Variations in GP-patient communication by ethnicity, age, and gender: evidence from a national primary care patient survey

Call to action on diabetes care: reaching communities facing health inequalities, health inequities and deprivation

This article presents evidence and policy on the importance of reaching out into local communities with inclusive approaches to try to reduce and prevent inequities and inequalities in diabetes care. The global emergency diabetes is causing and the risks and disproportionately high ethnic disparities are investigated. The article includes some suggestions on changing approaches to reduce health inequalities to enable diabetes care to become more accessible for those who need it the most.

Cross-sectional analyses of online appointment booking and repeat prescription ordering user characteristics in general practices of England in the years 2018-2020

OBJECTIVES

To explore the characteristics of the General Practice Patient Survey (GPPS) respondents using the different functionalities of the online services in the context of England's National Health Service General Practices. We hypothesised that respondents who are older, with lower socioeconomic status and non-white ethnicity would be less likely to use online services, while long-term conditions might increase their usage.

DESIGN

Cross-sectional study using respondent-level data from the GPPS in England of the years 2018, 2019 and 2020. We assessed the association between online services use and respondent characteristics using two-level mixed-effects logistic regression.

PARTICIPANTS

Survey respondents of the GPPS 2018-2020.

PRIMARY OUTCOME MEASURES

Online appointment booking and online repeat prescription ordering.

RESULTS

1 807 049 survey respondents were included in this study. 15% (n=263 938) used online appointment booking in the previous 12 months, and 19% (n=339 449) had ordered a repeat prescription in the previous 12 months. Respondents with a long-term condition, on regular multiple medications, who have deafness or hearing loss and who are from the lowest deprivation quintile were more likely to have used online services. Male respondents (compared with females) and respondents with black and other ethnicity compared with white ethnicity were less likely to use online services. Respondents over 85 years old were less likely to use online appointment booking and online repeat prescription ordering compared with the younger age groups.

CONCLUSIONS

Specific groups of respondents were more likely to use online services such as patients with long-term conditions or those with deafness or hearing loss. While online services could provide efficiency to patients and practices it is essential that alternatives continue to be provided to those that cannot use or choose not to use online services. Understanding the different patients' needs could inform solutions to increase the uptake and use of the services.

Reynolds N, R. Barnes M, Hull S, Finer S, Mathur R. Ethnic differences in early onset multimorbidity and associations with health service use, long-term prescribing, years of life lost, and mortality: A cross-sectional study using clustering in the UK Clinical Practice Research Datalink

BACKGROUND

The population prevalence of multimorbidity (the existence of at least 2 or more long-term conditions [LTCs] in an individual) is increasing among young adults, particularly in minority ethnic groups and individuals living in socioeconomically deprived areas. In this study, we applied a data-driven approach to identify clusters of individuals who had an early onset multimorbidity in an ethnically and socioeconomically diverse population. We identified associations between clusters and a range of health outcomes.

METHODS AND FINDINGS

Using linked primary and secondary care data from the Clinical Practice Research Datalink GOLD (CPRD GOLD), we conducted a cross-sectional study of 837,869 individuals with early onset multimorbidity (aged between 16 and 39 years old when the second LTC was recorded) registered with an English general practice between 2010 and 2020. The study population included 777,906 people of White ethnicity (93%), 33,915 people of South Asian ethnicity (4%), and 26,048 people of Black African/Caribbean ethnicity (3%). A total of 204 LTCs were considered. Latent class analysis stratified by ethnicity identified 4 clusters of multimorbidity in White groups and 3 clusters in South Asian and Black groups. We found that early onset multimorbidity was more common among South Asian (59%, 33,915) and Black (56% 26,048) groups compared to the White population (42%, 777,906). Latent class analysis revealed physical and mental health conditions that were common across all ethnic groups (i.e., hypertension, depression, and painful conditions). However, each ethnic group also presented exclusive LTCs and different sociodemographic profiles: In White groups, the cluster with the highest rates/odds of the outcomes was predominantly male (54%, 44,150) and more socioeconomically deprived than the cluster with the lowest rates/odds of the outcomes. On the other hand, South Asian and Black groups were more socioeconomically deprived than White groups, with a consistent deprivation gradient across all multimorbidity clusters. At the end of the study, 4% (34,922) of the White early onset multimorbidity population had died compared to 2% of the South Asian and Black early onset multimorbidity populations (535 and 570, respectively); however, the latter groups died younger and lost more years of life. The 3 ethnic groups each displayed a cluster of individuals with increased rates of primary care consultations, hospitalisations, long-term prescribing, and odds of mortality. Study limitations include the exclusion of individuals with missing ethnicity information, the age of diagnosis not reflecting the actual age of onset, and the exclusion of people from Mixed, Chinese, and other ethnic groups due to insufficient power to investigate associations between multimorbidity and health-related outcomes in these groups.

CONCLUSIONS

These findings emphasise the need to identify, prevent, and manage multimorbidity early in the life course. Our work provides additional insights into the excess burden of early onset multimorbidity in those from socioeconomically deprived and diverse groups who are disproportionately and more severely affected by multimorbidity and highlights the need to ensure healthcare improvements are equitable.

Ethnic inequalities in patient satisfaction with primary health care in England: Evidence from recent General Practitioner Patient Surveys (GPPS)

AIMS AND OBJECTIVES

This paper aims to improve understanding of factors that contribute to persistent ethnic disparities in patient satisfaction in England. The specific objectives are to (i) examine ethnic differences in patient satisfaction with their primary care in England; and (ii) establish factors that contribute to ethnic differences in patient satisfaction.

DATA AND METHODS

The study is based on secondary analysis of recent General Practitioner Patient Survey (GPPS) datasets of 2019, 2020 and 2021. Descriptive bivariate analysis was used to examine ethnic differences in patient satisfaction across the three years. This was followed with multilevel linear regression, with General Practice (GP) at level-1 and Clinical Commissioning Group (CCG) at level-2 to identify factors contributing to ethnic differences in patient satisfaction.

RESULTS

The findings show consistent negative correlations between the proportion of patients reporting good (very or fairly good) overall experience and each of the ethnic minority groups. Further examination of the distribution of patient satisfaction by ethnicity, based on combined ethnic minority groups, depicted a clear negative association between ethnic minority group and patient satisfaction at both GP and CCG levels. Multilevel regression analysis identified several service-related factors (especially ease of using GP website and being treated with care and concern) that largely explained the ethnic differences in patient satisfaction. Of all factors relating to patient characteristics considered in the analysis, none was significant after controlling for GP service-related factors.

CONCLUSIONS

Ethnic minority patients in England continue to consistently report lower satisfaction with their primary health care in recent years. This is largely attributable to supply (service related) rather than demand (patient characteristics) factors. These findings have important implications for health care system policy and practice at both GP and CCG levels in England.

Online and telephone access to general practice: a cross-sectional patient survey

Background

Improving access to primary health care in the UK has focused on the use of telephone and online access, but little is known about how awareness of and use varies between different patient groups.

Aim

To determine how patients are interacting with telephone and online channels for accessing general practice services and information, and to analyse how this varies according to patient characteristics and health status.

Design & setting

A cross-sectional self-administered survey of adult patients in general practices across the West Midlands, UK.

Method

Descriptive statistics were used to show participants’ awareness of and interaction with online information sources and remote access. Multivariable logistic regression was used to model the relationships between demographic and health characteristics, and awareness and use of online services and alternatives to face-to-face consultations (for example, telephone).

Results

A total of 2789 patients (19.0% response rate) from 43 general practices participated. The study found 60.8% (n = 1651/2715) of participants were aware of online services and 30.3% (n = 811/2674) reported having used one. Daily internet usage and frequently visiting the GP showed the strongest associations with knowledge and use of online services.

Conclusion

The study shows that there is the potential for inequitable awareness and use of telephone and online services in general practice populations. Given that their use has greatly increased owing to the COVID-19 pandemic, future service design will need to ensure equity is taken into account.

Effectiveness of community interventions for protecting and promoting the mental health of working-age adults experiencing financial uncertainty: a systematic review

BACKGROUND

The COVID-19 pandemic has created a period of global economic uncertainty. Financial strain, personal debt, recent job loss and housing insecurity are important risk factors for the mental health of working-age adults. Community interventions have the potential to attenuate the mental health impact of these stressors. We examined the effectiveness of community interventions for protecting and promoting the mental health of working-age adults in high-income countries during periods of financial insecurity.

METHODS

Eight electronic databases were systematically screened for experimental and observational studies published since 2000 measuring the effectiveness of community interventions on mental health outcomes. We included any non-clinical intervention that aimed to address the financial, employment, food or housing insecurity of participants. A review protocol was registered on the PROSPERO database (CRD42019156364) and results are reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

From 2326 studies screened, 15 met our inclusion criteria. Five categories of community intervention were identified: advice services colocated in healthcare settings; link worker social prescribing; telephone debt advice; food insecurity interventions; and active labour market programmes. In general, the evidence for effective and cost-effective community interventions delivered to individuals experiencing financial insecurity was lacking. From the small number of studies without a high risk of bias, there was some evidence that financial insecurity and associated mental health problems were amenable to change and differences by subpopulations were observed.

CONCLUSION

There is a need for well-controlled studies and trials to better understand effective ingredients and to identify those interventions warranting wider implementation.

Cancer diagnosis, treatment and care: A qualitative study of the experiences and health service use of Roma, Gypsies and Travellers

BACKGROUND

Early diagnosis and treatment are key to reducing deaths from cancer, but people from Black and Minority Ethnic (BME) groups are more likely to encounter delays in entering the cancer care system. Roma, Gypsies and Travellers are ethnic minorities who experience extreme health inequalities.

OBJECTIVE

To explore the experiences of cancer diagnosis, treatment and care among people who self-identify as Roma or Gypsies and Travellers.

METHODS

A participatory qualitative approach was taken. Peer researchers conducted semi-structured interviews (n = 37) and one focus group (n = 4) with community members in Wales and England, UK.

RESULTS

Cancer fatalism is declining, but Roma, Gypsies and Travellers experience barriers to cancer healthcare at service user, service provider and organisational levels. Communication was problematic for all groups, and Roma participants reported lack of access to interpreters within primary care. Clear communication and trusting relationships with health professionals are highly valued and most frequently found in tertiary care.

CONCLUSION

This study suggests that Roma, Gypsies and Travellers are motivated to access health care for cancer diagnosis and treatment, but barriers experienced in primary care can prevent or delay access to diagnostic and treatment services. Organisational changes, plus increased cultural competence among health professionals, have the potential to reduce inequalities in early detection of cancer.

The use of experimental vignette studies to identify drivers of variations in the delivery of health care: a scoping review

Background

Identifying how unwarranted variations in healthcare delivery arise is challenging. Experimental vignette studies can help, by isolating and manipulating potential drivers of differences in care. There is a lack of methodological and practical guidance on how to design and conduct these studies robustly. The aim of this study was to locate, methodologically assess, and synthesise the contribution of experimental vignette studies to the identification of drivers of unwarranted variations in healthcare delivery.

Methods

We used a scoping review approach. We searched MEDLINE, Embase, Web of Science and CINAHL databases (2007–2019) using terms relating to vignettes and variations in healthcare. We screened title/abstracts and full text to identify studies using experimental vignettes to examine drivers of variations in healthcare delivery. Included papers were assessed against a methodological framework synthesised from vignette study design recommendations within and beyond healthcare.

Results

We located 21 eligible studies. Study participants were almost exclusively clinicians (18/21). Vignettes were delivered via text (n = 6), pictures (n = 6), video (n = 6) or interactively, using face-to-face, telephone or online simulated consultations (n = 3). Few studies evaluated the credibility of vignettes, and many had flaws in their wider study design. Ten were of good methodological quality. Studies contributed to understanding variations in care, most commonly by testing hypotheses that could not be examined directly using real patients.

Conclusions

Experimental vignette studies can be an important methodological tool for identifying how unwarranted variations in care can arise. Flaws in study design or conduct can limit their credibility or produce biased results. Their full potential has yet to be realised.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01247-4.

Perceptions of Patient-Provider Communication Across the Six Largest Asian Subgroups in the USA

BACKGROUND

Asians are the fastest-growing racial/ethnic minority group in the USA and many face communication barriers when seeking health care. Given that a high proportion of Asians are immigrants and have limited English proficiency, poor patient-provider communication may explain Asians' relatively low ratings of care. Though Asians are linguistically, economically, and culturally heterogeneous, research on health care disparities typically combines Asians into a single racial/ethnic category.

OBJECTIVES

To estimate racial/ethnic differences in perceptions of provider communication among the six largest Asian subgroups.

DESIGN AND PARTICIPANTS

Using a nationally representative sample of adults from the 2014-2017 Medical Expenditure Panel Survey (N = 136,836, round-specific response rates range from 72% to 98%), we estimate racial/ethnic differences in perceptions of provider communication, adjusted for English proficiency, immigration status, and sociodemographic characteristics.

MAIN MEASURES

The main dependent variable is a 4-item scale ranging from 0 to 100 measuring how positively patients view their health care providers' communication, adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS©) program. Respondents report how often their providers explain things clearly, show respect, listen carefully, and spend enough time with them.

KEY RESULTS

Asians, overall, had less positive perceptions of their providers' communication than either Whites or Latinxs. However, only Chinese-White differences remained after differences in English proficiency and immigration status were controlled (difference = - 2.67, 95% CI - 4.83, - 0.51). No other Asian subgroup differed significantly from Whites.

CONCLUSIONS

Negative views of provider communication are not pervasive among all Asians but, rather, primarily reflect the perceptions of Chinese and, possibly, Vietnamese patients. Researchers, policymakers, health plan executives, and others who produce or use data on patients' experiences with health care should, if possible, avoid categorizing all Asians into a single group.

Primary care experience and remission of type 2 diabetes: a population-based prospective cohort study

BACKGROUND

Remission of Type 2 diabetes is achievable through dietary change and weight loss. In the UK, lifestyle advice and referrals to weight loss programmes predominantly occur in primary care where most Type 2 diabetes is managed.

OBJECTIVE

To quantify the association between primary care experience and remission of Type 2 diabetes over 5-year follow-up.

METHODS

A prospective cohort study of adults with Type 2 diabetes registered to 49 general practices in the East of England, UK. Participants were followed-up for 5 years and completed the Consultation and Relational Empathy measure (CARE) on diabetes-specific primary care experiences over the first year after diagnosis of the disease. Remission at 5-year follow-up was measured with HbA1c levels. Univariable and multivariable logistic regression models were constructed to quantify the association between primary care experience and remission of diabetes.

RESULTS

Of 867 participants, 30% (257) achieved remission of Type 2 diabetes at 5 years. Six hundred twenty-eight had complete data at follow-up and were included in the analysis. Participants who reported higher CARE scores in the 12 months following diagnosis were more likely to achieve remission at 5 years in multivariable models; odds ratio = 1.03 (95% confidence interval = 1.01-1.05, P = 0.01).

CONCLUSION

Primary care practitioners should pay greater attention to delivering optimal patient experiences alongside clinical management of the disease as this may contribute towards remission of Type 2 diabetes. Further work is needed to examine which aspects of the primary care experience might be optimized and how these could be operationalized.

Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey

BACKGROUND

The population of older adults (ie, those aged ≥55 years) in England is becoming increasingly ethnically diverse. Previous reports indicate that ethnic inequalities in health exist among older adults, but information is limited by the paucity of data from small minority ethnic groups. This study aimed to analyse inequalities in health-related quality of life (HRQoL) and five determinants of health in older adults across all ethnic groups in England.

METHODS

In this cross-sectional study, we analysed data from five waves (July 1, 2014, to April 7, 2017) of the nationally representative English General Practice Patient Survey (GPPS). Study participants were adults aged 55 years or older who were registered with general practices in England. We used regression models (age-adjusted and stratified by gender) to estimate the association between ethnicity and HRQoL, measured by use of the EQ-5D-5L index and its domains (mobility, self-care, usual activities, pain or discomfort, and anxiety or depression). We also estimated associations between ethnicity and five determinants of health (presence of long-term conditions or multimorbidity, experience of primary care, degree of support from local services, patient self-confidence in managing own health, and degree of area-level social deprivation). We examined robustness to differential handling of missing data, alternative EQ-5D-5L value sets, and differences in area-level social deprivation.

FINDINGS

There were 1 416 793 GPPS respondents aged 55 years and older. 1 394 361 (98·4%) respondents had complete data on ethnicity and gender and were included in our analysis. Of these, 152 710 (11·0%) self-identified as belonging to minority ethnic groups. HRQoL was worse for men or women, or both, in 15 (88·2%) of 17 minority ethnic groups than the White British ethnic group. In both men and women, inequalities were widest for Gypsy or Irish Traveller (linear regression coefficient -0·192 [95% CI -0·318 to -0·066] in men; -0·264 [-0·354 to -0·173] in women), Bangladeshi (-0·111 [-0·136 to -0·087] in men; -0·209 [-0·235 to -0·184] in women), Pakistani (-0·084 [-0·096 to -0·073] in men; -0·206 [-0·219 to -0·193] in women), and Arab (-0·061 [-0·086 to -0·035] in men; -0·145 [-0·180 to -0·110] in women) ethnic groups, with magnitudes generally greater for women than men. Differentials tended to be widest for the self-care EQ-5D-5L domain. Ethnic inequalities in HRQoL were accompanied by increased prevalence of long-term conditions or multimorbidity, poor experiences of primary care, insufficient support from local services, low patient self-confidence in managing their own health, and high area-level social deprivation, compared with the White British group.

INTERPRETATION

We found evidence of wide ethnic inequalities in HRQoL and five determinants of health for older adults in England. Outcomes varied between minority ethnic groups, highlighting heterogeneity in the direction and magnitude of associations. We recommend further research to understand the drivers of inequalities, together with policy changes to improve equity of socioeconomic opportunity and access to services for older adults from minority ethnic groups.

FUNDING

University of Manchester and National Institute for Health Research.

Barriers to diabetes awareness and self-help are influenced by people's demographics: perspectives of South Asians with type 2 diabetes

Aim: To determine whether barriers to diabetes awareness and self-help differ in South Asian participants of different demographic characteristics (age, gender, and literacy) with type 2 diabetes living in the United Kingdom. Methods: Six focus group discussions (FGDs) were carried out in patients who were categorized according to age (30-60 years, ≥60 years), gender (male, female) and literacy status (literate, illiterate). Data were analysed following the iterative process of thematic analysis techniques. Results: Barriers were demographic-specific. The illiterate groups reported language as the major barrier to improved diabetes awareness and self-help. The literate groups reported that information provided by healthcare providers was general, and not specific to their diet/culture. Major barriers to adherence to the recommended diet for diabetes included: insufficient knowledge/awareness about nutritional content of food (all groups); lack of self-will to resist eating sweets, especially during weddings/festivals (literate older groups/literate younger females/illiterate older males); difficulty cooking separate meals for diabetic and non-diabetic family members (illiterate/literate older females). Other barriers to seeking advice/help ranged from not wanting to disclose their diabetes as it may affect employment/work (literate groups) to fear of being singled out at social gatherings (illiterate groups). General lack of motivation to exercise was reported by all groups. Time constraints and not knowing what/how to exercise was reported by literate younger groups whilst the illiterate older groups reported to not having suitable exercising facilities at local communities. Different barriers were also reported when accessing healthcare; language barriers (illiterate groups), restricted access to doctors' appointments/difficulty attending specific appointment slots offered by General Practitioners (literate females). Conclusion: Different barriers exist to improved awareness about diabetes and self-help in different patient demographics. Lack of culturally appropriate diabetes educational/awareness programs in the community appeared to be a major barrier in most older and illiterate participants while younger participants reported time constraint.

Can Patient Reported Outcomes (PROs) from Population Surveys Provide Accurate Estimates of Pre-Admission Health Status of Emergency Hospital Admissions?

INTRODUCTION

The use of PROs for assessing the outcomes of emergency hospital admissions requires a means of estimating patients' pre-admission health status. A possible alternative to asking patients to recall how their health was before the incident causing admission is to use estimates derived from matched samples from population surveys. Our aims were to explore the impact of different methods of matching and to compare the results with estimates based on retrospective reporting.

METHODS

First, elective hip arthroplasty patients were matched to respondents to the General Practice Patient Survey using age, sex, socio-economic status and number of comorbidities. The impact of restricting matching for locality and specific co-morbidities was explored. Second, the best matching method was applied to emergency admissions for laparotomy and for percutaneous coronary intervention (PCI) after acute myocardial infarction. Data were stratified by patient characteristics. Differences in mean EQ-5D scores between the patients and matched population respondents were tested using t tests.

RESULTS

Modifying the most basic form of matching by also taking locality and the specific comorbid conditions into account made no significant difference to the mean EQ-5D score for hip arthroplasty patients. Even using the most detailed matching possible, patients' mean EQ-5D score was significantly different to that of the general population for all three cohorts. The difference was greatest for elective hip arthroplasty (0.22 v 0.64), less so for emergency laparotomy (0.56 v 0.72) and least for PCI (0.79 v 0.71). This reflects hip arthroplasty patients having a long-standing condition characterised by pain and limited mobility, whereas the other two cohorts may have enjoyed reasonable health until an unexpected acute episode led to their emergency admission.

CONCLUSION

Routine PRO data acquired from population surveys cannot be used as an accurate alternative to retrospectively reported PROMs by patients during their emergency admission episode.

Ethnic differences in the severity and clinical management of type 2 diabetes at time of diagnosis: A cohort study in the UK Clinical Practice Research Datalink

AIMS

To characterize ethnic differences in the severity and clinical management of type 2 diabetes at initial diagnosis.

METHODS

An observational cohort study of 179,886 people with incident type 2 diabetes between 2004 and 2017 in the Clinical Practice Research Datalink was undertaken; 63.4% of the cohort were of white ethnicity, 3.9% south Asian, and 1.6% black. Ethnic differences in clinical profile at diagnosis, consultation rates, and risk factor recording were derived from linear and logistic regression. Cox-proportional hazards regression was used to determine ethnic differences in time to initiation of therapeutic and non-therapeutic management following diagnosis. All analyses adjusted for age, sex, deprivation, and clustering by practice.

RESULTS

In the 12 months prior to diagnosis, non-white groups had fewer consultations compared to white groups, but risk factor recording was better than or equivalent to white groups for 9/10 risk factors for south Asian groups and 8/10 risk factors for black groups (p < 0.002). Blood pressure, BMI, cholesterol, eGFR, and CVD risk levels were more favourable in non-white groups, and prevalence of macrovascular disease was significantly lower (p < 0.003). Time to initiation of antidiabetic treatment and first risk assessment was faster in non-white groups relative to white groups, while time to risk factor measurement and diabetes review was slower.

CONCLUSIONS

We find limited evidence of systematic ethnic inequalities around the time of type 2 diabetes diagnosis. Ethnic disparities in downstream consequences may relate to genetic risk factors, or manifest later in the care pathway, potentially in relation to long-term risk factor control.

Ethnic inequalities in doctor-patient communication regarding personal care plans: the mediating effects of positive mental wellbeing

OBJECTIVE

There is limited understanding of ethnic inequalities in doctor-patient communication regarding personal care plans (PCPs). This study investigated the mediating effects of positive mental wellbeing on differences in PCP-related doctor-patient communication amongst South Asian and Caucasian UK residents.

DESIGN

Data from 10,980 respondents to the 2013 Health Survey for England was analysed using bootstrapping methods. Constructs from the WEMWBS (Warwick and Edinburgh Mental Wellbeing Scale) (Stewart-Brown, S., and K. Janmohamed. 2008. Warwick, UK) were assessed as mediators of relations between ethnicity and several doctor-patient communication variables, including PCP-related interactions; (a) had a PCP-related discussion about a long-term condition with a doctor/nurse, and (b) had this conversation within the past year, (c) agreed to a PCP with a health professional; and (d) talked to a doctor in the past 2 weeks.

RESULTS

Bootstrapped mediation analysis (Hayes, A. F. 2013. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-based Approach. New York, NY: The Guilford Press) showed that three positive mind-sets mediated associations between ethnicity and doctor-patient contact, including PCP-related communication. Being able to make up one's mind (ab = -0.05; BC_a CI [-0.14, 0.01]) mediated the effect of ethnicity on agreeing to a PCP, while having energy to spare (ab = 0.07; BC_a CI [-0.04, 0.12]), and feeling good about oneself (ab = 0.03; BC_a CI [0.01, 0.07]), mediated ethnic effects on talking to a doctor during the past fortnight. The mediating effect of reported energy persisted after controlling for medical history, perceived health, and other covariates.

CONCLUSIONS

Ethnic disparities in doctor-patient interaction, including PCP-related communication, are partly explained by positive mental wellbeing. Gauging positive psychological moods in patients, particularly self-worth, self-perceived vigour and decisiveness, are relevant to addressing ethnic inequalities in doctor-patient communication. As PCPs may have direct implications for patient health it is important for health professionals to address deficits in psychological functioning that may precipitate ethnic inequalities in setting up PCPs.

Jezikovne prepreke pri zdravstveni negi tujegovorečih pacientov

Uvod: Jezikovne prepreke ob stiku s tujegovorečim pacientom močno vplivajo na kakovost zdravstvene nege, saj onemogočajo učinkovito komunikacijo med medicinsko sestro in pacientom. Ne glede na spol, narodnost, raso, etnično poreklo, versko pripadnost ali drugo osebno okoliščino imajo pacienti pravico do enake obravnave pri zdravstveni oskrbi. Namen raziskave je bil ugotoviti, kako se medicinske sestre soočajo z jezikovnimi preprekami pri zdravstveni negi tujegovorečih pacientov. Metode: Uporabljena je bila kvalitativna metodologija raziskovanja. Podatki so bili zbrani z delno strukturiranimi intervjuji (n = 5). Vzorec je bil namenski. Za analizo podatkov je bila uporabljena metoda konvencionalne vsebinske analize besedila. Rezultati: S pomočjo vsebinske analize so bile oblikovane tri kategorije proučevanega fenomena: (1) Stik s tujegovorečim pacientom; (2) Soočanje s tujegovorečim pacientom; (3) Reševanje težav v komunikaciji s tujegovorečim pacientom. Soočanje s tujegovorečimi pacienti udeležencem v raziskavi predstavlja stisko, vendar ohranjajo empatičen odnos in se zavedajo nevarnosti, ki jih jezikovne prepreke predstavljajo za pacientovo varnost. Diskusija in zaključek: Udeleženci v raziskavi opozarjajo, da jezikovne prepreke lahko predstavljajo večja tveganja na področju zagotavljanja pacientove varnosti. Obravnavano področje je v slovenskem prostoru slabše raziskano, zato bi bilo treba proučiti različne dimenzije tako jezikovnih kot tudi kulturnih preprek ter sistemsko urediti področje zdravstvene obravnave tujegovorečih pacientov. To bi pomembno prispevalo k vzpostavitvi uspešne komunikacije ter varni in kakovostni zdravstveni negi. 

Discussions about predictive genetic testing for Lynch syndrome: the role of health professionals and families in decisions to decline

Unaffected relatives of individuals with Lynch syndrome can be offered predictive genetic testing to guide surveillance recommendations. The decision-making process of those who decline testing, particularly those who do not attend a clinical genetics service, is poorly understood. We have addressed this gap by interviewing 33 individuals from Lynch syndrome mutation-carrying families, unaffected by cancer, who declined predictive genetic testing. Here, we analyse the data provided by 20 participants who unequivocally declined testing. Those who indicated they did not have enough information to make a decision or intended to undergo testing in the future were excluded. Analysis revealed that few decliners discussed their decision with general practitioners or genetic counsellors. Family members were commonly involved to varying degrees, with participants either (1) making group decisions with family members, (2) feeling persuaded by family members to either accept or decline testing, (3) discussing the test but making their own decision. A minority did not discuss testing with family members while making their decision. This research reveals the health communication activities of an understudied group, those declining predictive testing, and indicates that for many, health professionals play a minor role in the decision compared to family.

Importance of accessibility and opening hours to overall patient experience of general practice: analysis of repeated cross-sectional data from a national patient survey

BACKGROUND

The UK government aims to improve the accessibility of general practices in England, particularly by extending opening hours in the evenings and at weekends. It is unclear how important these factors are to patients' overall experiences of general practice.

AIM

To examine associations between overall experience of general practice and patient experience of making appointments and satisfaction with opening hours.

DESIGN AND SETTING

Analysis of repeated cross-sectional data from the General Practice Patient Surveys conducted from 2011-2012 until 2013-2014. These covered 8289 general practice surgeries in England.

METHOD

Data from a national survey conducted three times over consecutive years were analysed. The outcome measure was overall experience, rated on a five-level interval scale. Associations were estimated as standardised regression coefficients, adjusted for responder characteristics and clustering within practices using multilevel linear regression.

RESULTS

In total, there were 2 912 535 responders from all practices in England (n = 8289). Experience of making appointments (β 0.24, 95% confidence interval [CI] = 0.24 to 0.25) and satisfaction with opening hours (β 0.15, 95% CI = 0.15 to 0.16) were modestly associated with overall experience. Overall experience was most strongly associated with GP interpersonal quality of care (β 0.34, 95% CI = 0.34 to 0.35) and receptionist helpfulness was positively associated with overall experience (β 0.16, 95% CI = 0.16 to 0.17). Other patient experience measures had minimal associations (β≤0.06). Models explained ≥90% of variation in overall experience between practices.

CONCLUSION

Patient experience of making appointments and satisfaction with opening hours were only modestly associated with overall experience. Policymakers in England should not assume that recent policies to improve access will result in large improvements in patients' overall experience of general practice.

Is telephone health coaching a useful population health strategy for supporting older people with multimorbidity? An evaluation of reach, effectiveness and cost-effectiveness using a 'trial within a cohort'

BACKGROUND

Innovative ways of delivering care are needed to improve outcomes for older people with multimorbidity. Health coaching involves 'a regular series of phone calls between patient and health professional to provide support and encouragement to promote healthy behaviours'. This intervention is promising, but evidence is insufficient to support a wider role in multimorbidity care. We evaluated health coaching in older people with multimorbidity.

METHODS

We used the innovative 'Trials within Cohorts' design. A cohort was recruited, and a trial was conducted using a 'patient-centred' consent model. A randomly selected group within the cohort were offered the intervention and were analysed as the intervention group whether they accepted the offer or not. The intervention sought to improve the skills of patients with multimorbidity to deal with a range of long-term conditions, through health coaching, social prescribing and low-intensity support for low mood.

RESULTS

We recruited 4377 older people, and 1306 met the eligibility criteria (two or more long-term conditions and moderate 'patient activation'). We selected 504 for health coaching, and 41% consented. More than 80% of consenters received the defined 'dose' of 4+ sessions. In an intention-to-treat analysis, those selected for health coaching did not improve on any outcome (patient activation, quality of life, depression or self-care) compared to usual care. We examined health care utilisation using hospital administrative and self-report data. Patients selected for health coaching demonstrated lower levels of emergency care use, but an increase in the use of planned services and higher overall costs, as well as a quality-adjusted life year (QALY) gain. The incremental cost per QALY was £8049, with a 70-79% probability of being cost-effective at conventional levels of willingness to pay.

CONCLUSIONS

Health coaching did not lead to significant benefits on the primary measures of patient-reported outcome. This is likely related to relatively low levels of uptake amongst those selected for the intervention. Demonstrating effectiveness in this design is challenging, as it estimates the effect of being selected for treatment, regardless of whether treatment is adopted. We argue that the treatment effect estimated is appropriate for health coaching, a proactive model relevant to many patients in the community, not just those seeking care.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ( ISRCTN12286422 ).

UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): a qualitative interview study

BACKGROUND

Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services, including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations.

AIMS

(1) Investigate the barriers to and facilitators of acceptability and uptake of immunisations among six Traveller communities across four UK cities; and (2) identify possible interventions to increase uptake of immunisations in these Traveller communities that could be tested in a subsequent feasibility study.

METHODS

Three-phase qualitative study underpinned by the social ecological model. Phase 1: interviews with 174 Travellers from six communities: Romanian Roma (Bristol); English Gypsy/Irish Traveller (Bristol); English Gypsy (York); Romanian/Slovakian Roma (Glasgow); Scottish Showpeople (Glasgow); and Irish Traveller (London). Focus on childhood and adult vaccines. Phase 2: interviews with 39 service providers. Data were analysed using the framework approach. Interventions were identified using a modified intervention mapping approach. Phase 3: 51 Travellers and 25 service providers attended workshops and produced a prioritised list of potentially acceptable and feasible interventions.

RESULTS

There were many common accounts of barriers and facilitators across communities, particularly across the English-speaking communities. Scottish Showpeople were the most similar to the general population. Roma communities experienced additional barriers of language and being in a new country. Men, women and service providers described similar barriers and facilitators. There was widespread acceptance of childhood and adult immunisation, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough. Cultural concerns about vaccines offered during pregnancy and about human papillomavirus were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified by Travellers and service providers as barriers for some. Trustful relationships with health professionals were important and continuity of care was valued. A few English-speaking Travellers described problems of booking and attending for immunisation. Service providers tailored their approach to Travellers, particularly the Roma. Funding cuts, NHS reforms and poor monitoring challenged their work. Five 'top-priority' interventions were agreed across communities and service providers to improve the immunisation among Travellers who are housed or settled on an authorised site: (1) cultural competence training for health professionals and frontline staff; (2) identification of Travellers in health records to tailor support and monitor uptake; (3) provision of a named frontline person in general practitioner practices to provide respectful and supportive service; (4) flexible and diverse systems for booking appointments, recall and reminders; and (5) protected funding for health visitors specialising in Traveller health, including immunisation.

LIMITATIONS

No Travellers living on the roadside or on unofficial encampments were interviewed. We should exert caution in generalising to these groups.

FUTURE WORK

To include development, implementation and evaluation of a national policy plan (and practice guidance plan) to promote the uptake of immunisation among Traveller communities.

STUDY REGISTRATION

Current Controlled Trials ISRCTN20019630 and UK Clinical Research Network Portfolio number 15182.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 72. See the NIHR Journals Library website for further project information.

Patient Experiences in a Linguistically Diverse Safety Net Primary Care Setting: Qualitative Study

BACKGROUND

The patient-centered medical home model intends to improve patient experience and primary care quality. Within an urban safety net setting in Northern California, United States, these desired outcomes are complicated by both the diversity of the patient community and the care continuity implications of a residency program.

OBJECTIVE

The objective of our study was to understand the patient experience beyond standardized satisfaction measures.

METHODS

We conducted a qualitative study, interviewing 19 patients from the clinic (English-, Spanish-, or Mien-speaking patients).

RESULTS

Some themes, such as the desire to feel confident in their doctor, emerged across language groups, pointing to institutional challenges. Other themes, such as distrust in care being provided, were tied distinctly to speaking a language different from one's provider. Still other themes, such as a sense of powerlessness, were related to cultural differences and to speaking a language (Mien) not spoken by staff.

CONCLUSIONS

Findings illuminate the need to understand cultural behaviors and interactional styles in a diverse patient population to create a high-quality medical home.

Exploring the impact and use of patients' feedback about their care experiences in general practice settings-a realist synthesis

Background

Policy encourages health care providers to listen and respond to feedback from patients, expecting that it will enhance care experiences. Enhancement of patients' experiences may not yet be a reality, particularly in primary health care settings.

Objective

To identify the issues that influence the use and impact of feedback in this context.

Design and Setting

A realist synthesis of studies of the use of patient feedback within primary health care settings.

Methods

Structured review of published studies between 1971 and January 2015.

Results

Eighteen studies were reported in 20 papers. Eleven studies reported patient survey scores as a primary outcome. There is little evidence that formal patient feedback led to enhanced experiences. The likelihood of patient feedback to health care staff stimulating improvements in future patients' experiences appears to be influenced predominantly by staff perceptions of the purpose of such feedback; the validity and type of data that is collected; and where, when and how it is presented to primary health care teams or practitioners and teams' capacity to change.

Conclusions

There is limited research into how patient feedback has been used in primary health care practices or its usefulness as a stimulant to improve health care experience. Using a realist synthesis approach, we have identified a number of contextual and intervention-related factors that appear to influence the likelihood that practitioners will listen to, act on and achieve improvements in patient experience. Consideration of these may support research and improvement work in this area.

Effect of health literacy on the quality of life of older patients with long-term conditions: a large cohort study in UK general practice

Purpose

The levels of health literacy in patients with long-term conditions (LTCs) are critical for better disease management and quality of life (QoL). However, the impact of health literacy on QoL in older adults with LTCs is unclear. This study examined the association between health literacy and domains of QoL in older people with LTCs, investigating key socio-demographic and clinical variables, as confounders.

Methods

A prospective cohort study was conducted on older adults (n = 4278; aged 65 years and over) with at least one LTC, registered in general practices in Salford, UK. Participants completed measures of health literacy, QoL, multi-morbidity, depression, social support, and socio-demographic characteristics. Multivariate linear regressions were performed to examine the effects of health literacy on four QoL domains at baseline, and then changes in QoL over 12 months.

Results

At baseline, poor health literacy was associated with lower scores in all four QoL domains (physical, psychological, social relationships and environment), after adjusting for the effects of multi-morbidity, depression, social support and socio-demographic factors. At 12-month follow-up, low health literacy significantly predicted declines in the physical, psychological and environment domains of QoL, but not in social relationships QoL.

Conclusions

This is the largest, most complete assessment of the effects of health literacy on QoL in older adults with LTCs. Low health literacy is an independent indicator of poor QoL older patients with LTCs. Interventions to improve health literacy in older people with LTCs are encouraged by these findings.

Patient-reported safety incidents in older patients with long-term conditions: a large cross-sectional study

BACKGROUND

Increasing evidence suggests that patient safety is a serious concern for older patients with long-term conditions. Despite this, there is a lack of research on safety incidents encountered by this patient group. In this study, we sought to examine patient reports of safety incidents and factors associated with reports of safety incidents in older patients with long-term conditions.

METHODS

The baseline cross-sectional data from a longitudinal cohort study were analysed. Older patients (n=3378 aged 65 years and over) with a long-term condition registered in general practices were included in the study. The main outcome was patient-reported safety incidents including availability and appropriateness of medical tests and prescription of wrong types or doses of medication. Binary univariate and multivariate logistic regression analyses were undertaken to examine factors associated with patient-reported safety incidents.

RESULTS

Safety incidents were reported by 11% of the patients. Four factors were significantly associated with patient-reported safety incidents in multivariate analyses. The experience of multiple long-term conditions (OR=1.09, 95% CI 1.05 to 1.13), a probable diagnosis of depression (OR=1.36, 95% CI 1.06 to 1.74) and greater relational continuity of care (OR=1.28, 95% CI 1.08 to 1.52) were associated with increased odds for patient-reported safety incidents. Perceived greater support and involvement in self-management was associated with lower odds for patient-reported safety incidents (OR=0.95, 95% CI 0.93 to 0.97).

CONCLUSIONS

We found that older patients with multimorbidity and depression are more likely to report experiences of patient safety incidents. Improving perceived support and involvement of patients in their care may help prevent patient-reported safety incidents.

Improving patient experience in primary care: a multimethod programme of research on the measurement and improvement of patient experience

Background

There has been an increased focus towards improving quality of care within the NHS in the last 15 years; as part of this, there has been an emphasis on the importance of patient feedback within policy, through National Service Frameworks and the Quality and Outcomes Framework. The development and administration of large-scale national patient surveys to gather representative data on patient experience, such as the national GP Patient Survey in primary care, has been one such initiative. However, it remains unclear how the survey is used by patients and what impact the data may have on practice.

Objectives

Our research aimed to gain insight into how different patients use surveys to record experiences of general practice; how primary care staff respond to feedback; and how to engage primary care staff in responding to feedback.

Methods

We used methods including quantitative survey analyses, focus groups, interviews, an exploratory trial and an experimental vignette study.

Results

(1)Understanding patient experience data. Patients readily criticised their care when reviewing consultations on video, although they were reluctant to be critical when completing questionnaires. When trained raters judged communication during a consultation to be poor, a substantial proportion of patients rated the doctor as ‘good’ or ‘very good’. Absolute scores on questionnaire surveys should be treated with caution; they may present an overoptimistic view of general practitioner (GP) care. However, relative rankings to identify GPs who are better or poorer at communicating may be acceptable, as long as statistically reliable figures are obtained. Most patients have a particular GP whom they prefer to see; however, up to 40% of people who have such a preference are unable regularly to see the doctor of their choice. Users of out-of-hours care reported worse experiences when the service was run by a commercial provider than when it was run by a not-for profit or NHS provider. (2)Understanding patient experience in minority ethnic groups. Asian respondents to the GP Patient Survey tend to be registered with practices with generally low scores, explaining about half of the difference in the poorer reported experiences of South Asian patients than white British patients. We found no evidence that South Asian patients used response scales differently. When viewing the same consultation in an experimental vignette study, South Asian respondents gave higher scores than white British respondents. This suggests that the low scores given by South Asian respondents in patient experience surveys reflect care that is genuinely worse than that experienced by their white British counterparts. We also found that service users of mixed or Asian ethnicity reported lower scores than white respondents when rating out-of-hours services. (3)Using patient experience data. We found that measuring GP–patient communication at practice level masks variation between how good individual doctors are within a practice. In general practices and in out-of-hours centres, staff were sceptical about the value of patient surveys and their ability to support service reconfiguration and quality improvement. In both settings, surveys were deemed necessary but not sufficient. Staff expressed a preference for free-text comments, as these provided more tangible, actionable data. An exploratory trial of real-time feedback (RTF) found that only 2.5% of consulting patients left feedback using touch screens in the waiting room, although more did so when reminded by staff. The representativeness of responding patients remains to be evaluated. Staff were broadly positive about using RTF, and practices valued the ability to include their own questions. Staff benefited from having a facilitated session and protected time to discuss patient feedback.

Conclusions

Our findings demonstrate the importance of patient experience feedback as a means of informing NHS care, and confirm that surveys are a valuable resource for monitoring national trends in quality of care. However, surveys may be insufficient in themselves to fully capture patient feedback, and in practice GPs rarely used the results of surveys for quality improvement. The impact of patient surveys appears to be limited and effort should be invested in making the results of surveys more meaningful to practice staff. There were several limitations of this programme of research. Practice recruitment for our in-hours studies took place in two broad geographical areas, which may not be fully representative of practices nationally. Our focus was on patient experience in primary care; secondary care settings may face different challenges in implementing quality improvement initiatives driven by patient feedback. Recommendations for future research include consideration of alternative feedback methods to better support patients to identify poor care; investigation into the factors driving poorer experiences of communication in South Asian patient groups; further investigation of how best to deliver patient feedback to clinicians to engage them and to foster quality improvement; and further research to support the development and implementation of interventions aiming to improve care when deficiencies in patient experience of care are identified.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Needles, Jabs and Jags: a qualitative exploration of barriers and facilitators to child and adult immunisation uptake among Gypsies, Travellers and Roma

BACKGROUND

Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services including immunisation. To improve immunisation rates, it is necessary to understand what helps and hinders individuals in these communities in taking up immunisations. This study had two aims. 1. Investigate the views of Travellers in the UK on the barriers and facilitators to acceptability and uptake of immunisations and explore their ideas for improving immunisation uptake; 2. Examine whether and how these responses vary across and within communities, and for different vaccines (childhood and adult).

METHODS

This was a qualitative, cross-sectional interview study informed by the Social Ecological Model. Semi-structured interviews were conducted with 174 Travellers from six communities: Romanian Roma, English Gypsy/Irish Travellers (Bristol), English Gypsy (York), Romanian/Slovakian Roma, Scottish Show people (Glasgow) and Irish Traveller (London). The focus was childhood and selected adult vaccines. Data were analysed using the Framework approach.

RESULTS

Common accounts of barriers and facilitators were identified across all six Traveller communities, similar to those documented for the general population. All Roma communities experienced additional barriers of language and being in a new country. Men and women described similar barriers and facilitators although women spoke more of discrimination and low literacy. There was broad acceptance of childhood and adult immunisation across and within communities, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough and described barriers to booking and attending immunisation. Cultural concerns about antenatal vaccines and HPV vaccination were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified as barriers across different communities. Trustful relationships with health professionals were important and continuity of care valued.

CONCLUSIONS

The experience of many Travellers in this study, and the context through which they make health decisions, is changing. This large study identified key issues that should be considered when taking action to improve uptake of immunisations in Traveller families and reduce the persistent inequalities in coverage.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20019630 .

Investigating the meaning of 'good' or 'very good' patient evaluations of care in English general practice: a mixed methods study

OBJECTIVE

To examine concordance between responses to patient experience survey items evaluating doctors' interpersonal skills, and subsequent patient interview accounts of their experiences of care.

DESIGN

Mixed methods study integrating data from patient questionnaires completed immediately after a video-recorded face-to-face consultation with a general practitioner (GP) and subsequent interviews with the same patients which included playback of the recording.

SETTING

12 general practices in rural, urban and inner city locations in six areas in England.

PARTICIPANTS

50 patients (66% female, aged 19-96 years) consulting face-to-face with 32 participating GPs.

MAIN OUTCOME MEASURES

Positive responses to interpersonal skills items in a postconsultation questionnaire ('good' and 'very good') were compared with experiences reported during subsequent video elicitation interview (categorised as positive, negative or neutral by independent clinical raters) when reviewing that aspect of care.

RESULTS

We extracted 230 textual statements from 50 interview transcripts which related to the evaluation of GPs' interpersonal skills. Raters classified 70.9% (n=163) of these statements as positive, 19.6% (n=45) neutral and 9.6% (n=22) negative. Comments made by individual patients during interviews did not always express the same sentiment as their responses to the questionnaire. Where questionnaire responses indicated that interpersonal skills were 'very good', 84.6% of interview statements concerning that item were classified as positive. However, where patients rated interpersonal skills as 'good', only 41.9% of interview statements were classified as positive, and 18.9% as negative.

CONCLUSIONS

Positive responses on patient experience questionnaires can mask important negative experiences which patients describe in subsequent interviews. The interpretation of absolute patient experience scores in feedback and public reporting should be done with caution, and clinicians should not be complacent following receipt of 'good' feedback. Relative scores are more easily interpretable when used to compare the performance of providers.

Understanding negative feedback from South Asian patients: an experimental vignette study

OBJECTIVES

In many countries, minority ethnic groups report poorer care in patient surveys. This could be because they get worse care or because they respond differently to such surveys. We conducted an experiment to determine whether South Asian people in England rate simulated GP consultations the same or differently from White British people. If these groups rate consultations similarly when viewing identical simulated consultations, it would be more likely that the lower scores reported by minority ethnic groups in real surveys reflect real differences in quality of care.

DESIGN

Experimental vignette study. Trained fieldworkers completed computer-assisted personal interviews during which participants rated 3 video recordings of simulated GP-patient consultations, using 5 communication items from the English GP Patient Survey. Consultations were shown in a random order, selected from a pool of 16.

SETTING

Geographically confined areas of ∼130 households (output areas) in England, selected using proportional systematic sampling.

PARTICIPANTS

564 White British and 564 Pakistani adults recruited using an in-home face-to-face approach.

MAIN OUTCOME MEASURE

Mean differences in communication score (on a scale of 0-100) between White British and Pakistani participants, estimated from linear regression.

RESULTS

Pakistani participants, on average, scored consultations 9.8 points higher than White British participants (95% CI 8.0 to 11.7, p<0.001) when viewing the same consultations. When adjusted for age, gender, deprivation, self-rated health and video, the difference increased to 11.0 points (95% CI 8.5 to 13.6, p<0.001). The largest differences were seen when participants were older (>55) and where communication was scripted to be poor.

CONCLUSIONS

Substantial differences in ratings were found between groups, with Pakistani respondents giving higher scores than White British respondents to videos showing the same care. Our findings suggest that the lower scores reported by Pakistani patients in national surveys represent genuinely worse experiences of communication compared to the White British majority.