Health care providers' perspectives on patient delay for seeking care for symptoms of acute myocardial infarction

Providers' Perspectives on Case Management of a Healthy Start Program: A Qualitative Study

Although Healthy Start case managers recognized the benefits of case management for facilitating optimal service delivery to women and their families, structural factors impact effective implementation. This study investigated case managers' views of 1) the structural challenges faced in implementing case management for program participants, and 2) possible strategies to enhance case management in medical home settings. Two focus groups were conducted separately with case managers from the four program service sites to gain insight into these issues noted above. Each group was co-facilitated by two evaluators using a previously developed semi-structured interview guide. The group discussions were audio recorded and the case managers' comments were transcribed verbatim. Transcripts were analyzed using thematic analysis, a deductive approach. Data were collected in 2013 and analyzed in 2015. Case managers are challenged by externalities (demographic shifts in target populations, poverty); contractual requirements (predefined catchment neighborhoods, caseload); limited support (client incentives, tailored training, and a high staff turnover rate); and logistic difficulties (organizational issues). Their approach to case management tends to be focused on linking Although Healthy Start case managers recognized the benefits of case management for facilitating optimal service delivery to women and their families, structural factors impact effective implementation. This study investigated case managers' views of 1) the structural challenges faced in implementing case management for program participants, and 2) possible strategies to enhance case management in medical home settings. Two focus groups were conducted separately with case managers from the four program service sites to gain insight into these issues noted above. Each group was co-facilitated by two evaluators using a previously developed semi-structured interview guide. The group discussions were audio recorded and the case managers' comments were transcribed verbatim. Transcripts were analyzed using thematic analysis, a deductive approach. Data were collected in 2013 and analyzed in 2015. Case managers are challenged by externalities (demographic shifts in target populations, poverty); contractual requirements (predefined catchment neighborhoods, caseload); limited support (client incentives, tailored training, and a high staff turnover rate); and logistic difficulties (organizational issues). Their approach to case management tends to be focused on linking clients to adequate services rather than reporting performance. Case managers favored measurable deliverables rather than operational work products. A proposed solution to current challenges emphasizes and encourages the iterative learning process and shared decision making between program targets, funders and providers. Case managers are aware of the challenging environment in which they operate for their clients and for themselves. However, future interventions will require clearly identified performance measures and increased systems support.

Time to treatment for acute coronary syndromes: the cost of indecision

BACKGROUND AND RESEARCH OBJECTIVES

: Multiple sociodemographic and environmental factors have been associated with urgent treatment-seeking behaviors for patients experiencing acute coronary syndromes (ACSs). However, variables that directly affect the decision to seek care in the emergency department (ED) have been less well defined. The objective of this study was to explore the factors associated with a decision to seek care for symptoms of ACSs and to describe patient characteristics associated with time to presentation.

SUBJECTS AND METHODS

: A cross-sectional, descriptive design was used. The nonprobability sample included 256 patients admitted to the hospital with ACSs. The study was conducted on cardiac step-down units at 2 large urban medical centers. Reasons for seeking care were elicited during structured interviews in the patient's room. These factors and other patient characteristics were treated as predictor variables in an analysis of time from symptom onset to arrival in the ED.

RESULTS AND CONCLUSIONS

: Five categories of decision making were identified through descriptive content analyses and were labeled new onset of chest pain, ongoing evaluation of symptom severity, symptoms other than chest pain that worsened or were unrelieved, externally motivated, and internally motivated. Median time from symptom onset to arrival in the ED was 9.5 hours for women and 6 hours for men. Patients who experienced constant pain (hazard ratio, 1.44; P =.01) and those with ST-segment elevation myocardial infarction (hazard ratio, 1.59; P = .004) sought treatment significantly sooner than patients with intermittent pain. Older patients sought treatment later (hazard ratio, 0.99; P = .02). Patients who are older and experience intermittent pain should be encouraged to seek emergent treatment for symptoms that may represent ACSs. New evidence of patients' decision-making processes and dangerous delay in time to treatment provides knowledge needed to counsel patients about the benefits of seeking care quickly when symptoms begin.

A personal perspective: at the crossroads of heart attack care: designing an effective nationwide public education program to hasten patient hospital arrival

This report presents a field-tested approach to the greatest health care problem facing our country, the fact that two-thirds of the deaths from acute myocardial infarction occur before hospital admission. Scores of fundraising appearances for the Missouri Heart Association during the 1950s and 1960s throughout the 1,000,000 population rural/urban Southwest Missouri region gave an ideal setting for teaching the public the early symptoms of heart attack. Audiences were advised that if any of these appeared they should immediately call their doctor or quickly get to the nearest hospital emergency room. These presentations led to a steady increase in hospital admissions. The Missouri Heart Association responded by launching the Early Warning Signs of Heart Attack Public and Professional Education Program in July 1971, incorporating these messages in radio, TV, and newspaper Public Service Announcements. In less than 6 months, analysis of consecutive admissions to the cardiovascular intensive care unit of the base hospital showed that the median time from the onset of symptoms to starting to the hospital was reduced from 4 to 2.2 hours; 64% of those patients called their doctor as their first step in seeking help and 58% went to the hospital by car. This message content was carried through the 1980s and 1990s under other auspices. The methods of the successful Missouri program are contrasted with others that have failed, establishing essential features in designing a nationwide program effective in hastening acute myocardial infarction patient hospital arrival.

The effect of health care provider consultation on acute coronary syndrome care-seeking delay

PROBLEM

The time required for health care provider (HCP) consultation during acute coronary syndrome (ACS) has not been systematically studied. This study seeks to understand who calls an HCP and the duration of HCP evaluation during ACS.

METHODS

Interviews were conducted with 1102 hospitalized patients with ACS in Columbus, Ohio. At discharge, diagnoses were acute myocardial infarction (560), unstable angina (214), cardiac disease (122), and noncardiac emergencies (206).

RESULTS

Among the 1102 patients studied, 40.9% (451) contacted an HCP. Situational factors were more important than demographic factors in accounting for medical evaluation phase incidence and duration. Advice from HCPs to call the emergency medical services or travel to the emergency department reduced medical evaluation phase duration. The median total time duration was 6 hours for HCP consulters and 1 hour 30 minutes for nonconsulters (P < .001). Patients foregoing HCP consultation experienced significantly greater hemodynamic instability than patients contacting an HCP. Calling an HCP significantly (P < .001) reduced emergency medical services use.

CONCLUSIONS

Consulting an HCP during ACS extended total time duration from symptom onset to emergency department arrival. In general, patients calling an HCP experienced a less severe ACS event than patients not contacting an HCP. There is a need for an epidemiologic study of calls to HCPs to develop a protocol for ACS call management.

Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Coronary heart disease multiple risk factor reduction. Providers' perspectives

BACKGROUND

Although primary care physicians understand the importance of preventive services for patients with multiple risk factors (MRF) for coronary heart disease, physician intervention is limited. This study investigated (1) physicians' views of challenges faced in managing patients with MRF; (2) the counseling and management methods they utilize; and (3) possible strategies to enhance MRF intervention in the primary care setting.

METHODS

Two focus groups were conducted with primary care physicians from varying settings to gain insight into these issues noted above. Each group was co-facilitated by a physician and a behavioral scientist using a previously developed semistructured interview guide. The group discussions were tape recorded and subsequently transcribed. Transcripts were analyzed using the constant comparative method for analysis.

RESULTS

Physicians are challenged by knowledge limitations (contribution of individual risk factors to overall risk); limited support (guidelines, materials, and staff); and logistic difficulties (organizational issues, time limitations). Their approach to MRF management tends to be highly individualized with an initial preference for lifestyle change interventions rather than prescription of medications with some qualifying circumstances. Physicians favored a serial rather than a parallel approach to MRF intervention, starting with behaviors that the patient perceives as a priority. Proposed solutions to current challenges emphasize physician education and the development of innovative approaches that include physician assistance and a team approach.

CONCLUSIONS

Physicians are aware of and sensitive to the complexity of MRF management for their patients and themselves. However, future MRF interventions will require nonphysician staff involvement and increased systems support.

Patient delay in seeking care for heart attack symptoms: findings from focus groups conducted in five U.S. regions

BACKGROUND

Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States.

METHODS

Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White).

FINDINGS

Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the "permission" of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a "male problem," an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice.

CONCLUSIONS

Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.

Measurement of nonverbal receptive abilities in medical students

Physicians have been reported to have difficulty in communicating with their patients. An element of this communication gap is proposed be related to the educational curriculum and the selection process of medical schools, in particular, with the emphasis on scientific methodology reducing exposure to humanistic values. This hypothesis was tested by measuring nonverbal receptive abilities in two groups. 30 medical students were compared with 30 college students who were not science majors but were age-, sex- and race-matched. The nonscience majors were better at perceiving nonverbal cues than medical students. Male nonscience majors had higher scores than male medical students while similar results were seen when female nonscience majors were compared with female medical students. Finally, medical students planning to practice as primary care specialists had higher scores than those interested in specialties which do not involve direct or prolonged patient care.