1
|
Finkelstein A, Brezis M, Taub A, Arad D. Disclosure following a medical error: lessons learned from a national initiative of workshops with patients, healthcare teams, and executives. Isr J Health Policy Res 2024; 13:13. [PMID: 38462624 PMCID: PMC10926562 DOI: 10.1186/s13584-024-00599-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 02/27/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Despite the increase in disclosures of medical errors, transparency remains a challenge. Recognized barriers include shame, fear of litigation, disciplinary actions, and loss of patient trust. In 2018, the Israeli Ministry of Health initiated a series of workshops about disclosure of medical errors. The workshops involved medical center executives, healthcare providers, patients, and family members of patients who had previously been harmed by a medical error. This study presents the lessons learned about perceived challenges in disclosure of errors in 15 such workshops. METHODS Data collection included participant observations in 15 workshops, full audio recordings of all of the workshops, and documentation of detailed field notes. Analysis was performed under thematic analysis guidelines. RESULTS We identified four main themes: "Providers agree on the value of disclosure of a medical error to the patient"; "Emotional challenges of disclosure of medical error to patients"; "The medico-legal discourse challenges transparency"; and "Providers and patients call for a change in the culture regarding disclosure of medical errors". Participant observations indicated that the presence of a patient who had experienced a tragedy in another hospital, and who was willing to share it created an intimate atmosphere that enabled an open conversation between parties. CONCLUSION The study shows the moral, human, and educational values of open discourse in a protective setting after the occurrence of a medical error. We believe that workshops like these may help foster a culture of institutional disclosure following medical errors. We recommend that the Ministry of Health extend such workshops to all healthcare facilities, establish guidelines and mandate training for skills in disclosure for all providers.
Collapse
Affiliation(s)
- Adi Finkelstein
- Department of Nursing, Faculty of Life and Health Sciences, Jerusalem College of Technology (JCT), Beit Hadfus 7 St., 9548307, Jerusalem, Israel.
| | - Mayer Brezis
- School of Public Health, Hebrew University Hadassah Medical Center, Ein-Kerem, PO Box 12000, 91120, Jerusalem, Israel
| | - Amiad Taub
- 'Ofek Back to Life' Organization, Sderot H'areches 13, 7178441, Modi'in, Israel
| | - Dana Arad
- Patient Safety Division, Ministry of Health, 39 Yeremiahu, 9101002, Jerusalem, Israel
| |
Collapse
|
2
|
Looman N, de Graaf J, Thoonen B, van Asselt D, de Groot E, Kramer A, Scherpbier N, Fluit C. Designing the learning of intraprofessional collaboration among medical residents. MEDICAL EDUCATION 2022; 56:1017-1031. [PMID: 35791303 PMCID: PMC9543842 DOI: 10.1111/medu.14868] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 05/21/2023]
Abstract
BACKGROUND To preserve quality and continuity of care, collaboration between primary-care and secondary-care physicians is becoming increasingly important. Therefore, learning intraprofessional collaboration (intraPC) requires explicit attention during postgraduate training. Hospital placements provide opportunities for intraPC learning, but these opportunities require interventions to support and enhance such learning. Design-Principles guide the design and development of educational activities when theory-driven Design-Principles are tailored into context-sensitive Design-Principles. The aim of this study was to develop and substantiate a set of theory-driven and context-sensitive Design-Principles for intraPC learning during hospital placements. METHODS Based on our earlier research, we formulated nine theory-driven Design-Principles. To enrich, refine and consolidate these principles, three focus group sessions with stakeholders were conducted using a Modified Nominal Group Technique. Next, two work conferences were conducted to test the feasibility and applicability of the Design-Principles for developing intraPC educational activities and to sharpen the principles into a final set of Design-Principles. RESULTS The theoretical Design-Principles were discussed and modified iteratively. Two new Design-Principles were added during focus group 1, and one more Design-Principle was added during focus group 2. The Design-Principles were categorised into three clusters: (i) Culture: building collaborative relations in a psychologically safe context where patterns or feelings of power dynamics between primary and secondary care physicians can be discussed; (ii) Connecting Contexts: making residents and supervisors mutually understand each other's work contexts and activities; and (iii) Making the Implicit Explicit: having supervising teams act as role models demonstrating intraPC and continuously pursuing improvement in intraPC to make intraPC explicit. Participants were unanimous in their view that the Design-Principles in the Culture cluster were prerequisites to facilitate intraPC learning. CONCLUSION This study led to the development of 12 theory-driven and context-sensitive Design-Principles that may guide the design of educational activities to support intraPC learning during hospital placements.
Collapse
Affiliation(s)
- Natasja Looman
- Department of Primary and Community CareRadboudumcNijmegenThe Netherlands
| | | | - Bart Thoonen
- Department of Primary and Community CareRadboudumcNijmegenThe Netherlands
| | | | - Esther de Groot
- Julius Center for Health Sciences and Primary CareUMC UtrechtUtrechtThe Netherlands
| | - Anneke Kramer
- Department of Public health and Primary CareLeiden UMCLeidenThe Netherlands
| | - Nynke Scherpbier
- Department of General Practice and Elderly CareUniversity Medical Centre GroningenGroningenThe Netherlands
| | - Cornelia Fluit
- Department for Research in Learning and EducationRadboudumc Health AcademyNijmegenThe Netherlands
| |
Collapse
|
3
|
Mounce LTA, Salema NE, Gangannagaripalli J, Ricci-Cabello I, Avery AJ, Kadam UT, Valderas JM. Development of 2 Short Patient-Report Questionnaires of Patient Safety in Primary Care. J Patient Saf 2022; 18:161-170. [PMID: 35344976 DOI: 10.1097/pts.0000000000000880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) is a valid and reliable instrument (61 items across 5 domains) of patients' perceptions of safety. Stakeholder feedback has supported shorter versions for improving choice and facilitating uptake of routine patient-centered evaluation. We sought to develop 2 shorter versions of PREOS-PC: one including the shortest possible scales that met established measurement performance standards and a screening version including a single item per domain. METHODS A total of 1244 patients from 45 general practices across England completed PREOS-PC questionnaires. All scale items in PREOS-PC underwent Item Response Theory analysis, applying standard criteria for the item reduction. Cognitive debriefing from 10 patient interviews allowed for the assessment of the instruments' readability. The instruments' psychometrics properties were reassessed in a validation sample of 1557 patients in 21 English general practices. RESULTS "PREOS-PC Compact" includes 25 items and 2 open-ended questions across the 5 domains, 44% of the length of the original instrument. "PREOS-PC Screen" consists of 6 items: the best-performing single items for 2 domains, 1 item modified from original items for each of the remaining 3 domains, and 1 open-ended question. The evaluation of the instruments confirmed they were acceptable to patients and met standards for readability; construct, convergent, and divergent validity; and reliability. CONCLUSIONS PREOS-PC Compact meets high-performance standards while reducing patient burden for routine monitoring of patient safety in primary care. PREOS-PC Screen is a concise tool apt for incorporation into audits and to target more in-depth review as needed.
Collapse
Affiliation(s)
- Luke T A Mounce
- From the Health Services and Policy Research Group, University of Exeter Medical School, Exeter
| | - Nde-Eshimuni Salema
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | | | | | - Anthony J Avery
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Umesh T Kadam
- Department of Health Sciences, University of Leicester, England
| | | |
Collapse
|
4
|
Kiss D, Pados E, Kovács A, Mádi P, Dervalics D, Bittermann É, Schmelowszky Á, Rácz J. "This is not life, this is just vegetation"-Lived experiences of long-term care in Europe's largest psychiatric home: An interpretative phenomenological analysis. Perspect Psychiatr Care 2021; 57:1981-1990. [PMID: 33811648 DOI: 10.1111/ppc.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/06/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Understanding the experiences of long-term care (LTC) may help to improve care by assisting mental health professionals and allowing mental health policies to be customized more effectively. DESIGN AND METHODS: Semistructured interviews were analyzed using interpretative phenomenological analysis (IPA). FINDINGS Three main themes emerged as a result: 1. Perception of selves, 2. Experience and representation of the institution, 3. Maintenance of safe spaces. PRACTICE IMPLICATIONS: Communication with patients, investigation of their identity processes, and relationship toward their past and present self during LTC might aid in well-being and sense of congruency in their identities. Nurses should encourage patients to keep connected with their memories and past selves through different activities.
Collapse
Affiliation(s)
- Dániel Kiss
- Doctoral School of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Eszter Pados
- Doctoral School of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Asztrik Kovács
- Doctoral School of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Péter Mádi
- Hungarian Rapid Response Police Unit, Budapest, Hungary
| | - Dóra Dervalics
- Kilátó Piarist Career Guidance and Labor Market Development Center, Budapest, Hungary
| | | | | | - József Rácz
- Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,Department of Addictology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
| |
Collapse
|
5
|
Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, Valderas JM. Identifying Factors Leading to Harm in English General Practices: A Mixed-Methods Study Based on Patient Experiences Integrating Structural Equation Modeling and Qualitative Content Analysis. J Patient Saf 2021; 17:e20-e27. [PMID: 32175959 DOI: 10.1097/pts.0000000000000669] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of the study was to identify the main factors leading to harm in primary care based on the experiences reported by patients. METHODS We conducted a mixed-methods, cross-sectional study in 45 primary care centers in England. A random sample of 6736 patients was invited to complete the Patient-Reported Experiences and Outcomes of Safety in Primary Care questionnaire. We fitted structural equation modeling on the quantitative data (n = 1244 respondents) to identify contributory factors and primary incidents leading to harm. We conducted content analyses of responses to seven open-ended questions (n = 386) to obtain deeper insight into patient perceptions of the causes of harm experienced. Results from quantitative and qualitative analyses were triangulated. RESULTS Patients reported harm related to physical health (13%), pain (11%), and mental health (19%) and harm that increased limitations in social activities (14%). Physical harm was associated with incidents affecting diagnosis (β = 0.43; delayed and wrong), and treatment (0.12; delayed, wrong treatment, or dose), which were in turn associated with incidents with patient-provider communication, coordination between providers, appointments, and laboratory tests. Pain was associated with laboratory tests (0.21; caused when collecting blood or tissue samples) and with problems booking an appointment when needed (0.13; delaying treatment for pain). Harm to mental health was associated with incidents related to the following: diagnosis (0.28), patient-provider communication (0.18), appointments (0.17), coordination between different providers (0.14), and laboratory tests (0.12). Harm increasing limitations in social activities was associated with incidents related to diagnosis (0.42) and diagnostic and monitoring procedures (0.20). CONCLUSIONS Our findings suggest the need for patient-centered strategies to reduce harm in primary care focusing on the improvement of the quality of diagnosis and patient-provider communication.
Collapse
Affiliation(s)
| | - Jaheeda Gangannagaripalli
- Health Services & Policy Research Group, Patient Centred Care, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Luke T A Mounce
- Health Services & Policy Research Group, Patient Centred Care, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Jose María Valderas
- Health Services & Policy Research Group, Patient Centred Care, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| |
Collapse
|
6
|
Competencies to promote collaboration between primary and secondary care doctors: an integrative review. BMC FAMILY PRACTICE 2020; 21:179. [PMID: 32878620 PMCID: PMC7469099 DOI: 10.1186/s12875-020-01234-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 07/29/2020] [Indexed: 12/02/2022]
Abstract
Background In a society where ageing of the population and the increasing prevalence of long-term conditions are major issues, collaboration between primary and secondary care is essential to provide continuous, patient-centred care. Doctors play an essential role at the primary-secondary care interface in realising ‘seamless’ care. Therefore, they should possess collaborative competencies. However, knowledge about these collaborative competencies is scarce. In this review we explore what competencies doctors need to promote collaboration between doctors at the primary-secondary care interface. Methods We conducted an integrative literature review. After a systematic search 44 articles were included in the review. They were analysed using a thematic analysis approach. Results We identified six themes regarding collaborative competencies: ‘patient-centred care: a common concern’, ‘roles and responsibilities’, ‘mutual knowledge and understanding’, ‘collaborative attitude and respect’, ‘communication’ and ‘leadership’. In every theme we specified components of knowledge, skills and attitudes as found in the reviewed literature. The results show that doctors play an important role, not only in the way they collaborate in individual patient care, but also in how they help shaping organisational preconditions for collaboration. Conclusions This review provides an integrative view on competencies necessary for collaborative practice at the primary-secondary care interface. They are part of several domains, showing the complexity of collaboration. The information gathered in this review can support doctors to enhance and learn collaboration in daily practice and can be used in educational programmes in all stages of medical education.
Collapse
|
7
|
Stephens AL, Bruce CR, Childress A, Malek J. Why Families Get Angry: Practical Strategies for Clinical Ethics Consultants to Rebuild Trust Between Angry Families and Clinicians in the Critical Care Environment. HEC Forum 2020; 31:201-217. [PMID: 30820819 DOI: 10.1007/s10730-019-09370-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Developing a care plan in a critical care context can be challenging when the therapeutic alliance between clinicians and families is compromised by anger. When these cases occur, clinicians often turn to clinical ethics consultants to assist them with repairing this alliance before further damage can occur. This paper describes five different reasons family members may feel and express anger and offers concrete strategies for clinical ethics consultants to use when working with angry families acting as surrogate decision makers for critical care patients. We reviewed records of consults using thematic analysis between January 2015 and June 2016. Each case was coded to identify whether the case involved a negative encounter with an angry family. In our review, we selected 11 cases with at least one of the following concerns or reasons for anger: (1) perceived or actual medical error, (2) concerns about the medical team's competence, (3) miscommunication, (4) perceived conflict of interest or commitment, or (5) loss of control. To successfully implement these strategies, clinical ethics consultants, members of the medical team, and family members should share responsibility for creating a mutually respectful relationship.
Collapse
Affiliation(s)
| | - Courtenay R Bruce
- The Methodist Hospital System, System Quality and Patient Safety, Houston, TX, USA
| | - Andrew Childress
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 301D, Houston, TX, 77030, USA
| | - Janet Malek
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, One Baylor Plaza, Suite 301D, Houston, TX, 77030, USA.
| |
Collapse
|
8
|
Terry D, Kim JA, Gilbert J, Jang S, Nguyen H. "Thank You for Listening": An Exploratory Study Regarding the Lived Experience and Perception of Medical Errors Among Those Who Receive Care. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2019; 52:292-302. [PMID: 31816256 DOI: 10.1177/0020731419893036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The issue of medical errors, or adverse events caused within a health care context or by a health care provider, is largely under-researched. While the experience and perspective of health care professionals regarding medical errors have been explored, little attention is paid to the health care consumers regarding their perceptions and experiences. Therefore, there is a need to better understand the public's views on medical errors to enhance patient safety and quality care. The current study sought to examine Australian public perceptions and experiences, especially concerning what errors had occurred, the perceived sources of the errors, and if the errors had been reported. This paper reports the qualitative findings of an online survey for Australian residents who have accessed or received medical services at any time in Australia. Responses from 304 surveys were analyzed and discussed, including demographic information and key themes about medical errors, which were categorized into engagement and patients' voices being heard, the quality of care being provided, and the system's accountability. Based on the findings, the study highlights the importance of effective health professional-patient communication, enhanced capacity to deliver high quality care, and improved mechanism for error reporting and resolution where patients feel safe and confident about positive changes being made.
Collapse
Affiliation(s)
- Daniel Terry
- School of Nursing and Healthcare Professions, Federation University Australia, Ballarat, Victoria, Australia
| | - Jeong-Ah Kim
- School of Nursing and Healthcare Professions, Federation University Australia, Ballarat, Victoria, Australia
| | - Julia Gilbert
- School of Nursing and Healthcare Professions, Federation University Australia, Ballarat, Victoria, Australia
| | - Sunny Jang
- Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, Tasmania, Australia
| | - Hoang Nguyen
- Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, Tasmania, Australia
| |
Collapse
|
9
|
Bousnina Z, Zaiem I. Patient’s reaction after health-care service failure: qualitative study. INTERNATIONAL JOURNAL OF PHARMACEUTICAL AND HEALTHCARE MARKETING 2019. [DOI: 10.1108/ijphm-08-2017-0047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
This paper aims to show the impact of service failure and to shed light on the vengeance of consumer in the health-care service.
Design/methodology/approach
A qualitative research through a retrospective study based on individual interviews was conducted. As this study is a sensitive topic, projective techniques were used to complement individual interviews, especially with care consumers who are reluctant subjects who prefer methods which preserve confidentiality. Practically, drawing interpretations method was used. The use of these drawings is to encourage reluctant interviewee to discuss on the study’s sensitive theme.
Findings
Empirical findings allowed first to approach care service failure in Tunisia that is an emerging post-revolutionary country-owned MENA. In this context, a comparison between the public and private sectors was proposed. Moreover, the results helped to understand service failure’s consequences related to patient’s reaction.
Practical implications
The Ministry of Health in collaboration with managers of public and private medical institutions will have to work on capitalization of knowledge, especially those learned from unsuccessful experiences.
Originality/value
Medical service failure can have multiple sources. The care consumer’s reaction to these failures can sometimes be extreme in form of revenge.
Collapse
|
10
|
Daker-White G, Hays R, Blakeman T, Croke S, Brown B, Esmail A, Bower P. Safety work and risk management as burdens of treatment in primary care: insights from a focused ethnographic study of patients with multimorbidity. BMC FAMILY PRACTICE 2018; 19:155. [PMID: 30193576 PMCID: PMC6128995 DOI: 10.1186/s12875-018-0844-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 08/29/2018] [Indexed: 11/17/2022]
Abstract
Background In primary health care, patient safety failures can arise in service access, doctor-patient relationships, communication between care providers, relational and management continuity, or technical procedures. Through the lens of multimorbidty, and using qualitative ethnographic methods, our study aimed to illuminate safety issues in primary care. Methods Data were triangulated from electronic health records (EHRs); observation of primary care consultations; annual interviews with patients, (informal) care providers and GPs. A thematic analysis of observation, interview and field note material sought to describe the patient safety issues encountered and any associated factors or processes. A more detailed longitudinal description of 6 cases was used to contextualise safety issues identified in observation, interviews and EHRs. Results Twenty-six patients were recruited. Events which could lead to harm were found in all areas of a framework based on published literature. “Under” and “over” consultation as a precursor of safety failures emerged through thematic analysis of observation and interview material. Other findings concerned workload (for doctors and patients) and the limitations of short consultation times. There were differences in health data collected directly from the patients versus that found in EHRs. Examples included reference to a stroke history and diagnoses for CKD and hypertension. Case study analysis revealed specific issues which appeared contextual to safety concerns, mostly around the management of polypharmacy and patient medication adherence. Clinical imperatives appear around risk management, but the study findings point to a potential conflict with patient expectations around investigation, diagnosis and treatment. Discussion Patient safety work involves further burdens on top of existing workload for both clinicians and patients. In this conceptualisation, safety work seemingly forms part of a negative feedback loop with patient safety itself. A line of argument drawn from the triangulation of findings from different sources, points to a tension between the desirability of a minimally disruptive medicine versus safety risks possibly associated with ‘under’ or ‘over’ consultation. Multimorbidity acts as a magnifier of tensions in the delivery of health services and quality care in general practice. More attention should be put on system design than patient or professional behaviour.
Collapse
Affiliation(s)
- Gavin Daker-White
- NIHR Greater Manchester Patient Safety Translational Research Centre (Greater Manchester PSTRC), Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
| | - Rebecca Hays
- NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Thomas Blakeman
- NIHR Collaboration in Applied Health Research and Care Greater Manchester, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Croke
- Division of Nursing Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Benjamin Brown
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Aneez Esmail
- NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
11
|
Ricci‐Cabello I, Saletti‐Cuesta L, Slight SP, Valderas JM. Identifying patient-centred recommendations for improving patient safety in General Practices in England: a qualitative content analysis of free-text responses using the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire. Health Expect 2017; 20:961-972. [PMID: 28244631 PMCID: PMC5600214 DOI: 10.1111/hex.12537] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND There is a growing interest in identifying strategies to achieve safer primary health-care provision. However, most of the research conducted so far in this area relies on information supplied by health-care providers, and limited attention has been paid to patients' perspectives. OBJECTIVE To explore patients' experiences and perceptions of patient safety in English general practices with the aim of eliciting patient-centred recommendations for improving patient safety. METHODS The Patient Reported Experiences and Outcomes of Safety in Primary Care questionnaire was sent to a random sample of 6736 primary care users registered in 45 English practices. We conducted a qualitative content analysis of responses to seven open-ended items addressing patients' experiences of safety problems, lessons learnt as a result of such experiences and recommendations for safer health care. RESULTS A total of 1244 (18.4%) participants returned completed questionnaires. Of those, 678 (54.5%) responded to at least one open-ended question. Two main themes emerged as follows: (i) experiences of safety problems and (ii) good practices and recommendations to improve patient safety in primary care. Most frequent experiences of safety problems were related to appointments, coordination between providers, tests, medication and diagnosis. Patients' responses to these problems included increased patient activation (eg speaking up about concerns with their health care) and avoidance of unnecessary health care. Recommendations for safer health care included improvements in patient-centred communication, continuity of care, timely appointments, technical quality of care, active monitoring, teamwork, health records and practice environment. CONCLUSION This study identified a number of patient-centred recommendations for improving patient safety in English general practices.
Collapse
Affiliation(s)
| | - Lorena Saletti‐Cuesta
- National Scientific and Technical Research Council (CONICET)Culture and Society Research and Study Centre (CIECS‐CONICET‐UNC)CórdobaArgentina
| | - Sarah P. Slight
- Division of PharmacySchool of Medicine, Pharmacy and HealthDurham UniversityStockton on TeesUK
- Department of PharmacyNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastleUK
- Division of General Internal MedicineCentre for Patient Safety Research and PracticeBrigham and Women's HospitalHarvard Medical SchoolBostonMAUSA
| | - Jose M. Valderas
- Health Services and Policy Research GroupPatient Centred CareUniversity of Exeter Collaboration for Academic Primary Care (APEx)University of Exeter Medical SchoolUniversity of ExeterExeterUK
| |
Collapse
|
12
|
Ricci-Cabello I, Reeves D, Bell BG, Valderas JM. Identifying patient and practice characteristics associated with patient-reported experiences of safety problems and harm: a cross-sectional study using a multilevel modelling approach. BMJ Qual Saf 2017; 26:899-907. [DOI: 10.1136/bmjqs-2016-006411] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 05/08/2017] [Accepted: 05/12/2017] [Indexed: 11/03/2022]
|
13
|
Patients' evaluations of patient safety in English general practices: a cross-sectional study. Br J Gen Pract 2017; 67:e474-e482. [PMID: 28583945 DOI: 10.3399/bjgp17x691085] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/08/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Description of safety problems and harm in general practices has previously relied on information from health professionals, with scarce attention paid to experiences of patients. AIM To examine patient-reported experiences and outcomes of patient safety in primary care. DESIGN AND SETTING Cross-sectional study in 45 general practices across five regions in the north, centre, and south of England. METHOD A version of the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire was sent to a random sample of 6736 patients. Main outcome measures included 'practice activation' (what a practice does to create a safe environment); 'patient activation' (how proactive are patients in ensuring safe healthcare delivery); 'experiences of safety events' (safety errors); 'outcomes of safety' (harm); and 'overall perception of safety' (how safe patients rate their practice). RESULTS Questionnaires were returned by 1244 patients (18.4%). Scores were high for 'practice activation' (mean [standard error] = 80.4 out of 100 [2.0]) and low for 'patient activation' (26.3 out of 100 [2.6]). Of the patients, 45% reported experiencing at least one safety problem in the previous 12 months, mostly related to appointments (33%), diagnosis (17%), patient provider communication (15%), and coordination between providers (14%). Twenty-three per cent of the responders reported some degree of harm in the previous 12 months. The overall assessment of level of safety of practices was generally high (86.0 out of 100 [16.8]). CONCLUSION Priority areas for patient safety improvement in general practices in England include appointments, diagnosis, communication, coordination, and patient activation.
Collapse
|
14
|
Ricci-Cabello I, Pons-Vigués M, Berenguera A, Pujol-Ribera E, Slight SP, Valderas JM. Patients' perceptions and experiences of patient safety in primary care in England. Fam Pract 2016; 33:535-42. [PMID: 27312563 DOI: 10.1093/fampra/cmw046] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND One of the most remarkable features of patient safety research in primary care is the sparse attention paid to patients' own experiences. OBJECTIVE To explore patient's perceptions and experiences of patient safety in primary care in England. METHODS We conducted a qualitative study in the South of England with an opportunistic sample of 27 primary care users. Information was obtained from four patient focus groups. A thematic content analysis was conducted by three analysts and consensus reached within the research team on the key themes that emerged. RESULTS Participants' conceptualizations of patient safety referred to high standards of health care delivery within a relationship of trust. Participants identified four main factors that they believed could potentially affect patient safety. These included factors related to (i) the patient (attitudes, behaviours and health literacy); (ii) the health professional (attitudes, behaviours and accuracy of diagnoses); (iii) the relationship between patients and health professionals (communication and trust); and (iv) the health care system (workload, resources, care coordination, accessibility, interdisciplinary teamwork and accuracy of health care records). Confidentiality, continuity of care and treatment-related safety emerged as cross-cutting major threats to patient safety. CONCLUSIONS The exploration of participants' perceptions and experiences allowed the identification of a wide variety of themes that were perceived to impact on patient safety in primary care. The findings of this study could be used to enrich current frameworks that are exclusively based on professional or health care system perspectives.
Collapse
Affiliation(s)
- Ignacio Ricci-Cabello
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK,
| | - Mariona Pons-Vigués
- Àrea de recerca. Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain, Centre de recerca adscrit. Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Anna Berenguera
- Àrea de recerca. Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain, Centre de recerca adscrit. Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Enriqueta Pujol-Ribera
- Àrea de recerca. Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain, Centre de recerca adscrit. Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Sarah Patricia Slight
- Department of Pharmacy, School of Medicine Pharmacy and Health, Durham University, Durham, UK, Department of Pharmacy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA and
| | - Jose Maria Valderas
- Institute for Health Research, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, Exeter, UK
| |
Collapse
|
15
|
Roddis JK, Holloway I, Bond C, Galvin KT. Living with a long-term condition: Understanding well-being for individuals with thrombophilia or asthma. Int J Qual Stud Health Well-being 2016; 11:31530. [PMID: 27534945 PMCID: PMC4989274 DOI: 10.3402/qhw.v11.31530] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2016] [Indexed: 11/14/2022] Open
Abstract
A range of literature has explored the experience of living with a long-term condition (LTC), and frequently treats such experiences and conditions as problematic. In contrast, other research has demonstrated that it may be possible to adapt and achieve well-being, even when living with such a condition. This tends to focus on meaning and the qualitative experience of living with an LTC, and offers alternative perspectives, often of the same or similar conditions. As a result of these conflicting views, this study chose to consider two conditions which, though they may lead to life-threatening illness on occasion, do not appear to impact significantly the lives of all those affected on a daily basis. The aim of this research was to explore and explain how people make sense of two long-term, potentially life-threatening health conditions, namely, thrombophilia and asthma. In doing so, it specifically considered the contribution made by information about the condition. A constructivist grounded theory approach was adopted; this enabled the generation of a theory regarding how people make sense of their LTC, whilst acknowledging the social circumstances in which this was situated. Semi-structured interviews were conducted with 16 participants who had given consent to take part in the research. The findings demonstrate that participants undergo a two-stage process—gaining knowledge and living with a long-term condition. The theory based on these findings indicates that those who are knowledgeable about their condition, making informed decisions in relation to it, and accept their condition are able to live with it, whilst those who do not accept their condition do not fully adapt to it or integrate it into their lives.
Collapse
Affiliation(s)
- Jennifer K Roddis
- Faculty of Health and Social Sciences at Bournemouth University, Bournemouth, UK;
| | - Immy Holloway
- Faculty of Health and Social Sciences at Bournemouth University, Bournemouth, UK
| | - Carol Bond
- Faculty of Health and Social Sciences at Bournemouth University, Bournemouth, UK
| | - Kathleen T Galvin
- College of Life, Health and Physical Sciences, University of Brighton, UK
| |
Collapse
|
16
|
Oliveira LPBAD, Santos SMAD. [An integrative review of drug utilization by the elderly in primary health care]. Rev Esc Enferm USP 2016; 50:167-79. [PMID: 27007434 DOI: 10.1590/s0080-623420160000100021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 10/10/2015] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To identify knowledge produced about drug utilization by the elderly in the primary health care context from 2006 to 2014. METHOD An integrative review of the PubMed, LILACS, BDENF, and SCOPUS databases, including qualitative research papers in Portuguese, English, and Spanish. It excluded papers with insufficient information regarding the methodological description. RESULTS Search found 633 papers that, after being subjected to the inclusion and exclusion criteria, made up a corpusof 76 publications, mostly in English and produced in the United States, England, and Brazil. Results were pooled in eight thematic categories showing the current trend of drug use in the elderly, notably the use of psychotropics, polypharmacy, the prevention of adverse events, and adoption of technologies to facilitate drug management by the elderly. Studies point out the risks posed to the elderly as a consequence of changes in metabolism and simultaneous use of several drugs. CONCLUSION There is strong concern about improving communications between professionals and the elderly in order to promote an exchange of information about therapy, and in this way prevent major health complications in this population.
Collapse
|
17
|
Rhodes P, McDonald R, Campbell S, Daker-White G, Sanders C. Sensemaking and the co-production of safety: a qualitative study of primary medical care patients. SOCIOLOGY OF HEALTH & ILLNESS 2016; 38:270-285. [PMID: 26547907 DOI: 10.1111/1467-9566.12368] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This study explores the ways in which patients make sense of 'safety' in the context of primary medical care. Drawing on qualitative interviews with primary care patients, we reveal patients' conceptualisation of safety as fluid, contingent, multi-dimensional, and negotiated. Participant accounts drew attention to a largely invisible and inaccessible (but taken for granted) architecture of safety, the importance of psycho-social as well as physical dimensions and the interactions between them, informal strategies for negotiating safety, and the moral dimension of safety. Participants reported being proactive in taking action to protect themselves from potential harm. The somewhat routinised and predictable nature of the primary medical care consultation, which is very different from 'one off' inpatient spells, meant that patients were not passive recipients of care. Instead they had a stock of accumulated knowledge and experience to inform their actions. In addition to highlighting the differences and similarities between hospital and primary care settings, the study suggests that a broad conceptualisation of patient safety is required, which encompasses the safety concerns of patients in primary care settings.
Collapse
Affiliation(s)
- Penny Rhodes
- NIHR School for Primary Care Research, University of Manchester
| | - Ruth McDonald
- Manchester Business School and NIHR School for Primary Care Research, University of Manchester
| | - Stephen Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre (GM PSTRC), NIHR School for Primary Care Research, University of Manchester & Research and Action in Public Health (CeRAPH), University of Canberra
| | - Gavin Daker-White
- NIHR Greater Manchester Patient Safety Translational Research Centre (GM PSTRC), University of Manchester
| | - Caroline Sanders
- NIHR School for Primary Care Research & Manchester Academic Health Sciences Centre (MAHSC), University of Manchester
| |
Collapse
|
18
|
Daker-White G, Hays R, McSharry J, Giles S, Cheraghi-Sohi S, Rhodes P, Sanders C. Blame the Patient, Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care. PLoS One 2015; 10:e0128329. [PMID: 26244494 PMCID: PMC4526558 DOI: 10.1371/journal.pone.0128329] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/26/2015] [Indexed: 11/26/2022] Open
Abstract
Objective Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model. Method Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies. Results Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system. Conclusion Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.
Collapse
Affiliation(s)
- Gavin Daker-White
- National Institute for Health Research (NIHR), Greater Manchester Patient Safety Translational Research Centre, Institute of Population Health, University of Manchester, Manchester, United Kingdom
- * E-mail:
| | - Rebecca Hays
- National Institute for Health Research (NIHR), Greater Manchester Patient Safety Translational Research Centre, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Jennifer McSharry
- Department of Psychology, National University of Ireland (NUI) Galway, Galway, Ireland
| | - Sally Giles
- National Institute for Health Research (NIHR), Greater Manchester Patient Safety Translational Research Centre, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Sudeh Cheraghi-Sohi
- National Institute for Health Research (NIHR), Greater Manchester Patient Safety Translational Research Centre, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Penny Rhodes
- NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Caroline Sanders
- NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| |
Collapse
|
19
|
Rhodes P, Campbell S, Sanders C. Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study. Health Expect 2015; 19:253-63. [PMID: 25644998 PMCID: PMC5024004 DOI: 10.1111/hex.12342] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2014] [Indexed: 11/29/2022] Open
Abstract
Introduction Patient safety research has tended to focus on hospital settings, although most clinical encounters occur in primary care, and to emphasize practitioner errors, rather than patients' own understandings of safety. Objective To explore patients' understandings of safety in primary care. Methods Qualitative interviews were conducted with patients recruited from general practices in northwest England. Participants were asked basic socio‐demographic information; thereafter, topics were largely introduced by interviewees themselves. Transcripts were coded and analysed using NVivo10 (qualitative data software), following a process of constant comparison. Results Thirty‐eight people (14 men, 24 women) from 19 general practices in rural, small town and city locations were interviewed. Many of their concerns (about access, length of consultation, relationship continuity) have been discussed in terms of quality, but, in the interviews, were raised as matters of safety. Three broad themes were identified: (i) trust and psycho‐social aspects of professional–patient relationships; (ii) choice, continuity, access, and the temporal underpinnings of safety; and (iii) organizational and systems‐level tensions constraining safety. Discussion Conceptualizations of safety included common reliance on a bureaucratic framework of accreditation, accountability, procedural rules and regulation, but were also individual and context‐dependent. For patients, safety is not just a property of systems, but personal and contingent and is realized in the interaction between doctor and patient. However, it is the systems approach that has dominated safety thinking, and patients' individualistic and relational conceptualizations are poorly accommodated within current service organization.
Collapse
Affiliation(s)
- Penny Rhodes
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health, University of Manchester, Manchester, UK
| | - Stephen Campbell
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health, University of Manchester, Manchester, UK
| | - Caroline Sanders
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| |
Collapse
|
20
|
Daker-White G, Hays R, Esmail A, Minor B, Barlow W, Brown B, Blakeman T, Bower P. MAXimising Involvement in MUltiMorbidity (MAXIMUM) in primary care: protocol for an observation and interview study of patients, GPs and other care providers to identify ways of reducing patient safety failures. BMJ Open 2014; 4:e005493. [PMID: 25138807 PMCID: PMC4139641 DOI: 10.1136/bmjopen-2014-005493] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Increasing numbers of older people are living with multiple long-term health conditions but global healthcare systems and clinical guidelines have traditionally focused on the management of single conditions. Having two or more long-term conditions, or 'multimorbidity', is associated with a range of adverse consequences and poor outcomes and could put patients at increased risk of safety failures. Traditionally, most research into patient safety failures has explored hospital or inpatient settings. Much less is known about patient safety failures in primary care. Our core aims are to understand the mechanisms by which multimorbidity leads to safety failures, to explore the different ways in which patients and services respond (or fail to respond), and to identify opportunities for intervention. METHODS AND ANALYSIS We plan to undertake an applied ethnographic study of patients with multimorbidity. Patients' interactions and environments, relevant to their healthcare, will be studied through observations, diary methods and semistructured interviews. A framework, based on previous studies, will be used to organise the collection and analysis of field notes, observations and other qualitative data. This framework includes the domains: access breakdowns, communication breakdowns, continuity of care errors, relationship breakdowns and technical errors. ETHICS AND DISSEMINATION Ethical approval was received from the National Health Service Research Ethics Committee for Wales. An individual case study approach is likely to be most fruitful for exploring the mechanisms by which multimorbidity leads to safety failures. A longitudinal and multiperspective approach will allow for the constant comparison of patient, carer and healthcare worker expectations and experiences related to the provision, integration and management of complex care. This data will be used to explore ways of engaging patients and carers more in their own care using shared decision-making, patient empowerment or other relevant models.
Collapse
Affiliation(s)
- Gavin Daker-White
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), University of Manchester, Manchester, UK
| | - Rebecca Hays
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), University of Manchester, Manchester, UK
| | - Aneez Esmail
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), University of Manchester, Manchester, UK
| | - Brian Minor
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), University of Manchester, Manchester, UK
| | - Wendy Barlow
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), University of Manchester, Manchester, UK
| | - Benjamin Brown
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Thomas Blakeman
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Peter Bower
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| |
Collapse
|