Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review

How do family doctors respond to reduced waiting times for cancer diagnosis in secondary care?

Reducing waiting times is a priority in public health systems. Efforts of healthcare providers to shorten waiting times could be negated if they simultaneously induce substantial increases in demand. However, separating out the effects of changes in supply and demand on waiting times requires an exogenous change in one element. We examine the impact of a pilot programme in some English hospitals to shorten waiting times for urgent diagnosis of suspected cancer on family doctors' referrals. We examine referrals from 6,666 family doctor partnerships to 145 hospitals between 1st April 2012 and 31st March 2019. Five hospitals piloted shorter waiting times initiatives in 2017. Using continuous difference-in-differences regression, we exploit the pilot as a 'supply shifter' to estimate the effect of waiting times on referral volumes for two suspected cancer types: bowel and lung. The proportion of referred patients breaching two-week waiting times targets for suspected bowel cancer fell by 3.9 percentage points in pilot hospitals in response to the policy, from a baseline of 4.8%. Family doctors exposed to the pilot increased their referrals (demand) by 10.8%. However, the pilot was not successful for lung cancer, with some evidence that waiting times increased, and a corresponding reduction in referrals of -10.5%. Family doctor referrals for suspected cancer are responsive at the margin to waiting times. Healthcare providers may struggle to achieve long-term reductions in waiting times if supply-side improvements are offset by increases in demand.

Patients' and professionals' experiences with remote care during COVID-19: a qualitative study in general practices in low-income neighborhoods

AIM

To explore how patients and general practice professionals in low-income neighborhoods experienced the increase of remote care during COVID-19.

BACKGROUND

As the GP (general practitioner) is the first point of contact in Dutch health care, there are concerns about access to remote care for patients from low-income neighborhoods. Now that general practice professionals have returned to the pre-pandemic ways of healthcare delivery, this paper looks back at experiences with remote care during COVID-19. It investigates experiences of both patients and general practice professionals with the approachability and appropriateness of remote care and their satisfaction.

METHODS

In this qualitative study, 78 patients and 18 GPs, 7 nurse practitioners and 6 mental health professionals were interviewed. Interviews were held on the phone and face-to-face in the native language of the participants.

FINDINGS

Remote care, especially telephone consultation, was generally well-approachable for patients from low-income neighborhoods. Contrarily, video calling was rarely used. This was partly because patients did not know how to use it. The majority of patients thought remote care was possible for minor ailments but would also still like to see the doctor face-to-face regularly. Patients were generally satisfied with remote care at the time, but this did not necessarily reflect their willingness to continue using it in the future. Moreover, there was lack in consensus among general practice professionals on the appropriateness of remote care for certain physical and mental complaints. Nurse practitioners and mental health professionals had a negative attitude toward remote care. In conclusion, it is important to take the opinions and barriers of patients and care providers into account and to increase patient-centered care elements and care provider satisfaction in remote care. Integrating remote care is not only important in times of crisis but also for future care that is becoming increasingly digitalized.

Patient and caregiver characteristics associated with differential use of primary care for children and young people in the UK: a scoping review

OBJECTIVE

To systematically map evidence to answer the research question: What is the relationship between the characteristics of children and young people (CYP) or their caregivers and primary care service use in the UK, taking into account underlying healthcare needs? DESIGN: Scoping review.

SETTING

Primary care.

ELIGIBILITY CRITERIA

English-language quantitative or mixed-methods studies published between 2012 and 2022.

DATA SOURCES

Medline, Embase, Scopus and Web of Science Social Sciences Citation Index, and grey literature.

RESULTS

22 eligible studies were identified, covering general practice (n=14), dental health (n=4), child mental health (MN) services (n=3) and immunisation (n=1). Only eight studies (36%) controlled for variables associated with healthcare need (eg, age, birth weight and long-term conditions). In these, evidence of horizontal inequity in primary care use was reported for CYP living in deprived areas in England, with and without complex needs. Horizontal inequity was also identified in primary care MN referrals for CYP in England identifying as mixed-race, Asian or black ethnicity, compared with their white British peers. No evidence of horizontal inequity was observed, however, in primary care use for CYP in England exposed to parental depression, or for CYP children from low-income households in Scotland. Increasing CYP's age was associated with decreasing primary care use across included studies. No studies were found regarding CYP from Gypsy or Traveller communities, children in care, or those with disabilities or special educational needs.

CONCLUSIONS

There is evidence that socioeconomic factors impact on CYP's primary care use, in particular age, ethnicity and deprivation. However, better quality evidence is required to evaluate horizontal inequity in use and address knowledge gaps regarding primary care use for vulnerable CYP populations and the impact of policy and practice related 'supply side' of primary care.

How do opt-in versus opt-out settings nudge patients toward electronic health record adoption? An exploratory study of facilitators and barriers in Austria and France

BACKGROUND

Electronic health records (EHR) are becoming an integral part of the health system in many developed countries, though implementations and settings vary across countries. Some countries have adopted an opt-out policy, in which patients are enrolled in the EHR system following a default nudge, while others have applied an opt-in policy, where patients have to take action to opt into the system. While opt-in systems may exhibit lower levels of active user requests for access, this contrasts with opt-out systems where a notable percentage of users may passively retain access. Thus, our research endeavor aims to explore facilitators and barriers that contribute to explaining EHR usage (i.e., actively accessing the EHR system) in two countries with either an opt-in or opt-out setting, exemplified by France and Austria.

METHODS

A qualitative exploratory approach using a semi-structured interview guideline was undertaken in both countries: 1) In Austria, with four homogenously composed group discussions, and 2) in France, with 19 single patient interviews. The data were collected from October 2020 to January 2021.

RESULTS

Influencing factors were categorized into twelve subcategories. Patients have similar experiences in both countries with regard to all facilitating categories, for instance, the role of health providers, awareness of EHR and social norms. However, we highlighted important differences between the two systems regarding hurdles impeding EHR usage, namely, a lack of communication as well as transparency or information security about EHR.

CONCLUSION

Implementing additional safeguards to enhance privacy protection and supporting patients to improve their digital ability may help to diminish the perception of EHR-induced barriers and improve patients' health and commitment in the long term.

PRACTICAL IMPLICATIONS

Understanding the differences and similarities will help to develop practical implications to tackle the problem of low EHR usage rates in the long run. This problem is prevalent in countries with both types of EHR default settings.

The performance of general practice in the English National Health Service (NHS): an analysis using Starfield's framework for primary care

General practice in the English National Health Service (NHS) is in crisis. In response, politicians are proposing fundamental reform to the way general practice is organized. But ideas for reform are contested, and there are conflicting interpretations of the problems to be addressed. We use Barbara Starfield's "4Cs" framework for high-performing primary care to provide an overall assessment of the current role and performance of general practice in England. We first assessed theoretical alignment between Starfield's framework and the role of general practice in England. We then assessed actual performance using publicly available national data and targeted literature searches. We found close theoretical alignment between Starfield's framework and the model of NHS general practice in England. But, in practice, its model of universal comprehensive care risks being undermined by worsening and inequitable access, while continuity of care is declining. Underlying causes of current challenges in general practice in England appear more closely linked to under-resourcing than the fundamental design of the system. General practice in England must evolve, but wholesale re-organization is likely to damage and distract. Instead, policymakers should focus on adequately resourcing general practice while supporting general practice teams to improve the quality and coordination of local services.

Navigating Pathways to Diagnosis in Idiopathic Subglottic Stenosis: A Qualitative Study

OBJECTIVE

Idiopathic subglottic stenosis is a rare disease, and time to diagnosis is often prolonged. In the United States, some estimate it takes an average of 9 years for patients with similar rare disease to be diagnosed. Patient experience during this period is termed the diagnostic odyssey. The aim of this study is to use qualitative methods grounded in behavioral-ecological conceptual frameworks to identify drivers of diagnostic odyssey length that can help inform efforts to improve health care for iSGS patients.

METHODS

Qualitative study using semi-structured interviews. Setting consisted of participants who were recruited from those enrolled in a large, prospective multicenter trial. We use directed content analysis to analyze qualitative semi-structured interviews with iSGS patients focusing on their pathways to diagnosis.

RESULTS

Overall, 30 patients with iSGS underwent semi-structured interviews. The patient-reported median time to diagnosis was 21 months. On average, the participants visited four different health care providers. Specialists were most likely to make an appropriate referral to otolaryngology that ended in diagnosis. However, when primary care providers referred to otolaryngology, patients experienced a shorter diagnostic odyssey. The most important behavioral-ecological factors in accelerating diagnosis were strong social support for the patient and providers' willingness to refer.

CONCLUSION

Several factors affected time to diagnosis for iSGS patients. Patient social capital was a catalyst in decreasing time to diagnosis. Patient-reported medical paternalism and gatekeeping limited specialty care referrals extended diagnostic odysseys. Additional research is needed to understand the effect of patient-provider and provider-provider relationships on time to diagnosis for patients with iSGS.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:815-824, 2024.

Factors Affecting the Preference for Hospitals Over Clinics in Primary Care in Korea

BACKGROUND

While the effect of gatekeeping was extensively studied, few efforts have been made to explain why the measures to strengthen gatekeeping do not work well in some countries. This study examined the patient factors related to the choice of level of health care facilities for outpatient care in Korea.

METHODS

We examined a population-based sample representative of the population of Korea aged 15 and over in the healthcare experience survey of 2021. A logistic regression model examined the factors associated with choosing hospitals or clinics for outpatient care.

RESULTS

Easy accessibility, kindness of medical staff, and recommendations from acquaintances were considered more important for those who chose clinics over hospitals. While those who chose clinics were more likely to feel that physicians and nurses more readily communicated with patients, those who chose hospitals were more likely to feel that the facility was comfortable. Whereas those who chose hospitals were more likely to trust the current health care system in Korea, those who chose clinics were more likely to think that the health care system needed to be reformed. The tendency was similar when analyzed only among those with good perceived health conditions and without chronic diseases.

CONCLUSION

This study demonstrates that the preference for hospitals over clinics is mainly based on desire rather than medical need and is not likely to be affected by measures intended to induce a voluntary change of behavior.

Evidence on bringing specialised care to the primary level-effects on the Quadruple Aim and cost-effectiveness: a systematic review

BACKGROUND

To achieve the Quadruple Aim of improving population health, enhancing the patient experience of care, reducing costs and improving professional satisfaction requires reorganisation of health care. One way to accomplish this aim is by integrating healthcare services on different levels. This systematic review aims to determine whether it is cost-effective to bring a hospital specialist into primary care from the perspectives of commissioners, patients and professionals.

METHODS

The review follows the PRISMA guidelines. We searched PubMed, Scopus and EBSCO (CINAHL and Academic Search Ultimate) for the period of 1992-2022. In total, 4254 articles were found, and 21 original articles that reported on both quality and costs, were included. The JBI and ROBINS-I tools were used for quality appraisal. In data synthesis, vote counting and effect direction plots were used together with a sign test. The strength of evidence was evaluated with the GRADE.

RESULTS

Cost-effectiveness was only measured in two studies, and it remains unclear. Costs and cost drivers for commissioners were lower in the intervention in 52% of the studies; this proportion rose to 67% of the studies when cost for patients was also considered, while health outcomes, patient experience and professional satisfaction mostly improved but at least remained the same. Costs for the patient, where measured, were mainly lower in the intervention group. Professional satisfaction was reported in 48% of the studies; in 80% it was higher in the intervention group. In 24% of the studies, higher monetary costs were reported for commissioners, whereas the clinical outcomes, patient experience and costs for the patient mainly improved.

CONCLUSIONS

The cost-effectiveness of the hospital specialist in primary care model remains inconclusive. Only a few studies have comprehensively calculated costs, evaluating cost drivers. However, it seems that when the service is well organised and the population is large enough, the concept can be profitable for the commissioner also. From the patient's perspective, the model is superior and could even promote equity through improved access. Professional satisfaction is mostly higher compared to the traditional model. The certainty of evidence is very low for cost and low for quality.

TRIAL REGISTRATION

PROSPERO CRD42022325232, 12.4.2022.

What impact do self-referral and direct access pathways for patients have on health inequalities?

BACKGROUND

There is increasing interest in self-referral and direct access as alternatives pathways to care to improve patient access to specialist services. The impact of these pathways on health inequalities is unknown.

OBJECTIVES

The purpose of this systematic review is to explore the impact of self-referral and direct access pathways on inequalities in health care use.

DESIGN

Three databases (Ovid Medline, Embase, Web of Science) and grey literature were systematically searched for articles from January 2000 to February 2023, reporting on self-referral and direct access pathways to care. Title and abstracts were screened against eligibility criteria to identify studies that evaluated the impact on health inequalities. Data were extracted from eligible studies after full text review and a quality assessment was performed using the ROBINS-I tool.

RESULTS

The search strategy identified 2948 articles. Nineteen records were included, covering seven countries and six healthcare services. The impact of self-referral and direct access on inequalities was mixed, suggesting that the relationship is dependent on patient and system factors. Typically self-referral pathways and direct access pathways tend to widen health inequalities. White, younger, educated women from less deprived backgrounds are more likely to self-refer, exacerbating existing health inequalities.

CONCLUSIONS

Self-referral pathways risk widening health inequalities. Further research is required to understand the context-dependent mechanisms by which this can occur, explore ways to mitigate this and even narrow health inequalities, as well as understand the impact on the wider healthcare system.

UK general practice service delivery research priorities: an adapted James Lind Alliance approach

BACKGROUND

General practice is in a state of crisis in a number of countries. In the UK, a range of measures have been introduced to address the situation, including innovations such as practice networks, multidisciplinary roles, and digital technologies. However, identifying what still needs fixing could benefit from more evidence, particularly in relation to day-to-day service delivery.

AIM

To identify the general practice workforce's top 10 research priorities to improve service delivery.

DESIGN AND SETTING

This priority-setting study used an adapted James Lind Alliance methodology and involved staff working in general practice across the UK.

METHOD

The study comprised four phases: an online qualitative survey issued to the general practice workforce (clinical and non-clinical groups); thematic analysis of free-text responses; generation of indicative research questions; and the undertaking of ranking exercises with responders of the original survey. An online workshop was held with participants at the final stage of prioritisation.

RESULTS

In total, 93 staff completed a survey in Phase 1, from which 20 themes were categorised and developed into research questions. Twenty- two staff responded to the first ranking activity and 11 took part in a second ranking activity to discuss themes that had a tied vote. The final top 10 research priorities were: volume of work; patient behaviour; consultations; employment pay and conditions; workload dumping and care of patients on waiting list; funding; overwhelming pressure; patient health education; complex patient needs; and interfaces with secondary care. However, there was no clear ranking of these 10 priorities; instead, they carried equal weight and were closely interconnected.

CONCLUSION

Applying a marginal-gains approach, by seeking to explore all 10 priorities simultaneously as opposed to concentrating on one area at a time, may provide more noticeable improvements overall. Systems-based approaches that take account of the marked role that context has may be a particularly useful lens for future research.

The impact of variation in out-of-hours doctors' referral practices: a Norwegian registry-based observational study

BACKGROUND

In a gatekeeping system, the individual doctor's referral practice is an important factor for hospital activity and patient safety.

OBJECTIVE

The aim of the study was to investigate the variation in out-of-hours (OOH) doctors' referral practice, and to explore these variations' impact on admissions for selected diagnoses reflecting severity, and 30-day mortality.

METHODS

National data from the doctors' claims database were linked with hospital data in the Norwegian Patient Registry. Based on the doctor's individual referral rate adjusted for local organizational factors, the doctors were sorted into quartiles of low-, medium-low-, medium-high-, and high-referral practice. The relative risk (RR) for all referrals and for selected discharge diagnoses was calculated using generalized linear models.

RESULTS

The OOH doctors' mean referral rate was 110 referrals per 1,000 consultations. Patients seeing a doctor in the highest referring practice quartile had higher likelihood of being referred to hospital and diagnosed with the symptom of pain in throat and chest, abdominal pain, and dizziness compared with the medium-low quartile (RR 1.63, 1.49, and 1.95). For the critical conditions of acute myocardial infarction, acute appendicitis, pulmonary embolism, and stroke, we found a similar, but weaker, association (RR 1.38, 1.32, 1.24, and 1.19). The 30-day mortality among patients not referred did not differ between the quartiles.

CONCLUSIONS

Doctors with high-referral practice referred more patients who were later discharged with all types of diagnoses, including serious and critical conditions. With low-referral practice, severe conditions might have been overlooked, although the 30-day mortality was not affected.

"I Get It, I'm Sick Too": An Autoethnographic Study of One Researcher/Practitioner/Patient With Chronic Illness

This autoethnographic research utilizes reflexivity as a method to explore my self-experience of Lyme disease while holding co-occurring identities as a researcher, health professional, and mother. Awareness of self is central in psychotherapy so that therapists do not adversely impact their clients. This is similar for researchers who are ethically required to acknowledge and reduce any potential risk(s) of harm to their participants. In this study, I describe and systematically analyze my experiences as a patient with symptom-persistent Lyme disease, contextualized through co-occurring identities as a mother, a regulated (mental) health professional, and a scholar investigating the embodied experience of being a Lyme disease patient in the Canadian context. The central research question guiding this study is: "What are my experiences with symptom-persistent Lyme disease?" The results of this study suggest reflexivity is an important practice in both health research and healthcare. Relationships with health professionals have a significant impact on patients' healthcare experiences, and engaging in reflexive practice may improve the responsivity of healthcare professionals toward patients' needs and embodied experiences and serve as a check on pre-existing power relations in healthcare. Further, this research contributes to the current academic knowledge on symptom-persistent Lyme disease by offering a reflexive representation of my experiences as a researcher who is also a health professional and a patient within the Canadian healthcare system. Representations of patients' experiences are critical in advancing health research and ensuring equitable care for patients. Autoethnography offers important insights into patients' disease experiences.

Examining preconditions for integrated care: a comparative social network analysis of the structure and dynamics of strong relations in child service networks

BACKGROUND

To help ensure that children and families get the right support and services at the right time, strong and stable relationships between various child service organizations are vital. Moreover, strong and stable relationships and a key network position for gatekeepers are important preconditions for interprofessional collaboration, the timely and appropriate referral of clients, and improved health outcomes. Gatekeepers are organizations that have specific legal authorizations regarding client referral. However, it is largely unclear how strong relations in child service networks are structured, whether the gatekeepers have strong and stable relationships, and what the critical relations in the overall structure are. The aim of this study is to explore these preconditions for integrated care by examining the internal structure and dynamics of strong relations.

METHODS

A comparative case study approach and social network analysis of three inter-organizational networks consisting of 65 to 135 organizations within the Dutch child service system. Multiple network measures (number of active organizations, isolates, relations, average degree centrality, Lambda sets) were used to examine the strong relation structure and dynamics of the networks. Ucinet was used to analyze the data, with use of the statistical test: Quadratic Assignment Procedure. Visone was used to visualize the graphs of the networks.

RESULTS

This study shows that more than 80% of the organizations in the networks have strong relations. A striking finding is the extremely high number of strong relations that gatekeepers need to maintain. Moreover, the results show that the most important gatekeepers have key positions, and their strong relations are relatively stable. By contrast, considering the whole network, we also found a considerable measure of instability in strong relationships, which means that child service networks must cope with major internal dynamics.

CONCLUSIONS

Our study addressed crucial preconditions for integrated care. The extremely high number of strong relations that particularly gatekeepers need to build and maintain, in combination with the considerable instability of strong relations considering the whole network, is a serious point of concern that need to be managed, in order to enable child service networks to improve internal coordination and integration of service delivery.

Gatekeepers in the health financing scheme: Assessment of knowledge, attitude, practices, and participation of Malaysian private general practitioners in the PeKa B40 scheme

This is cross-sectional research done to assess the readiness of the private Malaysian general practitioners (GPs) for the implementation of the national health financing scheme. The study focused on their levels of knowledge and attitudes towards the types of health financing scheme, gatekeeper roles in the health financing scheme, and their participation in the PeKa B40 scheme. Their acceptance and level of participation in the national health financing scheme (NHFS) were also assessed. A set of self-designed and pre-tested questionnaires focusing on the aforementioned objectives were mailed to the respondents. The selection of respondents was done by stratified random sampling of the GPs in all 14 Malaysian states at both urban and rural levels. Out of a calculated number of 362 GPs targeted, 296 responses were received which represented a response rate of 81.7%. The respondents had a mean age of 50.7 years 165 (55.75%) were males and 131 (44.3%) were females. The rural respondents totalled 158 (53.4%) as compared to those from urban 138 (46.6%) areas. The outcomes observed were that GPs with PeKa B40 provider status, positive attitude towards health financing schemes, gatekeeper roles, and PeKa B40, were strongly associated with their acceptance and level of participation in the NHFS. The GPs possessed a positive attitude and were generally ready to participate in the NHFS, but the lower scores in knowledge levels would require definite education and training plans to further enhance their readiness. More incentives should be given to GPs to enrol as PeKa B40 providers. The results of this study should be strongly considered by the government in the efforts to engage the Malaysian private GPs in the forthcoming NHFS. Most importantly, the role of GPs as gatekeepers needed to be implemented, and the PeKa B40 scheme be greatly improved.

Impact of altering referral threshold from out-of-hours primary care to hospital on patient safety and further health service use: a cohort study

OBJECTIVES

To estimate the impact of altering referral thresholds from out-of-hours services on older patients' further use of health services and risk of death.

DESIGN

Cohort study using patient data from primary and specialised health services and demographic data from Statistics Norway and the Norwegian Cause of Death Registry.

SETTING

Norway PARTICIPANTS: 491 653 patients aged 65 years and older contacting Norwegian out-of-hours services between 2008 and 2016.

ANALYSIS

Multivariable adjusted and instrumental variable associations between referrals to hospital from out-of-hours services and further health services use and death for up to 6 months.Physicians' proportions of acute referrals of older, unknown patients from out-of-hours work were used as an instrumental variable ('physician referral preference') for their threshold of referral for such patients whose clinical presentations were less clear cut.

RESULTS

For older patients, whose referrals could be attributed to their physicians' threshold for referral, mean length of stay in hospital increased 3.30 days (95% CI 3.13 to 3.27) within the first 10 days, compared with non-referred patients. Such referrals also increased 6 months use of outpatient specialist clinics and primary care physicians. Importantly, patients with referrals attributable to their physicians' threshold had a substantially reduced risk of death the first 10 days (HR 0.53, 95% CI 0.31 to 0.91), an effect sustaining through the 6-month follow-up period (HR 0.72, 95% CI 0.54 to 0.97).

CONCLUSIONS

Out-of-hours patients whose referrals are affected by physician referral threshold contribute substantially to the use of health services. However, the referral seems protective by reducing the risk of death in the first 6 months after the referral. Thus, raising the threshold for referral to lower pressure on overcrowded emergency departments and hospitals should not be encouraged without ensuring the accuracy of the referral decisions, ideally through high-quality randomised controlled trial evidence.

Examining clinical capability of township healthcare centres for rural health service planning in Sichuan, China: an administrative data analysis

OBJECTIVE

This study aimed to examine the clinical capability of township healthcare centres (THCs), the main primary care providers in rural China, as a basis for rural health service planning.

DESIGN

Observational study of quantitative analysis using administrative data.

SETTING

Three counties with low, middle and high social economic development level, respectively, in Sichuan province western China.

PARTICIPANTS

9 THCs and 6 county hospitals (CHs) were purposively selected in the three counties. Summary of electronic medical records of 31 633 admissions from 1 January 2015 to 30 December 2015 of these selected health institutions was obtained from the Health Information Centre of Sichuan province.

MAIN OUTCOME MEASURES

Six indicators in scope of inpatient services related to diseases and surgeries in the THCs as proxy of clinical capability, were compared against national standard of capability building of THCs, among counties, and between THCs and CHs of each county.

RESULTS

The clinical capability of THCs was suboptimal against the national standard, though that of the middle-developed county was better than that in the rich and the poor counties. THCs mainly provided services of infectious or inflammatory diseases, of respiratory and digestive systems, but lacked clinical services related to injuries, poisoning, pregnancy, childbirth and surgeries. A large proportion of the top 20 diseases of inpatients were potentially avoidable hospitalisations (PAHs) and were overlapped between THCs and CHs.

CONCLUSIONS

The clinical capability of THCs was generally suboptimal against national standard. It may be affected by the economics, population size, facilities, workforce and the share of services of THCs in local health systems. Identification of absent services and PAHs may help to identify development priorities of local THCs. Clarification of the roles of THCs and CHs in the tiered rural health system in China is warranted to develop a better integrated health system.

Patients values regarding primary health care: a systematic review of qualitative and quantitative evidence

BACKGROUND

Accessible and high-quality primary health care (PHC) is fundamental to countries moving towards universal health coverage. In order to improve the quality of patient-centered care provided in PHC, a comprehensive understanding of patients' values is crucial to address any gaps in the health care system. This systematic review aimed to identify patients' values relevant to PHC.

METHODS

We searched primary qualitative and quantitative studies about patients' values related to primary care in PubMed and EMBASE (Ovid) from 2009 to 2020. The studies' quality was assessed using Joanna Briggs Institute (JBI) Critical Appraisal Checklist for both quantitative and qualitative studies and Consolidated Criteria for Reporting Qualitative Studies (COREQ) for qualitative studies. A thematic approach was used in the data synthesis.

OUTCOME

The database search resulted in 1,817 articles. A total of 68 articles were full-text screened. Data were extracted from nine quantitative and nine qualitative studies that met the inclusion criteria. The participants of the studies were mainly the general population in high-income countries. Four themes emerged from the analysis: patients' values related to privacy and autonomy; values associated with the general practitioners including virtuous characteristics, knowledge and competence; values involving patient-doctor interactions such as shared decision-making and empowerment; and core values related to the primary care system such as continuity, referral, and accessibility.

CONCLUSIONS

This review reveals that the doctor's personal characteristics and their interactions with the patients are critical considerations concerning the primary care services from the patients' point of view. The inclusion of these values is essential to improve the quality of primary care.

How consequences of colorectal cancer treatment are managed: a qualitative study of stakeholder experiences about supportive care and current practices

PURPOSE

Colorectal cancer (CRC) survivors experience treatment-effects such as symptoms and functional impairments. There is limited evidence about how these are managed and what services or supports are available in the community. We aimed to identify current practice and available supports for managing consequences of treatment from clinician and CRC survivor perspectives.

METHODS

This qualitative study, informed by an interpretivist constructionist paradigm, included semi-structured interviews. Clinicians with experience of treating CRC patients and adult CRC survivors were recruited across Australia. Interviews explored experiences about problems experienced after CRC treatment and how these were managed. Data collection and analysis, using thematic analysis, was iterative whereby emergent themes during analysis were incorporated into subsequent interviews.

RESULTS

We interviewed 16 clinicians and 18 survivors. Survivors experienced a range of consequences of treatment amendable to support including allied health, information, and self-management. Barriers to support access included clinicians' worry about patient out-of-pocket expenses, long waitlists, lack of awareness about existing supports, and perception no therapeutic options were available. Healthcare professionals with expertise in CRC were often difficult to identify outside of cancer settings. Survivorship care could be improved with individualised timely information and identification of pathways to access healthcare providers with expertise in managing consequences of CRC treatment within primary care.

CONCLUSIONS

To improve CRC survivor lives posttreatment, routine assessment of consequences of treatment, individualised care planning involving relevant healthcare professionals, access to supportive care when needed, and improved information provision and engagement of a range of health professionals in follow-up care are needed.

Factors related to Japanese internal medicine doctors' retention or migration to rural areas: a nationwide retrospective cohort study

BACKGROUND

Internal medicine (IM) doctors in Japan play the role of primary care physicians; however, the shortage of rural physicians continues. This study aims to elucidate the association of age, sex, board certification, type of work, and main clinical work with the retention or migration of IM doctors to rural areas.

METHODS

This retrospective cohort study included 82,363 IM doctors in 2010, extracted from the national census data of medical doctors. The explanatory variables were age, sex, type of work, primary clinical work, and changes in board certification status. The outcome was retention or migration to rural areas. The first tertile of population density (PD) of municipalities defined as rural area. After stratifying the baseline ruralities as rural or non-rural areas, the odds ratios (ORs) of the explanatory variables were calculated using generalized estimation equations. The analyses were also performed after age stratification (<39, 40-59, ≥60 years old).

RESULTS

Among the rural areas, women had a significantly higher OR for retention, but obtaining board certification of IM subspecialties had a significantly lower OR. Among the non-rural areas, physicians who answered that their main work was IM without specific subspecialty and general had a significantly higher OR, but obtaining and maintaining board certification for IM subspecialties had a significantly lower OR for migration to rural areas. After age stratification, the higher OR of women for rural retention was significant only among those aged 40-59 years. Those aged under 40 and 40-59 years in the non-rural areas, who answered that their main work was IM without specific subspecialty had a significantly higher OR for migration to rural areas, and those aged 40-59 years in the rural areas who answered the same had a higher OR for rural retention.

CONCLUSIONS

Obtaining and maintaining board certification of IM subspecialties are possible inhibiting factors for rural work, and IM doctors whose main work involves subspecialties tend to work in non-rural areas. Once rural work begins, more middle-aged female IM doctors continued rural work compared to male doctors.

A health impact assessment of gender inequities associated with psychological distress during COVID19 in Australia's most locked down state-Victoria

BACKGROUND

Since March 2020, when the COVID19 pandemic hit Australia, Victoria has been in lockdown six times for 264 days, making it the world's longest cumulative locked-down city. This Health Impact Assessment evaluated gender disparities, especially women's mental health, represented by increased levels of psychological distress during the lockdowns.

METHODS

A desk-based, retrospective Health Impact Assessment was undertaken to explore the health impacts of the lockdown public health directive with an equity focus, on the Victorian population, through reviewing available qualitative and quantitative published studies and grey literature.

RESULTS

Findings from the assessment suggest the lockdown policies generated and perpetuated avoidable inequities harming mental health demonstrated through increased psychological distress, particularly for women, through psychosocial determinants.

CONCLUSION

Ongoing research is needed to elucidate these inequities further. Governments implementing policies to suppress and mitigate COVID19 need to consider how to reduce harmful consequences of these strategies to avoid further generating inequities towards vulnerable groups within the population and increasing inequalities in the broader society.

Patient experiences during the COVID-19 pandemic: a qualitative study in Dutch primary care

BACKGROUND

Changes in primary care provision during the COVID-19 pandemic could have affected patient experience of primary care both positively and negatively.

AIM

To assess the experiences of patients in primary care during the COVID-19 pandemic.

DESIGN & SETTING

A qualitative study of patients from regions with high and low COVID-19 prevalence in the Netherlands.

METHOD

A qualitative study using a phenomenological framework was performed among purposively sampled patients. Individual semi-structured interviews were performed and transcribed. Data were thematically analysed by means of an inductive approach.

RESULTS

Twenty-eight patients were interviewed (13 men and 15 women, aged 27-91 years). After thematic analysis, two main themes emerged: accessibility and continuity of primary care. Changes considered positive during the pandemic regarding accessibility and continuity of primary care included having a quieter practice, having more time for consultations, and the use of remote care for problems with low complexity. However, patients also experienced decreases in both care accessibility and continuity, such as feeling unwelcome, the GP postponing chronic care, seeing unfamiliar doctors, and care being segregated.

CONCLUSION

Despite bringing several benefits, patients indicated that the changes to primary care provision during the COVID-19 pandemic could have threatened care accessibility and continuity, which are core values of primary care. These insights can guide primary care provision not only in this and future pandemics, but also when implementing permanent changes to care provision in primary care.

Women's experiences along the ovarian cancer diagnostic pathway in Catalonia: A qualitative study

BACKGROUND

Early detection of symptoms and prompt diagnosis of ovarian cancer are considered important avenues for improving patient experiences and outcomes.

METHODS

This qualitative study used a phenomenological approach to perform patient interviews, collecting individual accounts of the prediagnostic phase in women diagnosed and treated for ovarian cancer in 2016-2017. Purposive sampling was used to obtain a diverse sample of 24 participants, while thematic content analysis was used to extract themes and subthemes from interview data.

RESULTS

Three themes and nine subthemes were identified. The first theme was women's delay in recognizing symptoms and seeking care, with subthemes on the lack of knowledge about early signs of ovarian cancer, gender-related barriers and false reassurance from negative test results. A second theme was missed opportunities during healthcare encounters, due to misattribution of women's symptoms by their physicians, underestimation of symptom severity and need for mediation and inadequate tests and/or false negative results. Finally, interviews highlighted the use of resources and alternative healthcare pathways, including complementary/alternative medicines, access to private health care and women's capacity for action and decision-making (agency) about their health.

CONCLUSION

Delayed diagnosis of ovarian cancer is rooted in both individual factors (lack of health literacy, reluctance to seek care) and systemic issues (missed opportunities in healthcare encounters, access to timely specialist care). Further research is needed to investigate the extent to which traditional gender roles and socioeconomic inequalities condition women's ability to manage their own health and to interact with health professionals and the health system.

PATIENT AND PUBLIC CONTRIBUTION

In addition to the patient participation during the interviews, one author was a representative of a patient association.

Diagnostic delay of myositis: an integrated systematic review

BACKGROUND

Idiopathic inflammatory myopathies (IIM) are a heterogenous group of rare muscular autoimmune diseases characterised by skeletal muscle inflammation with possible diagnostic delay. Our aim was to review the existing evidence to identify overall diagnostic delay for IIM, factors associated with diagnostic delay, and people's experiences of diagnostic delay.

METHODS

Three databases and grey literature sources were searched. Diagnostic delay was defined as the period between the onset of symptoms and the year of first diagnosis of IIM. We pooled the mean delay using random effects inverse variance meta-analysis and performed subgroup analyses.

RESULTS

328 titles were identified from which 27 studies were included. Overall mean diagnostic delay was 27.91 months (95% CI 15.03-40.79, I2 = 99%). Subgroup analyses revealed a difference in diagnostic delay between non-inclusion body myositis (IBM) and IBM types. There was no difference in diagnostic delay between studies in which myositis specific autoantibodies (MSA) were tested or not tested. In countries with gatekeeper health systems, where primary care clinicians authorize access to specialty care, people experienced longer periods of diagnostic delay than people with IIM in countries with non-gatekeeper systems. While studies discussed factors that may influence diagnostic delay, significant associations were not identified. No qualitative studies examining people's experiences of diagnostic delay were identified.

CONCLUSION

Diagnostic delay of IIM has extensive impacts on the quality of life of people living with this disease. Understanding the experiences of people with IIM, from symptom onset to diagnosis, and factors that influence diagnostic delay is critical to inform clinical practice and training activities aimed at increasing awareness of this rare disease and expediting diagnosis.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42022307236 URL of the PROSPERO registration: https://www.crd.york.ac.uk/PROSPEROFILES/307236_PROTOCOL_20220127.pdf.

The long-term impact of the COVID-19 pandemic on primary and specialized care provision and disease recognition in Germany

Background

The COVID-19 pandemic and the imposed lockdowns severely affected routine care in general and specialized physician practices.

Objective

To describe the long-term impact of the COVID-19 pandemic on the physician services provision and disease recognition in German physician practices and perceived causes for the observed changes.

Design

Observational study based on medical record data and survey data of general practitioners and specialists' practices.

Participants

996 general practitioners (GPs) and 798 specialist practices, who documented 6.1 million treatment cases for medical record data analyses and 645 physicians for survey data analyses.

Main measures

Within the medical record data, consultations, specialist referrals, hospital admissions, and documented diagnoses were extracted for the pandemic (March 2020-September 2021) and compared to corresponding pre-pandemic months in 2019. The additional online survey was used to assess changes in practice management during the COVID-19 pandemic and physicians' perceived main causes of affected primary and specialized care provision.

Main results

Hospital admissions (GPs: -22% vs. specialists: -16%), specialist referrals (-6 vs. -3%) and recognized diseases (-9 vs. -8%) significantly decreased over the pandemic. GPs consultations initially decreased (2020: -7%) but compensated at the end of 2021 (+3%), while specialists' consultation did not (-2%). Physicians saw changes in patient behavior, like appointment cancellation, as the main cause of the decrease. Contrary to this, they also mentioned substantial modifications of practice management, like reduced (nursing) home visits (41%) and opening hours (40%), suspended checkups (43%), and delayed consultations for high-risk patients (71%).

Conclusion

The pandemic left its mark on primary and specialized healthcare provision and its utilization. Both patient behavior and organizational changes in practice management may have caused decreased and non-compensation of services. Evaluating the long-term effect on patient outcomes and identifying potential improvements are vital to better prepare for future pandemic waves.

Experiences and management strategies of Norwegian GPs during the COVID-19 pandemic: a longitudinal interview study

OBJECTIVE

When the COVID-19 pandemic reached Norway, primary health care had to reorganize to ensure safe patient treatment and maintain infection control. General practitioners (GPs) are key health care providers in the municipalities. Our aim was to explore the experiences and management strategies of Norwegian GPs during the COVID-19 pandemic - over time, and in the context of a sudden organizational change.

DESIGN

Longitudinal qualitative interview study with two interview rounds. The first round of interviews was conducted from September-December 2020, the second round from January-April 2021. In the first interview round, we performed eight semi-structured interviews with GPs from eight municipalities in Norway. In the second round, five of the GPs were re-interviewed. Consecutive interviews were performed 2-4 months apart. To analyze the data, we used thematic analysis.

RESULTS

The COVID-19 pandemic required GPs to balance several concerns, such as continuity of care and their own professional efforts. Several GPs experienced challenges in the collaboration with the municipality and in relation to defining their own professional position. Guided by The Norwegian Association of General practitioners, The Norwegian College of General Practice and collegial support, they found viable solutions and ended up with a feeling of having adapted to a new normal.

CONCLUSIONS

Although our study demonstrates that the GPs adapted to the changing conditions, the current municipal health care models are not ideal. There is a need for clarification of responsibilities between GPs and the municipality to facilitate a more coordinated future pandemic response.Key PointsFacing the COVID-19 pandemic, the primary health care service in Norway had to reorganize to ensure safe patient treatment and maintain infection control.Several GPs experienced challenges in collaboration with the municipalities.There is a need for clarification of responsibilities between GPs and the municipality.

Practice characteristics influencing variation in provision of depression care in general practice in Norway; a registry-based cohort study (The Norwegian GP-DEP study)

BACKGROUND

There is growing evidence of variation in treatment for patients with depression, not only across patient characteristics, but also with respect to the organizational and structural framework of general practitioners' (GPs') practice. However, the reasons for these variations are sparsely examined. This study aimed to investigate associations of practice characteristics with provision of depression care in general practices in Norway.

METHODS

A nationwide cohort study of residents aged ≥ 18 years with a new depression episode in general practice during 2009-2015, based on linked registry data. Exposures were characteristics of GP practice: geographical location, practice list size, and duration of GP-patient relationship. Outcomes were talking therapy, antidepressant medication and sick listing provided by GP during 12 months from date of diagnosis. Associations between exposure and outcome were estimated using generalized linear models, adjusted for patients' age, gender, education and immigrant status, and characteristics of GP practice.

RESULTS

The study population comprised 285 113 patients, mean age 43.5 years, 61.6% women. They were registered with 5 574 GPs. Of the patients, 52.5% received talking therapy, 34.1% antidepressant drugs and 54.1% were sick listed, while 17.3% received none of the above treatments. Patients in rural practices were less likely to receive talking therapy (adjusted relative risk (adj RR) = 0.68; 95% confidence interval (CI) = 0.64-0.73) and more likely to receive antidepressants (adj RR = 1.09; 95% CI = 1.04-1.14) compared to those in urban practices. Patients on short practice lists were more likely to receive medication (adj RR = 1.08; 95% CI = 1.05-1.12) than those on long practice lists. Patients with short GP-patient relationship were more likely to receive talking therapy (adj RR = 1.20; 95% CI = 1.17-1.23) and medication (adj RR = 1.08; 95% CI = 1.04-1.12), and less likely to be sick-listed (RR = 0.88; 95% CI = 0.87-0.89), than patients with long GP-patient relationship.

CONCLUSIONS

Provision of GP depression care varied with practice characteristics. Talking therapy was less commonly provided in rural practices and among those with long-lasting GP-patient relationship. These differences may indicate some variation, and therefore, its reasons and clinical consequences need further investigation.

Changes in the Number of Physicians and Hospital Bed Capacity in Europe

OBJECTIVES

Our aim was to examine the numbers of practicing physicians and total numbers of hospital beds in European Organisation for Economic Co-operation and Development countries.

METHODS

Data analyzed were derived from the "Organisation for Economic Co-operation and Development Health Statistics 2020" database between 1980 and 2018. The selected countries were compared according to the type of healthcare system and geographical location by parametric and nonparametric tests.

RESULTS

In 1980, Bismarck-type systems showed an average number of physicians of 2.3 persons/1000 population; in Beveridge-type systems, it was 1.7 persons. By 2018, it leveled out reaching 3.9 persons in both healthcare system types. In 1980, average physician number/1000 was 2.5 persons in Eastern Europe; in Western Europe, it was 1.9 persons. By 2018 this proportion changed with Western Europe having the higher number (3.7 persons; 3.9 persons). In 1980, average number of hospital beds/1000 population was 9.6 in Bismarck-type systems whereas in Beveridge-type systems it was 8.8. By 2018, it decreased to 5.6 in Bismarck-type systems (-42%) and to 3.1 in Beveridge-type systems (-65%). In 1980, the average number of hospital beds/1000 population in Eastern Europe was 10.3; in Western Europe, it was 8.5. By 2018, the difference between the 2 regions did not change.

CONCLUSIONS

Although the number of physicians was 33% higher in 1980 in Eastern Europe than in Western Europe, by 2018 the number of physicians was 5% higher in Western Europe. In general, regardless of the healthcare system and geographical location, the proportion of physicians per 1000 population has improved due to a larger decrease in the number of hospital beds.

Nursing contributions to virtual models of care in primary care: a scoping review protocol

INTRODUCTION

Since the onset of the COVID-19 pandemic, virtual care has gained increased attention, particularly in primary care for the ongoing delivery of routine services. Nurses have had an increased presence in virtual care and have contributed meaningfully to the delivery of team-based care in primary care; however, their exact contributions in virtual models of primary care remain unclear. The Nursing Role Effectiveness Model, applied in a virtual care and primary care context, outlines the association between structural variables, nursing roles and patient outcomes. The aim of this scoping review is to identify and synthesise the international literature surrounding nurse contributions to virtual models of primary care.

METHODS AND ANALYSIS

The Joanna Briggs Institute scoping review methodology will guide this review. We performed preliminary searches in April 2022 and will use CINAHL, MEDLINE, Embase and APA PsycInfo for the collection of sources for this review. We will also consider grey literature, such as dissertations/theses and organisational reports, for inclusion. Studies will include nurses across all designations (ie, nurse practitioners, registered nurses, practical nurses). To ensure studies capture roles, nurses should be actively involved in healthcare delivery. Sources require a virtual care and primary care context; studies involving the use of digital technology without patient-provider interaction will be excluded. Following a pilot test, trained reviewers will independently screen titles/abstracts for inclusion and extract relevant data. Data will be organised using the Nursing Role Effectiveness Model, outlining the virtual care and primary care context (structure component) and the nursing role concept (process component).

ETHICS AND DISSEMINATION

This review will involve the collection and analysis of secondary sources that have been published and/or are publicly available. Therefore, ethics approval is not required. Scoping review findings will be published in a peer-reviewed journal and presented at relevant conferences, targeting international primary care stakeholders.

Portuguese Primary Healthcare and Prevention Quality Indicators for Diabetes Mellitus - A Data Envelopment Analysis

BACKGROUND

Diabetes mellitus (DM) is a worldwide public health priority. The increasing prevalence and the budget constraints force to have effective healthcare, especially at the primary healthcare (PHC) level. We aim to assess primary care efficiency considering the best use of human resources to produce optimal diabetes care in terms of prevention quality indicators (PQIs) rates across national ACES (health centre groupings).

METHODS

We conducted a two-stage data envelopment analysis (DEA) to assess the technical efficiency of 54 Portuguese primary care health centre groupings for the 2016-2017 biennium. In the first stage, efficiency scores were obtained through five output-oriented DEA models under vector return to scale (VRS) assumption, using three input variables representing key primary care human resources and one output representing each one of the five PQIs related to diabetes. In the second stage, Tobit regression models were estimated to assess the determinants of primary care efficiency in diabetes care.

RESULTS

A total of 13 ACES reached the efficiency frontier. Better managing human resources could reduce PQI rates by 52.3% in 2016 and 49.1% in 2017. Higher proportion of patients under 65 years old and better controlled with a hemoglobin A1c (HbA1c) ≤6.5% were associated with better efficiency in diabetes care, whereas higher prevalence of DM and unemployment worsened hospitalizations rates by diabetes short-term complications and lower-extremity amputation.

CONCLUSION

Inefficiency in DM care was found in most of the primary care settings which can substantially improve the avoidable hospitalization rates by DM using their current level human resources. These findings help to improve diabetes care by targeting human resources at primary care level, which should be integrated into performance assessments considering broader and integrated scopes.

Cost of running a full-service receiving office at a centralised testing laboratory in South Africa

Background

The National Health Laboratory Service operates a platform of 226 laboratories across South Africa, ranging from highly sophisticated central academic hospitals to distant rural hospitals. The core function of the National Health Laboratory Service is to provide cost-effective and efficient health laboratory services in the public healthcare sector.

Objective

This study aimed to assess the comprehensive cost of running a full-service receiving office (RO) at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) laboratory.

Methods

Top-down costing was conducted, with the cost per registration as the main outcome of interest. The annual equivalent costs (AEC) for the following categories were determined: registration materials, collection materials, staffing, laboratory equipment, building and electricity, and other operating costs. Data for the period from 01 April 2019 to 31 March 2020 were included in the analyses.

Results

The AEC was $1 657 483.00 United States dollars (USD) and the cost per registration was $0.766 USD. Staff contributed 59.9% of the total cost per registration, while collection materials contributed 21.4%. The RO core staff (data clerks) contributed 50.8% of the total staffing costs, while messengers and drivers contributed 31.2%. The introduction of order entry at the CMJAH and other primary healthcare facilities reduced the total AEC by 20%. A single order entry application would serve both the CMJAH and primary healthcare facilities - hence we would prefer to not refer to order entries.

Conclusion

Providing a comprehensive RO service costs approximately $1.00 USD per registration. The implementation of order entry at the CMJAH would reduce AECs substantially and improve efficiency.

Beyond patient-sharing: Comparing physician- and patient-induced networks

The sharing of patients reflects collaborative relationships between various healthcare providers. Patient-sharing in the outpatient sector is influenced by both physicians' activities and patients' preferences. Consequently, a patient-sharing network arises from two distinct mechanisms: the initiative of the physicians on the one hand, and that of the patients on the other. We draw upon medical claims data to study the structure of one patient-sharing network by differentiating between these two mechanisms. Owing to the institutional requirements of certain healthcare systems rather following the Bismarck model, we explore different triadic patterns between general practitioners and medical specialists by applying exponential random graph models. Our findings imply deviation from institutional expectations and reveal structural realities visible in both networks.

Effects of GP characteristics on unplanned hospital admissions and patient safety. A 9-year follow-up of all Norwegian out-of-hours contacts

BACKGROUND

There are substantial differences in hospital referrals between general practitioners (GPs); however, there is little research on the consequences for patient safety and further healthcare use.

OBJECTIVE

To investigate associations between out-of-hours GP characteristics, unplanned hospital admissions, and patient safety.

METHODS

This cohort study included all Norwegian out-of-hours services contacts from 2008 to 2016, linked to registry data on patient characteristics, healthcare use and death, and GP age, sex, specialist status, out-of-hours service experience, and prior admission proportion. We estimated the impact from GP characteristics on (i) immediate unplanned hospital admissions for "all conditions," (ii) immediate unplanned hospital admissions for "critical conditions," (iii) 30-day unplanned hospital admissions, (iv) 30-day hospital costs, and (v) 30-day risk of death. To limit confounding, we matched patients in groups by age, time, and location, with an assumption of random assignment of GPs to patients with this design.

RESULTS

Patients under the care of older and male GPs had fewer immediate unplanned hospital admissions, but the effects on cumulative 30-day unplanned hospital admissions and costs were small. The GPs' prior admission proportion was strongly associated with both immediate and 30-day unplanned hospital admissions. Higher prior admission proportion was also associated with admitting more patients with critical conditions. There was little evidence of any associations between GP characteristics and 30-day risk of death.

CONCLUSIONS

GPs' prior admission proportion was strongly associated with unplanned hospital admissions. We found little effects on 30-day mortality, but more restrictive referral practices may threaten patient safety through missing out on critical cases.

Clinical perspectives on the identification of neurodevelopmental conditions in children and changes in referral pathways: qualitative interviews

OBJECTIVE

Previous work has raised questions about the role of general practitioners (GPs) in the identification of neurodevelopmental conditions such as autism spectrum disorders (autism) and attention deficit hyperactivity disorders (ADHD). This study aimed to explore how GPs identify these conditions in practice and their perspectives on recent changes to local referral pathways that mean referrals to the neurodevelopmental team come through educational professionals and health visitors, rather than GPs. This study also aimed to explore Child and Adolescent Mental Health Services (CAMHS) specialist's perspectives on the role of GPs.

SETTING

GP practices, local neurodevelopmental services and specialist CAMHS services in the UK.

PARTICIPANTS

semistructured interviews were conducted with GPs (n=8), specialists in local CAMHS (n=7), and professionals at national CAMHS services around the country (n=10). Interviews were conducted between January and May 2019. A framework approach informed by thematic analysis was used to analyse the data.

RESULTS

GPs drew on various forms of tacit and explicit information including behavioural markers, parental report, prior knowledge of the family, expert and lay resources. Opinions varied between GPs regarding changes to the referral pathway, with some accepting the changes and others describing it as a 'disaster'. CAMHS specialists tended to feel that GPs required more neurodevelopmental training and time to conduct consultations.

CONCLUSION

This study adds to the literature showing that GPs use an array of information sources when making referral decisions for autism and ADHD. Further work is urgently required to evaluate the impact of reconfiguring neurodevelopmental referral pathways such that GPs have a diminished role in identification.

To which non-physician health professionals do French general practitioners refer their patients to and what factors are associated with these referrals? Secondary analysis of the French national cross-sectional ECOGEN study

Background

Multiprofessional practice is a key component in primary care. Examining general practitioner (GP) referral frequency to non-physician health professionals (NPHP) can provide information about how primary care is organised and works which is useful for policymakers. Our study aimed to describe French GP referral frequency to various NPHPs in France and identify associated factors.

Methods

This is an ancillary study to the observational, cross-sectional (ECOGEN) study conducted in 2011/2012 in France among 128 GPs. Data about consultations using the standardised International Classification of Primary Care (ICPC-2), and patient and GP characteristics were collected from 20,613 GP consultations. Referrals were identified through inductive and deductive approaches using ICPC-2 codes, keywords, and deep, open manual searches. Referral frequency was described overall and per NPHP. Patient, GP, and consultation-related factors associated with referral rates were described for the three most frequently identified NPHPs. To minimise potential sources of bias, this observational study followed the STROBE guidelines.

Results

French GPs referred 6.8% of patients to NPHPs, with physiotherapists, podiatrists, and nurses accounting for 85.2% of referrals. Older patients, retired patients, multiple health problems managed, and longer consultation durations were found to be associated with higher referral rates (p < 0.001). Specific trends were observed for nurse, physiotherapist, and podiatrist referrals. Women (p < 0.001) and regular patients (p = 0.002) were more likely to receive physiotherapy referrals while people with no professional activity were less likely (p < 0.001). Female GPs and those working in urban practices were more likely to issue a physiotherapy referral (p < 0.001), while GPs working in rural practices (p < 0.001) and those with higher annual consultation numbers (p = 0.002) were more likely to refer to a nurse. Working in multiprofessional centres appeared to have little impact on referral rates, being only slightly associated with podiatrist referrals (p = 0.003).

Conclusions

Referral frequency is more associated with patient characteristics and clinical situations than GP-related factors suggesting patients needing referral most are most often referred. Furthermore, the three NPHPs that GPs refer to the most are those for which a referral is required for reimbursement in France, suggesting that health system legislation and NPHP reimbursement are strong determinants for referrals.

Does Internet Use Affect Medical Decisions among Older Adults in China? Evidence from CHARLS

Background: The rapid growth of the elderly population poses a huge challenge for people to access medical services. The key to get rid of the dilemma is for patients to go firstly to primary medical institutions. Existing studies have identified numerous factors that can affect patients’ health institution choice. However, we currently know little about the role of Internet use in the patients’ medical decisions. The objective of this study is to explore health-seeking behavior and institution choice under the background of the Internet era from the perspective of older adults, and to analyze whether the Internet could guide patients to the appropriate medical institution so as to accomplish hierarchical treatment. Methods: The dataset comprises 9416 people aged 45 or above from the China Health and Retirement Longitudinal Survey (CHARLS), which, through multistage cluster sampling, was conducted in 2011, 2013, and 2015. Logistic regression, PSM, and FE model are used to estimate the influence of Internet use on the health care decision-making behavior. Results: Internet use has a significant positive impact on the self-treatment of common diseases (β = 0.05, p < 0.05). In terms of medical institution choices, those who use Internet are more inclined to choose top-level hospitals than community health service institutions to treat common diseases (β = 0.06, p < 0.01). Conclusions: The Internet has lowered the obstacles to learning about common ailments, resulting in a substitution impact of self-treatment for hospital care. However, Internet use may aggravate older adults’ perception of the risk of disease, which exacerbates the tendency of going to higher-level medical institutions for medical treatment. The finding of the study is useful for further rational planning and utilization of the Internet in order to guide patients to appropriate medical institution, which helps to improve the efficiency of the overall medical and health services.

Exploring the implementation and underlying mechanisms of centralized referral systems to access specialized health services in Quebec

BACKGROUND

In 2016, Quebec, a Canadian province, implemented a program to improve access to specialized health services (Accès priorisé aux services spécialisés (APSS)), which includes single regional access points for processing requests to such services via primary care (Centre de répartition des demandes de services (CRDS)). Family physicians fill out and submit requests for initial consultations with specialists using a standardized form with predefined prioritization levels according to listed reasons for consultations, which is then sent to the centralized referral system (the CRDS) where consultations with specialists are assigned. We 1) described the APSS-CRDS program in three Quebec regions using logic models; 2) compared similarities and differences in the components and processes of the APSS-CRDS models; and 3) explored contextual factors influencing the models' similarities and differences.

METHODS

We relied on a qualitative study to develop logic models of the implemented APSS-CRDS program in three regions. Semi-structured interviews with health administrators (n = 9) were conducted. The interviews were analysed using a framework analysis approach according to the APSS-CRDS's components included in the initially designed program, Mitchell and Lewis (2003)'s logic model framework, and Chaudoir and colleagues (2013)'s framework on contextual factors' influence on an innovation's implementation.

RESULTS

Findings show the APSS-CRDS program's regional variability in the implementation of its components, including its structure (centralized/decentralized), human resources involved in implementation and operation, processes to obtain specialists' availability and assess/relay requests, as well as monitoring methods. Variability may be explained by contextual factors' influence, like ministerial and medical associations' involvement, collaborations, the context's implementation readiness, physician practice characteristics, and the program's adaptability.

INTERPRETATION

Findings are useful to inform decision-makers on the design of programs like the APSS-CRDS, which aim to improve access to specialists, the essential components for the design of these types of interventions, and how contextual factors may influence program implementation. Variability in program design is important to consider as it may influence anticipated effects, a next step for the research team. Results may also inform stakeholders should they wish to implement similar programs to increase access to specialized health services via primary care.

Is There a Role for Self-Referral in Pediatric Weight Management?

Background: A physician or health care provider (HCP) referral is usually needed for children to access multidisciplinary health services for obesity management; however, offering families the option to self-refer can enhance equity and access to care. Methods: We completed a retrospective medical record review to explore patient characteristics and program engagement of children with obesity who were self- (n = 18) or HCP-referred (n = 120) for obesity management. Results: Our descriptive data suggested that children who were self-referred presented with a healthier clinical profile and missed fewer appointments than their peers referred by HCPs. Conclusions: Prospective research is needed to examine whether health services and treatment outcomes differ between self- and HCP-referred children in obesity management.

Making complex decisions in uncertain times: experiences of Dutch GPs as gatekeepers regarding hospital referrals during COVID-19-a qualitative study

BACKGROUND

General practitioners often act as gatekeeper, authorizing patients' access to hospital care. This gatekeeping role became even more important during the current COVID-19 crisis as uncertainties regarding COVID-19 made estimating the desirability of hospital referrals (for outpatient or inpatient hospitalization) complex, both for COVID and non-COVID suspected patients. This study explored Dutch general practitioners' experiences and ethical dilemmas faced in decision making about hospital referrals in times of the COVID-19 pandemic.

METHODS

Semi-structured interviews with Dutch general practitioners working in the Netherlands were conducted. Participants were recruited via purposive sampling. Thematic analysis was conducted using content coding.

RESULTS

Fifteen interviews were conducted, identifying four themes: one overarching regarding (1) COVID-19 uncertainties, and three themes about experienced ethical dilemmas: (2) the patients' self-determination vs. the general practitioners' paternalism, (3) the general practitioners' duty of care vs. the general practitioners' autonomy rights, (4) the general practitioners' duty of care vs. adequate care provision.

CONCLUSIONS

Lack of knowledge about COVID-19, risks to infect loved ones, scarcity of hospital beds and loneliness of patients during hospital admission were central in dilemmas experienced. When developing guidelines for future crises, this should be taken into account.

Revisiting the four core functions (4Cs) of primary care: operational definitions and complexities

BACKGROUND

The four primary care (PC) core functions (the '4Cs', ie, first contact, comprehensiveness, coordination and continuity) are essential for good quality primary healthcare and their achievement leads to lower costs, less inequality and better population health. However, their broad definitions have led to variations in their assessment, in the innovations implemented to improve these functions and ultimately in their performance.

OBJECTIVES

To update and operationalise the 4Cs' definitions by using a literature review and analysis of enhancement strategies, and to identify innovations that may lead to their enhancement.

METHODS

Narrative, descriptive analysis of the 4Cs definitions, coming from PC international reports and organisations, to identify measurable features for each of these functions. Additionally, we performed an electronic search and analysis of enhancement strategies to improve these four Cs, to explore how the 4Cs inter-relate.

RESULTS

Specific operational elements for first contact include modality of contact, and conditions for which PC should be approached; for comprehensiveness, scope of services and spectrum of population needs; for coordination, links between PC and higher levels of care and social/community-based services, and workforce managing transitions and for continuity, type, level and context of continuity. Several innovations like enrolment, digital health technologies and new or enhanced PC provider's roles, simultaneously influenced two or more of the 4Cs.

CONCLUSION

Providing clear, well-defined operational elements for these 4Cs to measure their achievement and improve the way they function, and identifying the complex network of interactions among them, should contribute to the field in a way that supports efforts at practice innovation to optimise the processes and outcomes in PC.

Illness perception and health care use in individuals with irritable bowel syndrome: results from an online survey

BACKGROUND

Individual illness perception is known to influence a range of outcome variables. However, little is known regarding illness perception in irritable bowel syndrome (IBS) and its relation to the use of the health care system. This study hypothesised a relationship between illness perception and inappropriate health care use (under-, over- and misuse).

METHODS

An internet-based, cross-sectional study in participants affected by IBS symptoms was carried out (April - October 2019) using open questions as well as validated standardized instruments, e.g. the illness perception questionnaire revised (IPQ-R) and its subscales. Sub-group comparisons were done non-parametrically and effect sizes were reported. Potential predictors of (1) conventional health care utilisation and (2) utilisation of treatment approaches with lacking or weak evidence regarding effectiveness in IBS were examined with logistic regression analyses and reported as odds ratio (OR) and 95% confidence interval.

RESULTS

Data from 513 individuals were available. More than one-third (35.7%) of participants were classified as high utilisers (> 5 doctor visits during the last year). Several indicators of inappropriate health care use were detected, such as a low proportion of state-of-the-art gynaecological evaluation of symptoms (35.0% of women) and a high proportion of individuals taking ineffective and not recommended non-steroidal antirheumatic drugs for IBS (29.4%). A majority (57.7%) used treatment approaches with lacking or weak evidence regarding the effectiveness in IBS (e.g. homeopathy). Being a high utiliser as defined above was predicted by the perceived daily life consequences of IBS (IPQ-R subscale "consequences", OR = 1.189 [1.100-1.284], p ≤ 0.001) and age (OR = 0.980 [0.962-0.998], p = 0.027). The use of treatment approaches with lacking or weak evidence was forecasted by the perceived daily life consequences (OR = 1.155 [1.091-1.223], p ≤ 0.001) and gender (reference category male: OR = 0.537 [0.327-0.881], p = 0.014), however effect sizes were small.

CONCLUSIONS

Daily life consequences, perceived cure and personal control as aspects of individual disease perception seem to be related to individuals' health care use. These aspects should be a standard part of the medical interview and actively explored. To face inappropriate health care use patients and professionals need to be trained. Interdisciplinary collaborative care may contribute to enhanced quality of medical supply in IBS.

Primary Care Networks and Starfield's 4Cs: A Case for Enhanced Chronic Disease Management

The primary care network (PCN) was implemented as a healthcare delivery model which organises private general practitioners (GPs) into groups and furnished with a certain level of resources for chronic disease management. A secondary qualitative analysis was conducted with data from an earlier study exploring facilitators and barriers GPs enrolled in PCN's face in chronic disease management. The objective of this study is to map features of PCN to Starfield's "4Cs" framework. The "4Cs" of primary care-comprehensiveness, first contact access, coordination and continuity-offer high-quality design options for chronic disease management. Interview transcripts of GPs (n = 30) from the original study were purposefully selected. Provision of ancillary services, manpower, a chronic disease registry and extended operating hours of GP practices demonstrated PCN's empowering features that fulfil the "4Cs". On the contrary, operational challenges such as the lack of an integrated electronic medical record and disproportionate GP payment structures limit PCNs from maximising the "4Cs". However, the enabling features mentioned above outweighs the shortfalls in all important aspects of delivering optimal chronic disease care. Therefore, even though PCN is in its early stage of development, it has shown to be well poised to steer GPs towards enhanced chronic disease management.

Do patients bypass primary care for common health problems under a free-access system? Experience of Taiwan

Background

A common challenge for free-access systems is that people may bypass primary care and seek secondary care through self-referral. Taiwan’s government has undertaken various initiatives to mitigate bypass; however, little is known about whether the bypass trend has decreased over time. This study examined the extent to which patients bypass primary care for treatment of common diseases and factors associated with bypass under Taiwan’s free-access system.

Methods

This repeated cross-sectional study analyzed data from Taiwan’s National Health Insurance Research Database. A random sample of 1 million enrollees was drawn repeatedly from the insured population during 2000–2017. To capture visits beyond the community level, the bypass rate was defined as the proportion of self-referred visits to the top two levels of providers, namely academic medical centers and regional hospitals, among all visits to all providers. Subgroup analyses were conducted for visits with a single diagnosis. Logistic regressions were used to investigate factors associated with bypass.

Results

The standardized bypass rate for all diseases analyzed exhibited a decreasing trend. In 2017, it was low for common cold (0.7–1.3%), moderate for hypertension (14.0–29.5%), but still high for diabetes (32.0–47.0%). Moreover, the likelihood of bypass was higher for male, patients with higher salaries or comorbidities, and in areas with more physicians practicing in large hospitals or less physicians working in primary care facilities.

Conclusions

Although the bypass trend has decreased over time, continuing efforts may be required to reduce bypass associated with chronic diseases. Both patient sociodemographic and market characteristics were associated with the likelihood of bypass. These results may help policymakers to develop strategies to mitigate bypass.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05908-w.

Mixed methods study protocol to examine perceptions of family medicine among long-term patients of a family medicine clinic in Japan

INTRODUCTION

Family physicians or general practitioners play central roles in many countries' primary care systems, but family medicine (FM) remains relatively unestablished in Japan. Previous studies in Japan have examined the general population's understanding of FM as a medical specialty, but none have explored this topic using actual FM clinic patients. Here, we describe a protocol to explore the perceptions of FM among long-term patients of one of Japan's oldest FM clinics.

METHODS AND ANALYSIS

The study will be conducted at the Motowanishi Family Clinic in Hokkaido, Japan, using patients who have attended the clinic for over 10 years. The analysis will adopt a two-phase explanatory sequential mixed methods design. During phase I, quantitative data from participants' medical records will be collected and reviewed, and patients' perceptions of FM will be assessed through a questionnaire. The correlations between participants' knowledge that the clinic specialises in FM and various characteristics will be examined. In phase II, qualitative data will be collected through semi-structured interviews of approximately 10 participants selected using maximum variation sampling based on phase I results. A thematic analysis will be conducted in phase II to identify patients' perceptions and changes in perceptions. Finally, each theme identified in phase II will be transformed into a quantitative variable to analyse the relationships between the phases. A joint display will be used to integrate the phases' findings and examine how phase II results explain phase I results.

ETHICS AND DISSEMINATION

The institutional review board of the Japan Primary Care Association has approved this research (2019-003). The results will be presented at the association's annual academic meeting and submitted for publication in relevant journals. The findings will also be provided to the patients via the clinic's internal newsletter.

Performance and Sociodemographic Determinants of Excess Outpatient Demand of Rural Residents in China: A Cross-Sectional Study

Excess healthcare utilization is rapidly rising in rural China. This study focused on excess outpatient demand (EOD) and aimed to measure its performance and sociodemographic determinants among China’s rural residents. A total of 1290 residents from four counties in central China were enrolled via multistage cluster random sampling. EOD is the condition in which the level of hospital a patient chooses is higher than the indicated level in the governmental guide. A multilevel logistic regression was used to examine the sociodemographic determinants of EOD. Residents with EOD accounted for 85.83%. The risk of EOD was 51.17% and value was 5.69. The value of EOD in diseases was higher than that in symptoms (t = −21.498, p < 0.001). Age (OR = 0.489), educational level (OR = 1.986) and hospital distance difference (OR = 0.259) were the main sociodemographic determinants of EOD. Excess outpatient demand was evident in rural China, but extreme conditions were rare. Results revealed that age, educational level and hospital distance were the main sociodemographic determinants of EOD. The capacity of primary healthcare institutions, universality of common disease judgement and understanding of institution’s scope of disease curing capabilities of residents should be improved to reduce EOD.

Effectiveness of primary care gatekeeping: difference-in-differences evaluation of a pilot scheme in China

INTRODUCTION

This paper evaluates the effectiveness of a gatekeeping pilot in shifting resources and patient visits from hospitals to primary care facilities under the Chinese New Rural Cooperative Medical Scheme.

METHODS

We applied a difference-in-differences regression analysis using claims data from a pilot district in northern China. The study covered 200 685 enrollees in 17 townships in 2012 and followed-up the townships over 12 year-quarters until the end of 2014.

RESULTS

The gatekeeping pilot led to significantly more patients visiting primary care facilities (55.3%, p=0.001), but there was little evidence of increased ambulatory spending on primary care (1.6%, p=0.884). The pilot reduced hospital visits by 23.9% (p=0.048) and ambulatory spending at the hospitals by 22.4% (p=0.011).

CONCLUSIONS

This first impact evaluation of gatekeeping outside high-income countries found that gatekeeping policy did not seem to have expanded the care provided by primary care facilities, despite an increased volume of claimed visits. Although claimed patient visits and expenditure at hospitals reduced, we suspect this may have been because patients found it either cumbersome or difficult to obtain reimbursement for their care.

Perceptions, experiences, and understandings of cluster headache among GPs and neurologists: a qualitative study

BACKGROUND

Cluster headache is a severe primary headache with a similar prevalence to that of multiple sclerosis. Cluster headache is characterised by unilateral trigeminal distribution of pain, ipsilateral cranial autonomic features, and a tendency to circadian and circannual periodicity.

AIM

To explore the perceptions, experiences, and understandings of cluster headache among GPs and neurologists.

DESIGN AND SETTING

Qualitative interview study in primary care surgeries and neurology departments in the north of England.

METHOD

Semi-structured interviews were conducted with GPs and neurologists, recorded, and transcribed. A thematic analysis was applied to the dataset.

RESULTS

Sixteen clinicians participated in this study: eight GPs and eight neurologists. Four main themes were identified following thematic analysis: challenges with the cluster headache diagnosis; impact of cluster headache; challenges with treatment; and appropriateness of referrals to secondary care. Clinicians recognised the delays in the diagnosis of cluster headache, misdiagnosis, and mismanagement, and were aware of the potential impact cluster headache can have on patients' mental health and ability to remain in employment. Findings highlighted tensions between primary and secondary care around the cost of medication and the remit of prescribing treatment regimens. Patients' anxiety, their need for reassurance, and their insistence about seeing a specialist are some of the reasons for referrals.

CONCLUSION

Clinicians acknowledged delays in diagnosis, misdiagnosis, and mismanagement of cluster headache. The responsibility of prescribing causes ongoing tensions between primary and secondary care. Clear referral and management pathways for primary headaches are required to improve patient outcomes and healthcare costs.