences in clinical and organisational behaviour.
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Affiliation(s)
- Thomas A. Willis
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Tim Stokes
- Department of General Practice & Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Liz Glidewell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Paul Carder
- West Yorkshire Research & Development, NHS Bradford Districts CCG, Douglas Mill, Bradford, United Kingdom
| | | | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
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The future burden of disability in the UK: the time for urgent action is now. THE LANCET PUBLIC HEALTH 2017; 2:e298-e299. [DOI: 10.1016/s2468-2667(17)30098-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 05/12/2017] [Indexed: 11/22/2022] Open
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Sheringham J, Sequeira R, Myles J, Hamilton W, McDonnell J, Offman J, Duffy S, Raine R. Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes. BMJ Qual Saf 2017; 26:449-459. [PMID: 27651515 DOI: 10.1136/bmjqs-2016-005679] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/24/2016] [Accepted: 08/18/2016] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Lung cancer survival is low and comparatively poor in the UK. Patients with symptoms suggestive of lung cancer commonly consult primary care, but it is unclear how general practitioners (GPs) distinguish which patients require further investigation. This study examined how patients' clinical and sociodemographic characteristics influence GPs' decisions to initiate lung cancer investigations. METHODS A factorial experiment was conducted among a national sample of 227 English GPs using vignettes presented as simulated consultations. A multimedia-interactive website simulated key features of consultations using actors ('patients'). GP participants made management decisions online for six 'patients', whose sociodemographic characteristics systematically varied across three levels of cancer risk. In low-risk vignettes, investigation (ie, chest X-ray ordered, computerised tomography scan or respiratory consultant referral) was not indicated; in medium-risk vignettes, investigation could be appropriate; in high-risk vignettes, investigation was definitely indicated. Each 'patient' had two lung cancer-related symptoms: one volunteered and another elicited if GPs asked. Variations in investigation likelihood were examined using multilevel logistic regression. RESULTS GPs decided to investigate lung cancer in 74% (1000/1348) of vignettes. Investigation likelihood did not increase with cancer risk. Investigations were more likely when GPs requested information on symptoms that 'patients' had but did not volunteer (adjusted OR (AOR)=3.18; 95% CI 2.27 to 4.70). However, GPs omitted to seek this information in 42% (570/1348) of cases. GPs were less likely to investigate older than younger 'patients' (AOR=0.52; 95% CI 0.39 to 0.7) and black 'patients' than white (AOR=0.68; 95% CI 0.48 to 0.95). CONCLUSIONS GPs were not more likely to investigate 'patients' with high-risk than low-risk cancer symptoms. Furthermore, they did not investigate everyone with the same symptoms equally. Insufficient data gathering could be responsible for missed opportunities in diagnosis.
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Affiliation(s)
| | | | - Jonathan Myles
- Queen Mary University of London, Centre for Cancer Prevention, London, UK
| | - William Hamilton
- University of Exeter, Peninsula College of Medicine and Dentistry, Exeter, UK
| | - Joe McDonnell
- Department of Public Health, London Borough of Waltham Forest, London, UK
| | - Judith Offman
- Queen Mary University of London, Centre for Cancer Prevention, London, UK
| | - Stephen Duffy
- Queen Mary University of London, Centre for Cancer Prevention, London, UK
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Forrest LF, Adams J, Ben-Shlomo Y, Buckner S, Payne N, Rimmer M, Salway S, Sowden S, Walters K, White M. Age-related references in national public health, technology appraisal and clinical guidelines and guidance: documentary analysis. Age Ageing 2017; 46:500-508. [PMID: 27989991 PMCID: PMC5405753 DOI: 10.1093/ageing/afw235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Indexed: 12/05/2022] Open
Abstract
Background older people may be less likely to receive interventions than younger people. Age bias in national guidance may influence entire public health and health care systems. We examined how English National Institute for Health & Care Excellence (NICE) guidance and guidelines consider age. Methods we undertook a documentary analysis of NICE public health (n = 33) and clinical (n = 114) guidelines and technology appraisals (n = 212). We systematically searched for age-related terms, and conducted thematic analysis of the paragraphs in which these occurred (‘age-extracts’). Quantitative analysis explored frequency of age-extracts between and within document types. Illustrative quotes were used to elaborate and explain quantitative findings. Results 2,314 age-extracts were identified within three themes: age documented as an a-priori consideration at scope-setting (518 age-extracts, 22.4%); documentation of differential effectiveness, cost-effectiveness or other outcomes by age (937 age-extracts, 40.5%); and documentation of age-specific recommendations (859 age-extracts, 37.1%). Public health guidelines considered age most comprehensively. There were clear examples of older-age being considered in both evidence searching and in making recommendations, suggesting that this can be achieved within current processes. Conclusions we found inconsistencies in how age is considered in NICE guidance and guidelines. More effort may be required to ensure age is consistently considered. Future NICE committees should search for and document evidence of age-related differences in receipt of interventions. Where evidence relating to effectiveness and cost-effectiveness in older populations is available, more explicit age-related recommendations should be made. Where there is a lack of evidence, it should be stated what new research is needed.
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Affiliation(s)
- Lynne F. Forrest
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, Newcastle upon Tyne, UK
- School of GeoSciences, University of Edinburgh, Edinburgh, UK
| | - Jean Adams
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, Newcastle upon Tyne, UK
- MRC Epidemiology Unit, University of Cambridge, Cambridge, Cambridgeshire, UK
- Address correspondence to: Jean Adams. Tel: (+44) 1223 769 142; Fax: (+44) 1223 330 316.
| | - Yoav Ben-Shlomo
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Stefanie Buckner
- Institute of Public Health, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Nick Payne
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Melanie Rimmer
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sarah Salway
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sarah Sowden
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Kate Walters
- Centre for Ageing and Population Studies, University College London, UK
| | - Martin White
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, Newcastle upon Tyne, UK
- MRC Epidemiology Unit, University of Cambridge, Cambridge, Cambridgeshire, UK
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Cooper C, Lodwick R, Walters K, Raine R, Manthorpe J, Iliffe S, Petersen I. Inequalities in receipt of mental and physical healthcare in people with dementia in the UK. Age Ageing 2017; 46:393-400. [PMID: 27916749 PMCID: PMC5378291 DOI: 10.1093/ageing/afw208] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Indexed: 11/25/2022] Open
Abstract
Background UK Dementia Strategies prioritise fair access to mental and physical healthcare. We investigated whether there are inequalities by deprivation or gender in healthcare received by people with dementia, and compared healthcare received by people with and without dementia. Methods we investigated primary care records of 68,061 community dwelling dementia patients and 259,337 people without dementia (2002–13). We tested hypotheses that people with dementia from more deprived areas, and who are women receive more psychotropic medication, fewer surgery consultations, are less likely to receive annual blood pressure, weight monitoring and an annual review, compared with those from less deprived areas and men. Results only half of people with dementia received a documented annual review. Deprivation was not associated with healthcare received. Compared to men with dementia, women with dementia had lower rates of surgery consultations (adjusted incidence rate ratio (IRR) 0.90, 95% CI 0.90–0.91), of annual blood pressure monitoring (adjusted IRR 0.96, 95% CI 0.95–0.97) and of annual weight monitoring (adjusted IRR 0.91, 95% CI 0.90–0.93). Men with dementia were less likely to be taking psychotropic medication than women with dementia. People with dementia had fewer surgery consultations and were less likely to have their weight and blood pressure monitored at least annually, compared to the non-dementia group. Conclusions people with dementia, in particular women, appear to receive less primary healthcare, but take more psychotropic medication that may negatively impact their physical health. Reducing these inequalities and improving access of people with dementia to preventative healthcare could improve the health of people with dementia.
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Affiliation(s)
- Claudia Cooper
- Camden and Islington Mental Health and Social Care Trust, Psychiatry of Older People, Archway Campus Holborn Union Building, Highgate Hill, London N19 5NL, United Kingdom of Great Britain and Northern Ireland
- Address correspondence to: C. Cooper. Tel: 0207 679 9367.
| | - Rebecca Lodwick
- University College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Kate Walters
- University College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Rosalind Raine
- UCL, Epidemiology & Public Health, London, United Kingdom of Great Britain and Northern Ireland
| | - Jill Manthorpe
- King's College London, Social Care Workforce Research Unit, London SE1 9NN, United Kingdom of Great Britain and Northern Ireland
| | - Steve Iliffe
- University College London, Department of Primary Care & Population Health, London, United Kingdom of Great Britain and Northern Ireland
- UK Dementias & Neurodegenerative Diseases Research Network, London, United Kingdom of Great Britain and Northern Ireland
| | - Irene Petersen
- University College London, London, United Kingdom of Great Britain and Northern Ireland
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Lefbom BK, Peckens NK. Impact of collaborative care on survival time for dogs with congestive heart failure and revenue for attending primary care veterinarians. J Am Vet Med Assoc 2017; 249:72-6. [PMID: 27308884 DOI: 10.2460/javma.249.1.72] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the effects of in-person collaborative care by primary care veterinarians (pcDVMs) and board-certified veterinary cardiologists (BCVCs) on survival time of dogs after onset of congestive heart failure (CHF) and on associated revenue for the attending pcDVMs. DESIGN Retrospective cohort study. ANIMALS 26 small-breed dogs treated for naturally occurring CHF secondary to myxomatous mitral valve disease at a multilocation primary care veterinary hospital between 2008 and 2013. PROCEDURES Electronic medical records were reviewed to identify dogs with confirmed CHF secondary to myxomatous mitral valve disease and collect information on patient care, survival time, and pcDVM revenue. Data were compared between dogs that received collaborative care from the pcDVM and a BCVC and dogs that received care from the pcDVM alone. RESULTS Dogs that received collaborative care had a longer median survival time (254 days) than did dogs that received care from the pcDVM alone (146 days). A significant positive correlation was identified between pcDVM revenue and survival time for dogs that received collaborative care (ie, the longer the dog survived, the greater the pcDVM revenue generated from caring for that patient). CONCLUSIONS AND CLINICAL RELEVANCE Findings suggested that collaborative care provided to small-breed dogs with CHF by a BCVC and pcDVM could result in survival benefits for affected dogs and increased revenue for pcDVMs, compared with care provided by a pcDVM alone.
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DaSilva P, Gray JAM. English lessons: can publishing an atlas of variation stimulate the discussion on appropriateness of care? Med J Aust 2016; 205:S5-S7. [DOI: 10.5694/mja15.00896] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 04/29/2016] [Indexed: 11/17/2022]
Affiliation(s)
| | - JA Muir Gray
- Value Based Healthcare, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Abstract
BACKGROUND Older patients differ from younger patients in their perceptions of trust in doctors; their sense of shared decision making is particularly associated with their trust in the GP. Enhancing trust and improving shared decision making are thought to have positive health outcomes. Older patients are sometimes reported as being less frequently involved in decisions about their health care, however, and in having more unmet healthcare needs than younger patients. AIM This study explored older patients' trust in their GPs and their perceptions of shared decision making. DESIGN AND SETTING Qualitative methods were used. Systematic sampling identified 20 participants, aged ≥65 years, from three GP surgeries in Devon, UK. METHOD A constant comparative approach was applied to thematic analysis of transcribed interviews. RESULTS All participants valued feeling involved in decisions but differed regarding how they felt involved. Trust influenced preferences for shared decision making: a trusted GP 'ally', to competently manage participants' increasing health-information requirements throughout the vulnerable ageing process, was important. Trust was affected by factors contributing to the facilitation of involvement. GP characteristics, communication skills, consultation duration, and continuity of care were common themes. CONCLUSION Although limited geographically and subsequently by ethnic group, the present sample allows for reasonable transferability of the study to other UK populations. A range of factors are highlighted for consideration when planning primary healthcare delivery: to facilitate the optimal involvement of older patients in decisions about their health care, while enhancing their trust in the GP; to help minimise potential health inequalities for this patient group.
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Evans LW, van Woerden H, Davies GR, Fone D. Impact of service redesign on the socioeconomic inequity in revascularisation rates for patients with acute myocardial infarction: a natural experiment and electronic record-linked cohort study. BMJ Open 2016; 6:e011656. [PMID: 27797993 PMCID: PMC5093375 DOI: 10.1136/bmjopen-2016-011656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM To investigate the impact of service redesign in the provision of revascularisation procedures on the historical socioeconomic inequity in revascularisation rates for patients with acute myocardial infarction (AMI). DESIGN Natural experiment and retrospective cohort study using linked data sets in the Secure Anonymised Information Linkage databank. NON-RANDOMISED INTERVENTION An increase in the capacity of revascularisation procedures and service redesign in the provision of revascularisation in late 2011 to early 2012. SETTING South Wales cardiac network, Census 2011 population 1 359 051 aged 35 years and over. PARTICIPANTS 9128 participants admitted to an NHS hospital with a first AMI between 1 January 2010 and 30 June 2013, with 6-months follow-up. MAIN OUTCOME MEASURE Hazard ratios (HRs) for the time to revascularisation for deprivation quintiles, age, gender, comorbidities, rural-urban classification and revascularisation facilities of admitting hospital. RESULTS In the preintervention period, there was a statistically significant decreased adjusted risk of revascularisation for participants in the most deprived quintile compared to the least deprived quintile (HR 0.80; 95% CI 0.69 to 0.92, p=0.002). In the postintervention period, the increase in revascularisation rates was statistically significant in all quintiles, and there was no longer any statistically significant difference in the adjusted revascularisation risk between the most and the least deprived quintile (HR 1.04; 95% CI 0.89 to 1.20, p<0.649). However, inequity persisted for those aged 75 years and over (HR 0.40; 95% CI 0.35 to 0.46, p<0.001) and women (HR 0.77; 95% CI 0.70 to 0.86, p<0.001). CONCLUSIONS Socioeconomic inequity of access to revascularisation was no longer apparent following redesign of revascularisation services in the south Wales cardiac network, although inequity persisted for women and those aged 75+ years. Increasing the capacity of revascularisation did not differentially benefit participants from the least deprived areas.
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Affiliation(s)
- Lloyd W Evans
- Public Health Wales Observatory, Public Health Wales, Carmarthen, UK
| | | | - Gareth R Davies
- Public Health Wales Observatory, Public Health Wales, Carmarthen, UK
| | - David Fone
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Thorsen O, Hartveit M, Johannessen JO, Fosse L, Eide GE, Schulz J, Bærheim A. Typologies in GPs' referral practice. BMC FAMILY PRACTICE 2016; 17:76. [PMID: 27430983 PMCID: PMC4949760 DOI: 10.1186/s12875-016-0495-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 07/13/2016] [Indexed: 12/04/2022]
Abstract
Background GPs’ individual decisions to refer and the various ways of working when they refer are important determinants of secondary care use. The objective of this study was to explore and describe potential characteristics of GPs’ referral practice by investigating their opinions about referring and their self-reported experiences of what they do when they refer. Methods Observational cross-sectional study using data from 128 Norwegian GPs who filled in a questionnaire with statements on how they regarded the referral process, and who were invited to collect data when they actually referred to hospital during one month. Only elective referrals were recorded. The 57 participants (44,5 %) recorded data from 691 referrals. The variables were included in a principal component analysis. A multiple linear regression analysis was conducted to identify typologies with GP’s age, gender, specialty in family medicine and location as independent variables. Results Eight principal components describe the different ways GPs think and work when they refer. Two typologies summarize these components: confidence characterizing specialists in family medicine, mainly female, who reported a more patient-centred practice making priority decisions when they refer, who confer easily with hospital consultants and who complete the referrals during the consultation; uncertainty characterizing young, mainly male non-specialists in family medicine, experiencing patients’ pressure to be referred, heavy workload, having reluctance to cooperate with the patient and reporting sparse contact with hospital colleagues. Conclusions Training specialists in family medicine in patient-centred method, easy conference with hospital consultant and cooperation with patients while making the referral may foster both self-reflections on own competences and increased levels of confidence. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0495-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olav Thorsen
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway. .,Department of Research, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway.
| | - Miriam Hartveit
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway.,Section for Research and Innovation, Helse Fonna HF, Box 2170, Haugesund, N-5504, Norway
| | - Jan Olav Johannessen
- Centre for Clinical Psychosis Research, Division of Psychiatry, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway.,Faculty of Social Sciences, University of Stavanger, Box 8100, Stavanger, N-4068, Norway
| | - Lars Fosse
- Department of Orthopaedics, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway
| | - Geir Egil Eide
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway.,Centre for Clinical Research, Haukeland University Hospital, Box 1400, Bergen, N-5021, Norway
| | - Jörn Schulz
- Department of Research, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway.,Section of Biostatistics, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway
| | - Anders Bærheim
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway
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Raine R, Fitzpatrick R, Barratt H, Bevan G, Black N, Boaden R, Bower P, Campbell M, Denis JL, Devers K, Dixon-Woods M, Fallowfield L, Forder J, Foy R, Freemantle N, Fulop NJ, Gibbons E, Gillies C, Goulding L, Grieve R, Grimshaw J, Howarth E, Lilford RJ, McDonald R, Moore G, Moore L, Newhouse R, O’Cathain A, Or Z, Papoutsi C, Prady S, Rycroft-Malone J, Sekhon J, Turner S, Watson SI, Zwarenstein M. Challenges, solutions and future directions in the evaluation of service innovations in health care and public health. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04160] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
HeadlineEvaluating service innovations in health care and public health requires flexibility, collaboration and pragmatism; this collection identifies robust, innovative and mixed methods to inform such evaluations.
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Affiliation(s)
- Rosalind Raine
- Department of Applied Health Research, University College London, London, UK
| | - Ray Fitzpatrick
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Helen Barratt
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames, Department of Applied Health Research, University College London, London, UK
| | - Gywn Bevan
- Department of Management, London School of Economics and Political Science, London, UK
| | - Nick Black
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ruth Boaden
- Alliance Manchester Business School, University of Manchester, Manchester, UK
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Manchester, UK
| | - Peter Bower
- National Institute for Health Research (NIHR) School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Marion Campbell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jean-Louis Denis
- Canada Research Chair in Governance and Transformation of Health Organizations and Systems, École Nationale d’Administration Publique, Ville de Québec, QC, Canada
| | - Kelly Devers
- Health Policy Centre, Urban Institute, Washington, DC, USA
| | - Mary Dixon-Woods
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Lesley Fallowfield
- Sussex Health Outcomes Research and Education in Cancer (SHORE-C), University of Sussex, Brighton, UK
| | - Julien Forder
- School of Social Policy, Sociology and Social Research, University of Kent, Canterbury, UK
| | - Robbie Foy
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Nick Freemantle
- Department of Primary Care and Population Health, University College London, London, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Elizabeth Gibbons
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Clare Gillies
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East Midlands and NIHR Research Design Service East Midlands, University of Leicester, Leicester, UK
| | - Lucy Goulding
- King’s Improvement Science, Centre for Implementation Science, King’s College London, London, UK
| | - Richard Grieve
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Emma Howarth
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East of England, University of Cambridge, Cambridge, UK
| | | | - Ruth McDonald
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Graham Moore
- School of Social Sciences, Cardiff University, Cardiff, UK
| | - Laurence Moore
- Medical Research Council (MRC)/Chief Scientist Office (CSO) Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Robin Newhouse
- Indiana University School of Nursing, Indianapolis, IN, USA
| | - Alicia O’Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Zeynep Or
- Institut de Recherche et Documentation en Économie de la Santé, Paris, France
| | - Chrysanthi Papoutsi
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, Imperial College London, London, UK
| | | | | | - Jasjeet Sekhon
- Department of Political Science and Statistics, University of California Berkeley, Berkeley, CA, USA
| | - Simon Turner
- Department of Applied Health Research, University College London, London, UK
| | | | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine, Western University, London, ON, Canada
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Hendijani R, Bischak DP. The effect of social relationships on the rates of referral to specialists. INTERNATIONAL JOURNAL OF OPERATIONS & PRODUCTION MANAGEMENT 2016. [DOI: 10.1108/ijopm-02-2015-0086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– In order to decrease patient waiting time and improve efficiency, healthcare systems in some countries have recently begun to shift away from decentralized systems of patient referral from general practitioners (GPs) to specialists toward centralized ones. From a queueing theory perspective, centralized referral systems can decrease waiting time by reducing the variation in the referral process. However, from a social psychological perspective, a close relationship between referring physician and specialist, which is characteristic of decentralized referral systems, may safeguard against high referral rates; since GPs refer patients directly to the specialists whom they know, they may be reluctant to damage that relationship with an inappropriate referral. The purpose of this paper is to examine the effect upon referral behavior of a relationship between physicians, as is found in a decentralized referral system, vs a centralized referral system, which is characterized by an anonymous GP-specialist relationship. In a controlled experiment where family practice residents made decisions concerning referral to specialists, physicians displaying high confidence referred significantly fewer patients in a close relationship condition than in a centralized referral system, suggesting that for some physicians, referral behavior can be affected by the design of the service system and will, in turn, affect system performance.
Design/methodology/approach
– The authors used a controlled experiment to test the research hypotheses.
Findings
– Physicians displaying high confidence referred significantly fewer patients in a close relationship condition than in a centralized referral system, suggesting that for some physicians, referral behavior can be affected by system attributes and will, in turn, affect system performance.
Research limitations/implications
– The current study has some limitations, however. First, the sample consisted only of family practice residents and did not have the knowledge and experience of GPs regarding the referral process. Second, the authors used hypothetical patient case descriptions instead of real-world patients. Repeating this experiment with primary care physicians in real setting would be beneficial.
Practical implications
– The study indicates that decentralized referral systems may act (rightly or wrongly) as a restraint on the rate of referrals to specialists. Thus, an implementation of a centralized referral system should be expected to produce an increase in referrals simply due to the change in the operational system setup. Even if centralized referral systems are more efficient and can facilitate the referral process by creating a central queue rather than multiple single queues for patients, the removal of social ties such as long-term social relationships that are developed between GPs and specialists in decentralized referral systems may act to counterbalance these theoretical gains.
Social implications
– This study provide support for the idea that non-clinical factors play an important role in referrals to specialists and hence in the quality of provided care, as was suggested by previous studies in this area (Hajjaj et al., 2010; Reid et al., 1999). The design of the service system may inadvertently influence some doctors to refer too many patients to specialists when there is no need for a specialist visit. In high-utilization health systems, this may cause some patients to be delayed (or even denied) in obtaining specialist access. Healthcare systems may be able to implement behavioral-based techniques in order to mitigate the negative consequences of a shift to centralized referral systems. One approach would be to try to create a feeling of close relationship among doctors in centralized referral systems. High communication and frequent interaction among GPs and specialists can boost the feelings of teamwork and personal efficacy through social comparison (Schunk, 1989, 1991) and vicarious learning (Zimmerman, 2000), which can in turn motivate GPs to take control of the patient care process when appropriate, instead of referring patients to specialists.
Originality/value
– The authors’ study is the first examining the effect of social relationships between GPs and specialists on the referral patterns. Considering the significant implications of referral decisions on patients, doctors, and the healthcare systems, the study can shed light into a better understanding of the social and behavioral aspects of the referral process.
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Alsaeed D, Davies N, Gilmartin JFM, Jamieson E, Kharicha K, Liljas AEM, Raimi-Abraham BT, Aldridge J, Smith FJ, Walters K, Orlu Gul M. Older people's priorities in health and social care research and practice: a public engagement workshop. RESEARCH INVOLVEMENT AND ENGAGEMENT 2016; 2:2. [PMID: 29062503 PMCID: PMC5611594 DOI: 10.1186/s40900-016-0016-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 01/26/2016] [Indexed: 06/07/2023]
Abstract
PLAIN ENGLISH SUMMARY A one day public engagement workshop was held to focus on the priorities of older people about research and practice in health and social care. Seventy-five older people from the general public and a variety of backgrounds attended this event to share their views and discuss what should be prioritised. The main aim of this workshop was to identify and prioritise issues that are important to older people that would benefit from further research, as well as create an environment for older people to share ideas and problems related to these important issues. Key priorities brought up by participants included loneliness and isolation, support and training for professional and family carers, post-surgical care, negative perceptions of older people and inequalities related to public services and healthcare. Participants further suggested older people should be actively involved in all stages of the research process. ABSTRACT As the world's population ages, there is an increasing need for research that addresses the priorities of older people. A public engagement workshop focusing on the priorities of older people for research and practice in health and social care was attended by seventy-five people aged 70 years and above in London, United Kingdom (UK). The workshop aimed to identify and prioritise issues important to older people that would benefit from further research and act as a platform to promote sharing of ideas and problems related to these important issues. Key priorities emerged including loneliness and isolation, support and training for professional and family carers, post-surgical care, negative perceptions of older people and inequalities related to public services and healthcare. Participants further suggested older people should be actively involved in all stages of the research process.
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Affiliation(s)
- Dalal Alsaeed
- University College London, School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Nathan Davies
- University College London, Institute of Epidemiology & Health, Primary Care & Population Health, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Julia Fiona-Maree Gilmartin
- University College London, School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Elizabeth Jamieson
- University College London, School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Kalpa Kharicha
- University College London, Institute of Epidemiology & Health, Primary Care & Population Health, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Ann E. M. Liljas
- University College London, Institute of Epidemiology & Health, Primary Care & Population Health, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | | | - Janine Aldridge
- Age UK London, Greater London Forum for Older People, 1st Floor, 21 St Georges Road, London, SE1 6ES, UK
| | - Felicity J. Smith
- University College London, School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Kate Walters
- University College London, Institute of Epidemiology & Health, Primary Care & Population Health, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Mine Orlu Gul
- University College London, School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
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Joseph-Williams N, Davies F, Wood F, Edwards A. Choosing a Specialist. Med Decis Making 2015; 35:688-90. [DOI: 10.1177/0272989x15583267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 03/26/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Natalie Joseph-Williams
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK (NJW, FD, FW, AE)
| | - Freya Davies
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK (NJW, FD, FW, AE)
| | - Fiona Wood
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK (NJW, FD, FW, AE)
| | - Adrian Edwards
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK (NJW, FD, FW, AE)
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Affiliation(s)
- Thomas D Brothers
- Dalhousie University (Brothers, To, Van Zoost), Halifax, NS; The Ottawa Hospital (Turnbull), Ottawa Ont
| | - Matthew J To
- Dalhousie University (Brothers, To, Van Zoost), Halifax, NS; The Ottawa Hospital (Turnbull), Ottawa Ont
| | - Colin Van Zoost
- Dalhousie University (Brothers, To, Van Zoost), Halifax, NS; The Ottawa Hospital (Turnbull), Ottawa Ont
| | - Jeffrey Turnbull
- Dalhousie University (Brothers, To, Van Zoost), Halifax, NS; The Ottawa Hospital (Turnbull), Ottawa Ont
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Lamberts MP, Kievit W, Özdemir C, Westert GP, van Laarhoven CJHM, Drenth JPH. Value of EGD in patients referred for cholecystectomy: a systematic review and meta-analysis. Gastrointest Endosc 2015; 82:24-31. [PMID: 25910659 DOI: 10.1016/j.gie.2015.01.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 01/02/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND As many as 33% of patients with symptomatic cholelithiasis report persisting abdominal pain after cholecystectomy, suggesting alternative causes of these symptoms. EGD may serve as a tool to identify additional symptomatic abdominal disorders beforehand to avoid unnecessary gallbladder surgery. There is controversy as to whether routine EGD before cholecystectomy is appropriate. OBJECTIVE To perform a systematic review and meta-analysis to assess the value of EGD before cholecystectomy. DESIGN A systematic literature search was conducted to identify studies that reported the proportion of patients who were referred for cholecystectomy, but in whom initial surgery could be avoided after treatment of abnormalities detected with EGD. Pooled estimates with 95% confidence intervals (CIs) were calculated by using random-effects models. SETTING Meta-analysis of 12 cohort studies. PATIENTS A total of 6317 patients with cholelithiasis underwent EGD. RESULTS The pooled estimate of abnormalities detected with EGD was 36.3% (95% CI, 28.0-45.0). In a total of 3.8% (95% CI, 1.4-7.6) of patients referred for cholecystectomy who underwent previous EGD, gallbladder surgery was avoided. LIMITATIONS Lack of information regarding characteristics of patients referred for cholecystectomy, criteria for performing EGD, algorithms for the treatment of identified pathologies, and response criteria for the decision to avoid cholecystectomy in included studies. CONCLUSIONS Our study indicates that, despite the high diagnostic yield of EGD, its value as a tool to prevent gallbladder surgery is limited. EGD should only be considered selectively in patients with cholelithiasis referred for cholecystectomy.
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Affiliation(s)
- Mark P Lamberts
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, the Netherlands; Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wietske Kievit
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Cihan Özdemir
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gert P Westert
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03240] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BackgroundDemand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.ObjectiveThis research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.DesignThe approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.SettingPrimary health care.Main outcome measuresReferral from primary to secondary care.Review methodsSystematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.ResultsFrom a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.ConclusionsThe findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.Study registrationThe study is registered as PROSPERO CRD42013004037.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Buckley Woods
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Lee
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Nick Payne
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Melanie Rimmer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Dunlay SM, Redfield MM, Jiang R, Weston SA, Roger VL. Care in the last year of life for community patients with heart failure. Circ Heart Fail 2015; 8:489-96. [PMID: 25834184 DOI: 10.1161/circheartfailure.114.001826] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 03/19/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Healthcare utilization peaks at the end of life (EOL) in patients with heart failure. However, it is unclear what factors affect end of life utilization in patients with heart failure and if utilization has changed over time. METHODS AND RESULTS Southeastern Minnesota residents with heart failure were prospectively enrolled into a longitudinal cohort study from 2003 to 2011. Patients who died before December 31, 2012, were included in the analysis. Information on hospitalizations and outpatient visits in the last year of life was obtained using administrative sources. Negative binomial regression was used to assess the association between patient characteristics and utilization. The 698 decedents (47.3% men; 53.4% preserved ejection fraction) experienced 1528 hospitalizations (median 2 per person; range, 0-12; 37.6% because of cardiovascular causes) and 12 927 outpatient visits (median 14 per person; range, 0-119) in their last year of life. Most patients (81.5%) were hospitalized at least once and 28.4% died in the hospital. Patients who were older and those with dementia had lower utilization. Patients who were married, resided in a skilled nursing facility, and had more comorbidities had higher utilization. Patients with preserved ejection fraction had higher rates of noncardiovascular hospitalizations although other utilization was similar. Over time, rates of hospitalizations and outpatient visits decreased, whereas palliative care consults and enrollment in hospice increased. CONCLUSIONS Although patient factors remain associated with differential healthcare utilization at the end of life, utilization declined over time and use of palliative care services increased. These results are encouraging given the high resource use in patients with heart failure.
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Affiliation(s)
- Shannon M Dunlay
- From the Division of Cardiovascular Diseases, Department of Medicine (S.M.D., M.M.R., V.L.R.) and Department of Health Sciences Research (S.M.D., R.J., S.A.W., V.L.R.), Mayo Clinic, Rochester, MN.
| | - Margaret M Redfield
- From the Division of Cardiovascular Diseases, Department of Medicine (S.M.D., M.M.R., V.L.R.) and Department of Health Sciences Research (S.M.D., R.J., S.A.W., V.L.R.), Mayo Clinic, Rochester, MN
| | - Ruoxiang Jiang
- From the Division of Cardiovascular Diseases, Department of Medicine (S.M.D., M.M.R., V.L.R.) and Department of Health Sciences Research (S.M.D., R.J., S.A.W., V.L.R.), Mayo Clinic, Rochester, MN
| | - Susan A Weston
- From the Division of Cardiovascular Diseases, Department of Medicine (S.M.D., M.M.R., V.L.R.) and Department of Health Sciences Research (S.M.D., R.J., S.A.W., V.L.R.), Mayo Clinic, Rochester, MN
| | - Véronique L Roger
- From the Division of Cardiovascular Diseases, Department of Medicine (S.M.D., M.M.R., V.L.R.) and Department of Health Sciences Research (S.M.D., R.J., S.A.W., V.L.R.), Mayo Clinic, Rochester, MN
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Hardcastle AC, Mounce LTA, Richards SH, Bachmann MO, Clark A, Henley WE, Campbell JL, Melzer D, Steel N. The dynamics of quality: a national panel study of evidence-based standards. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundShortfalls in the receipt of recommended health care have been previously reported in England, leading to preventable poor health.ObjectivesTo assess changes over 6 years in the receipt of effective health-care interventions for people aged 50 years or over in England with cardiovascular disease, depression, diabetes or osteoarthritis; to identify how quality varied with participant characteristics; and to compare the distribution of illness burden in the population with the distributions of diagnosis and treatment.Setting and participantsInformation on health-care quality indicators and participant characteristics was collected using face-to-face structured interviews and nurse visits in participants’ homes by the English Longitudinal Study of Ageing in 2004–5, 2006–7, 2008–9 and 2010–11. A total of 16,773 participants aged 50 years or older were interviewed at least once and 5114 were interviewed in all four waves; 5404 reported diagnosis of one or more of four conditions in 2010–11.Main outcome measuresPercentage of indicated health care received by eligible participants for 19 quality indicators: seven for cardiovascular disease, three for depression, five for diabetes and four for osteoarthritis, and condition-level quality indicator achievement, including achievement of a bundle of three diabetes indicators.AnalysisChanges in quality indicator achievement over time and variations in quality with participant characteristics were tested with Pearson’s chi-squared test and logistic regression models. The size of inequality between the hypothetically wealthiest and poorest participants, for illness burden, diagnosis and treatment, was estimated using slope indices of wealth inequality.ResultsAchievement of indicators for cardiovascular disease was 82.7% [95% confidence interval (CI) 79.9% to 85.5%] in 2004–5 and 84.2% (95% CI 82.1% to 86.2%) in 2010–11, for depression 63.3% (95% CI 57.6% to 69.0%) and 59.8% (95% CI 52.4% to 64.3%), for diabetes 76.0% (95% CI 74.1% to 77.8%) and 76.5% (95% CI 74.8% to 78.1%), and for osteoarthritis 31.2% (95% CI 28.5% to 33.8%) and 35.6% (95% CI 34.2% to 37.1%). Achievement of the diabetes care bundle was 67.8% (95% CI 64.5% to 70.9%) in 2010–11. Variations in quality by participant characteristics were generally small. Diabetes indicator achievement was worse in participants with cognitive impairment [odds ratio (OR) 0.5, 95% CI 0.4 to 0.7] and better in those living alone (OR 1.7, 95% CI 1.3 to 2.0). Hypertension care was better for those aged over 74 years (vs. 50–64 years) (OR 3.2, 95% CI 2.0 to 5.3). Osteoarthritis care was better for those with severe (vs. mild) pain (OR 1.8, 95% CI 1.4 to 2.2), limiting illness (OR 1.8, 95% CI 1.5 to 2.1), and obesity (OR 1.6, 95% CI 1.2 to 2.0). Previous non-achievement of the diabetes care bundle was the biggest predictor of non-achievement 2 years later (OR 3.3, 95% CI 2.2 to 4.7). Poorer participants were always more likely than wealthier participants to have illness burden (statistically significant OR 3.9 to 16.0), but not always more likely to be diagnosed or receive treatment (0.2 to 5.3).ConclusionsShortfalls in quality of care for these four conditions have persisted over 6 years, with only half of the level of indicated health care achieved for osteoarthritis, compared with the other three conditions. Quality for osteoarthritis improved slightly over time but remains poor. The relatively high prevalence of specific illness burden in poorer participants was not matched by an equally high prevalence of diagnosis or treatment, suggesting that barriers to equity may exist at the stage at diagnosis. Further research is needed into the association between quality and health system characteristics at the level of clinicians, general practices or hospitals, and regions. Linkage to routinely collected data could provide information on health service characteristics at the individual patient level.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Antonia C Hardcastle
- Population Health and Primary Care Group, Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Luke TA Mounce
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Suzanne H Richards
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Max O Bachmann
- Population Health and Primary Care Group, Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Allan Clark
- Population Health and Primary Care Group, Norwich Medical School, University of East Anglia, Norfolk, UK
| | - William E Henley
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - John L Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - David Melzer
- Epidemiology and Public Health Group, University of Exeter Medical School, Exeter, UK
| | - Nicholas Steel
- Population Health and Primary Care Group, Norwich Medical School, University of East Anglia, Norfolk, UK
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Sheaff R, Charles N, Mahon A, Chambers N, Morando V, Exworthy M, Byng R, Mannion R, Llewellyn S. NHS commissioning practice and health system governance: a mixed-methods realistic evaluation. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundBy 2010 English health policy-makers had concluded that the main NHS commissioners [primary care trusts (PCTs)] did not sufficiently control provider costs and performance. After the 2010 general election, they decided to replace PCTs with general practitioner (GP)-controlled Clinical Commissioning Groups (CCGs). Health-care commissioners have six main media of power for exercising control over providers, which can be used in different combinations (‘modes of commissioning’).ObjectivesTo: elicit the programme theory of NHS commissioning policy and empirically test its assumptions; explain what shaped NHS commissioning structures; examine how far current commissioning practice allowed commissioners to exercise governance over providers; examine how commissioning practices differ in different types of commissioning organisation and for specific care groups; and explain what factors influenced commissioning practice and the relationships between commissioners and providers.DesignMixed-methods realistic evaluation, comprising: Leximancer and cognitive frame analyses of policy statements to elicit the programme theory of NHS commissioning policy; exploratory cross-sectional analysis of publicly available managerial data about PCTs; systematic comparison of case studies of commissioning in four English sites – including commissioning for older people at risk of unplanned hospital admission; mental health; public health; and planned orthopaedic surgery – and of English NHS commissioning practice with that of a German sick-fund and an Italian region (Lombardy); action learning sets, to validate the findings and draw out practical implications; and two framework analyses synthesising the findings and testing the programme theory empirically.ResultsIn the four English case study sites, CCGs were formed by recycling former commissioning structures, relying on and maintaining the existing GP commissioning leaderships. The stability of distributed commissioning depended on the convergence of commissioners’ interests. Joint NHS and local government commissioning was more co-ordinated at strategic than operational level. NHS providers’ responsiveness to commissioners reflected how far their interests converged, but also providers’ own internal ability to implement agreements. Commissioning for mental health services and to prevent recurrent unplanned hospital readmissions relied more on local ‘micro-commissioning’ (collaborative care pathway design) than on competition. Service commissioning was irrelevant to intersectoral health promotion, but not clinical prevention work. On balance, the possibility of competition did not affect service outcomes in the ways that English NHS commissioning policies assumed. ‘Commodified’ planned orthopaedic surgery most lent itself to provider competition. In all three countries, tariff payments increased provider activity and commissioners’ costs. To contain costs, commissioners bundled tariff payments into blocks, agreed prospective case loads with providers and paid below-tariff rates for additional cases. Managerial performance, negotiated order and discursive control were the predominant media of power used by English, German and Italian commissioners.ConclusionsCommissioning practice worked in certain respects differently from what NHS commissioning policy assumed. It was often laborious and uncertain. In the four English case study sites financial and ‘real-side’ contract negotiations were partly decoupled, clinician involvement being least on the financial side. Tariff systems weakened commissioners’ capacity to choose providers and control costs. Commissioners adapted the systems to solve this problem. Our findings suggest a need for further research into whether or not differently owned providers (corporate, third sector, public, professional partnership, etc.) respond differently to health-care commissioners and, if so, what specific implications for commissioning practice follow. They also suggest that further work is needed to assess how commissioning practices impact on health system integration when care pathways have to be constructed across multiple providers that must tender competitively for work, perhaps against each other.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Rod Sheaff
- School of Government, Plymouth University, Plymouth, UK
| | - Nigel Charles
- School of Government, Plymouth University, Plymouth, UK
| | - Ann Mahon
- Manchester Business School, Manchester University, Manchester, UK
| | - Naomi Chambers
- Manchester Business School, Manchester University, Manchester, UK
| | | | | | - Richard Byng
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | - Sue Llewellyn
- Manchester Business School, Manchester University, Manchester, UK
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Steel N, Hardcastle AC, Bachmann MO, Richards SH, Mounce LTA, Clark A, Lang I, Melzer D, Campbell J. Economic inequalities in burden of illness, diagnosis and treatment of five long-term conditions in England: panel study. BMJ Open 2014; 4:e005530. [PMID: 25344482 PMCID: PMC4212182 DOI: 10.1136/bmjopen-2014-005530] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We compared the distribution by wealth of self-reported illness burden (estimated from validated scales, biomarker and reported symptoms) for angina, cataract, depression, diabetes and osteoarthritis, with the distribution of self-reported medical diagnosis and treatment. We aimed to determine if the greater illness burden borne by poorer participants was matched by appropriately higher levels of diagnosis and treatment. DESIGN The English Longitudinal Study of Ageing, a panel study of 12,765 participants aged 50 years and older in four waves from 2004 to 2011, selected using a stratified random sample of households in England. Distribution of illness burden, diagnosis and treatment by wealth was estimated using regression analysis. OUTCOME MEASURES The main outcome measures were ORs for the illness burden, diagnosis and treatment, respectively, adjusted for age, sex and wealth. We estimated the illness burden for angina with the Rose Angina scale, diabetes with fasting glycosylated haemoglobin, depression with the Centre for Epidemiologic Studies Depression Scale, osteoarthritis with self-reported pain and disability and cataract with self-reported poor vision. Medical diagnoses were self-reported for all conditions. Treatment was defined as β-blocker prescription for angina, surgery for osteoarthritis and cataract, and receipt of predefined effective interventions for diabetes and depression. RESULTS Compared with the wealthiest, the least wealthy participant had substantially higher odds for illness burden from any of the five conditions at all four time points, with ORs ranging from 4.2 (95% CI 2.6 to 6.8) for diabetes to 15.1 (11.4 to 20.0) for osteoarthritis. The ORs for diagnosis and treatment were smaller in all five conditions, and ranged from 0.9 (0.5 to 1.4) for diabetes treatment to 4.5 (3.3 to 6.0) for angina diagnosis. CONCLUSIONS The substantially higher illness burden in less wealthy participants was not matched by appropriately higher levels of diagnosis and treatment.
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Affiliation(s)
- N Steel
- Department of Population Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK
| | - A C Hardcastle
- Department of Population Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK
| | - M O Bachmann
- Department of Population Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK
| | | | | | - A Clark
- Department of Population Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK
| | - I Lang
- NIHR CLAHRC South West Peninsula, Exeter, UK
| | - D Melzer
- University of Exeter Medical School, Exeter, UK
| | - J Campbell
- University of Exeter Medical School, Exeter, UK
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Alonazi WB, Thomas SA. Quality of care and quality of life: convergence or divergence? Health Serv Insights 2014; 7:1-12. [PMID: 25114568 PMCID: PMC4122532 DOI: 10.4137/hsi.s13283] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/12/2013] [Accepted: 11/22/2013] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to explore the impact of quality of care (QoC) on patients' quality of life (QoL). In a cross-sectional study, two domains of QoC and the World Health Organization Quality of Life-Bref questionnaire were combined to collect data from 1,059 pre-discharge patients in four accredited hospitals (ACCHs) and four non-accredited hospitals (NACCHs) in Saudi Arabia. Health and well-being are often restricted to the characterization of sensory qualities in certain settings such as unrestricted access to healthcare, effective treatment, and social welfare. The patients admitted to tertiary health care facilities are generally able to present themselves with a holistic approach as to how they experience the impact of health policy. The statistical results indicated that patients reported a very limited correlation between QoC and QoL in both settings. The model established a positive, but ultimately weak and insignificant, association between QoC (access and effective treatment) and QoL (r = 0.349, P = 0.000; r = 0.161, P = 0.000, respectively). Even though the two settings are theoretically different in terms of being able to conceptualize, adopt, and implement QoC, the outcomes from both settings demonstrated insignificant relationships with QoL as the results were quite similar. Though modern medicine has substantially improved QoL around the world, this paper proposes that health accreditation has a very limited impact on improving QoL. This paper raises awareness of this topic with multiple healthcare professionals who are interested in correlating QoC and QoL. Hopefully, it will stimulate further research from other professional groups that have new and different perspectives. Addressing a transitional health care system that is in the process of endorsing accreditation, investigating the experience of tertiary cases, and analyzing deviated data may limit the generalization of this study. Global interest in applying public health policy underlines the impact of such process on patients' outcomes. As QoC accreditation does not automatically produce improved QoL outcomes, the proposed study encourages further investigation of the value of health accreditation on personal and social well-being.
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Affiliation(s)
- Wadi B Alonazi
- Department of Health and Hospital Administration, Faculty of Business Administration, King Saud University, Riyadh, Saudi Arabia
| | - Shane A Thomas
- Deputy Dean (International), Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
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