Between delivering chronic care and answering patients' burdens: Understanding HIV specialist nurses' experiences in the age of treatment

AIM(S)

To understand the experiences of HIV nurses in the context of ambivalence between biomedical treatment advancements and the continuing burden for people living with HIV and negative representations of HIV.

DESIGN

An interpretative phenomenological study was conducted using in-depth interviews.

METHODS

Twenty-one interviews with nurses were conducted between November 2021 and March 2022. A thematic analysis was performed.

RESULTS

Six themes related to the nurses' experiences emerged. Despite effective treatment for most people with HIV, nurses identify patient populations that require additional care. Nurses are flexible in making extra appointments to accommodate complex issues in these patients. Nurses develop a unique relationship with their patients based on trust and empathy, linked to patient's experiences with stigma and discrimination for people with HIV. Nurses perceive their tasks as becoming increasingly complex. There is explicit awareness about the changes in HIV care from acute to chronic care and how this affects nurses' tasks. Nurses continue to differentiate HIV from other chronic conditions.

CONCLUSION

Biomedical advancements change the organization of HIV care while public health concerns remain and patient population has particular needs due to negative social representations of HIV. Nurses navigate these issues in their everyday care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

A potential re-evaluation of the role of nurses in providing chronic HIV care.

IMPACT

Our study addresses the roles of HIV nurses as care is shifting towards chronic care models. The unique relationship between nurses and patients is key in understanding the importance of nurses in the care trajectory. These findings impact the institutional role of nurses in HIV treatment centres and the institutional organization of HIV care.

REPORT METHOD

The COREQ guideline was used.

PATIENT OR PUBLIC CONTRIBUTION

Amsterdam UMC (AMC) staff, the national organization of HIV Nurses and patient organizations contributed to the study design.

Clinical care advice for monitoring of islet autoantibody positive individuals with presymptomatic type 1 diabetes

BACKGROUND/AIM

Type 1 diabetes is an autoimmune disease that involves the development of autoantibodies against pancreatic islet beta-cell antigens, preceding clinical diagnosis by a period of preclinical disease activity. As screening activity to identify autoantibody-positive individuals increases, a rise in presymptomatic type 1 diabetes individuals seeking medical attention is expected. Current guidance on how to monitor these individuals in a safe but minimally invasive way is limited. This article aims to provide clinical guidance for monitoring individuals with presymptomatic type 1 diabetes to reduce the risk of diabetic ketoacidosis (DKA) at diagnosis.

METHODS

Expert consensus was obtained from members of the Fr1da, GPPAD, and INNODIA consortia, three European diabetes research groups. The guidance covers both specialist and primary care follow-up strategies.

RESULTS

The guidance outlines recommended monitoring approaches based on age, disease stage and clinical setting. Individuals with presymptomatic type 1 diabetes are best followed up in specialist care. For stage 1, biannual assessments of random plasma glucose and HbA1c are suggested for children, while annual assessments are recommended for adolescents and adults. For stage 2, 3-monthly clinic visits with additional home monitoring are advised. The value of repeat OGTT in stage 1 and the use of continuous glucose monitoring in stage 2 are discussed. Primary care is encouraged to monitor individuals who decline specialist care, following the guidance presented.

CONCLUSIONS

As type 1 diabetes screening programs become more prevalent, effective monitoring strategies are essential to mitigate the risk of complications such as DKA. This guidance serves as a valuable resource for clinicians, providing practical recommendations tailored to an individual's age and disease stage, both within specialist and primary care settings.

The Impact of Specialist Care on Teenage and Young Adult Patient-Reported Outcomes in England: A BRIGHTLIGHT Study

Purpose: In England, health care policy promotes specialized age-appropriate cancer services for teenagers and young adults (TYA), for those aged 13-24 years at diagnosis. Specialist Principal Treatment Centers (PTCs) provide enhanced age-specific care for TYA, although many still receive all or some of their care in adult or children's cancer services. Our aim was to determine the patient-reported outcomes associated with TYA-PTC based care. Methods: We conducted a multicenter cohort study, recruiting 1114 TYA aged 13-24 years at diagnosis. Data collection involved a bespoke survey at 6,12,18, 24, and 36 months after diagnosis. Confounder adjusted analyses of perceived social support, illness perception, anxiety and depression, and health status, compared patients receiving NO-TYA-PTC care with those receiving ALL-TYA-PTC and SOME-TYA-PTC care. Results: Eight hundred and thirty completed the first survey. There was no difference in perceived social support, anxiety, or depression between the three categories of care. Significantly higher illness perception was observed in the ALL-TYA-PTC and SOME-TYA-PTC group compared to the NO-TYA-PTC group, (adjusted difference in mean (ADM) score on Brief Illness Perception scale 2.28 (95% confidence intervals [CI] 0.48-4.09) and 2.93 [1.27-4.59], respectively, p = 0.002). Similarly, health status was significantly better in the NO-TYA-PTC (ALL-TYA-PTC: ADM -0.011 [95%CI -0.046 to 0.024] and SOME-TYA-PTC: -0.054 [-0.086 to -0.023]; p = 0.006). Conclusion: The reason for the difference in perceived health status is unclear. TYA who accessed a TYA-PTC (all or some care) had higher perceived illness. This may reflect greater education and promotion of self-care by health care professionals in TYA units.

Telemedicine in specialist outpatient care during COVID-19: a qualitative study

BACKGROUND

COVID-19 accelerated healthcare changes, introducing various telehealth services. Work is needed to determine the suitability of telemedicine in the post-pandemic era.

AIMS

To explore perceptions and experiences of telemedicine among patients and providers (clinicians and health administrators) who were involved in telemedicine appointments in hospital outpatient clinics in 2020-2022.

DESIGN, SETTING AND PARTICIPANTS

Qualitative study: semi-structured interviews were conducted with 37 participants (16 patients and 21 providers) in various hospital specialist outpatient clinics in a New South Wales local health district.

RESULTS

Patients were generally satisfied with telemedicine consultations, especially during COVID restrictions, because of the convenience of accessing care from home and minimising the risk of COVID exposure. However, patients considered that the inability to receive a physical examination was a significant disadvantage of telemedicine. Providers had ambivalent perceptions and expressed concerns about mis- and under-diagnoses because of the inability to conduct physical examinations. They considered telemedicine suitable for review appointments but noted an associated increased workload and stressed the need for sustainable funding models (Medicare items). Both patients and providers recognised the need for education/training and better integration of telemedicine platforms into existing infrastructure to facilitate an optimal hybrid model of care.

CONCLUSION

Despite expressing some concerns over its limitations, patients valued telemedicine for its convenience and for meeting their needs during the pandemic. While acknowledging that patients experienced some benefits from telemedicine, clinicians expressed concerns about potential missed diagnoses, uncertain clinical outcomes and lack of administrative and technological infrastructure. The ultimate test of telemedicine will be its impact on clinical outcomes versus longstanding models of in-person care.

Effect on orofacial pain in patients with chronic pain participating in a multimodal rehabilitation programme - a pilot study

OBJECTIVES

Orofacial pain in patients taking part in a multimodal rehabilitation programme (MMRP) due to chronic bodily pain is common but it is not known whether such a rehabilitation programme can also have an effect on the presence of orofacial pain. The first aim of this study was to evaluate the effect of an MMRP on orofacial pain frequency. The second aim was to evaluate differences in the effect on quality of life and on psychosocial factors related to chronic pain.

METHODS

MMRP was evaluated through validated questionnaires from the Swedish Quality Registry for Pain Rehabilitation (SQRP). Fifty-nine patients participating in MMRP filled out the two screening questions for orofacial pain in addition to the SQRP questionnaires before and after participation in MMRP during the period August 2016 to March 2018.

RESULTS

Pain intensity decreased significantly after the MMRP (p=0.005). Fifty patients (69.4 %) reported orofacial pain before MMRP and no significant decrease after the programme (p=0.228). Among individuals with orofacial pain, the self-reported level of depression decreased after participation in the programme (p=0.004).

CONCLUSIONS

Even though orofacial pain is common among patients with chronic bodily pain, participation in a multimodal pain programme was not enough to reduce frequent orofacial pain. This finding implies that specific orofacial pain management including information about jaw physiology could be a justified component of patient assessment prior to a multimodal rehabilitation programme for chronic bodily pain.

Evaluation of an Electronic Consultation Service for COVID-19 Care

PURPOSE

COVID-19 has increased the need for innovative virtual care solutions. Electronic consultation (eConsult) services allow primary care practitioners to pose clinical questions to specialists using a secure remote application. We examined eConsult cases submitted to a COVID-19 specialist group in order to assess usage patterns, impact on response times and referrals, and the content of clinical questions being asked.

METHODS

This was a mixed-methods analysis of eConsult cases submitted between March and September 2020 in Ontario, Canada to 2 services. We performed a descriptive analysis of the average response time and the total time spent by the specialist for eConsults. Primary care practitioners completed a post-eConsult questionnaire that asked about the outcome of the eConsult. We performed an inductive and deductive content analysis of a subset of cases to identify common themes among the clinical questions asked.

RESULTS

A total of 208 primary care practitioners submitted 289 eConsult cases. The median specialist response time was 0.6 days (range = 3 minutes to 15 days); the average time spent by specialists per case was 16 minutes (range = 5 to 59 minutes). In 69 cases (24%), the eConsult enabled avoidance of a face-to-face referral. Content analysis of 51 cases identified 5 major themes: precautions for high-risk and special populations, diagnostic clarification and/or need for COVID-19 testing, guidance on self-isolation and return to work, guidance on personal protective equipment, and management of chronic symptoms.

CONCLUSIONS

This study demonstrates the considerable potential of eConsults during a pandemic as our service was quickly implemented across Ontario and resulted in primary care practitioners' rapid and low-barrier access to specialist input.

The Effect of the COVID-19 Pandemic on the Social Inequalities of Health Care Use in Hungary: A Nationally Representative Cross-Sectional Study

Background: The social representation of restricted health care use during the COVID-19 pandemic has not been evaluated properly yet in Hungary. Objective: Our study aimed to quantify the effect of COVID-19 pandemic measures on general practitioner (GP) visits, specialist care, hospitalization, and cost-related prescription nonredemption (CRPNR) among adults, and to identify the social strata susceptible to the pandemic effect. Methods: This cross-sectional study was based on nationally representative data of 6611 (N_prepandemic = 5603 and N_pandemic = 1008) adults. Multivariable logistic regression models were applied to determine the sociodemographic and clinical factors influencing health care use by odds ratios (ORs) along with the corresponding 95% confidence intervals (CI). To identify the social strata susceptible to the pandemic effect, the interaction of the time of data collection with the level of education, marital status, and Roma ethnicity, was tested and described by iORs. Results: While the CRPNR did not change, the frequency of GP visits, specialist care, and hospitalization rates was remarkably reduced by 22.2%, 26.4%, and 6.7%, respectively, during the pandemic. Roma proved to be not specifically affected by the pandemic in any studied aspect, and the pandemic restructuring of health care impacted the social subgroups evenly with respect to hospital care. However, the pandemic effect was weaker among primary educated adults (iOR_{GP visits, high-school vs. primary-education} = 0.434; 95% CI 0.243–0.776, OR_{specialist visit, high-school vs. primary-education} = 0.598; 95% CI 0.364–0.985), and stronger among married adults (iOR_{GP visit, widowed vs. married} = 2.284; 95% CI 1.043–4.998, iOR_{specialist visit, widowed vs. married} = 1.915; 95% CI 1.157–3.168), on the frequency of GP visits and specialist visits. The prepandemic CRPNR inequality by the level of education was increased (iOR_{high-school vs. primary-education} = 0.236; 95% CI 0.075–0.743). Conclusion: Primary educated and widowed adults did not follow the general trend, and their prepandemic health care use was not reduced during the pandemic. This shows that although the management of pandemic health care use restrictions was implemented by not increasing social inequity, the drug availability for primary educated individuals could require more support.

Health care use in response to health shocks: Does socio-economic status matter?

We investigate how utilization of primary care, specialist care, and emergency department (ED) care (and the mix across the three) changes in response to a change in health need. We determine whether any changes in utilization are impacted by socio-economic status. The use of a unique Australian data set that consists of a large survey linked to multiple years of detailed administrative records enables us to better control for individual heterogeneity and allows us to exploit changes in health that are related to the onset of two health shocks: a new diagnosis of diabetes and heart disease. We extend the analysis by also examining changes to patient out-of-pocket costs. We find significant differences in the mix between primary and specialist care use according to income and type of health shock but no evidence of using ED as a substitute for other care. Our results indicate that low- and high-income patients navigate very different pathways for their care following the onset of diabetes and to a lesser extent heart disease. These pathways appear to be chosen on the basis of ability to pay, rather than the most effective or efficient bundle of care delivered through a combination of GP and specialist care.

Economic Analysis of Specialist Referral Patterns in Mackay, Queensland Following HealthPathways Implementation

INTRODUCTION

HealthPathways is a clinical information portal developed in New Zealand that enables general practitioners to manage and refer their patients in a local context. We analyzed specialist outpatient appointment costs in Mackay, Queensland before and after HealthPathways implementation.

METHODS

We retrospectively examined specialist outpatient costs for patients referred by Mackay general practitioners for conditions with varying levels of HealthPathways implementation. Ranked from most clinical pathways available to none, chronic diabetes, cardiology, respiratory, and urology visits from January to March 2015, pre-pathways, and January to March 2017, post-pathways, were assessed. Monte Carlo simulation was used to estimate cost changes. Per-visit costs were multiplied by visit numbers to estimate policy impact.

RESULTS

The mean cost per visit increased from $220 to $305 for diabetes and $270 to $323 for respiratory, and decreased from $296 to $257 for cardiology and $444 to $293 for urology. The policy impact for each disease group over 3 months after accounting for visit numbers was a likely saving of $30 360 for diabetes and $10 270 for cardiology, and a likely cost increase of $24 449 for respiratory and $20 536 for urology.

CONCLUSIONS

We observed that conditions with more comprehensive clinical pathways cost Mackay HHS substantially less following implementation. Costs for low and no pathway implementation referrals increased slightly over the same period.

Clinical Questions Asked by Long-Term Care Providers Through eConsult: A Retrospective Study

Introduction

eConsult allows primary care providers (PCPs) to access timely specialist advice and informs patient care. To understand the use of eConsult in long-term care (LTC) settings, we examined the clinical content and types of questions asked by LTC PCPs.

Methods

A descriptive, retrospective study of eConsults submitted through the Champlain BASE™ eConsult Service between January 1, 2017, and December 31, 2018, by LTC PCPs was conducted. Cases were classified using validated taxonomies. Descriptive statistics were generated for content and question type classifications, service utilization data, and close-out survey responses.

Results

22 LTC PCPs submitted 113 eConsults. They sought advice about drug treatment (58%), diagnosis (44%), and management (38%) in a breadth of clinical areas, often skin-related (39%). Long-term care PCPs frequently asked more than one question type (42%). They received advice within 1 week (91%) and rated eConsult as very helpful and educational. Three case examples are presented.

Conclusion

This study demonstrates the type of advice LTC PCPs are seeking through eConsult and its usefulness in this setting. Long-term care stakeholders are encouraged to consider implementing eConsult in other regions, as a means to improve access to timely specialist advice, support clinical decision-making, and improve residents’ quality of life.

A retrospective review of specialist referrals for refugees into Greece's health system: A humanitarian organization's perspective

AIM

Refugee arrivals to Europe have numbered more than one million since 2015 with the majority arriving through Greece. The healthcare needs of refugees have placed strains on Greece's healthcare system which has already been affected by its ongoing economic crisis. At the peak of arrivals during 2016, primary healthcare was primarily provided by humanitarian organizations with specialist referrals into the Greek healthcare system. There is little published literature on the type and impacts of specialist referrals for refugees in Greece. The aim of this retrospective review is to identify the type and impacts of specialist referrals for refugees into Greece's health system.

METHODS

This retrospective study reviewed the number and type of specialty referrals from one humanitarian organization providing primary healthcare for refugees in Greece. All consultations during an 8-month period (December 1, 2016-July 31, 2017) were reviewed.

RESULTS

Of 4168 consultations, 42% were patients aged 17 years or younger, 52% were male, and 90% were Syrian. Two hundred and thirty-three patients (11%) required a specialist referral; 25% were for dental (provided by another humanitarian organization), 10% each for obstetrics and gynecology and pediatrics, and 8% for ophthalmology. Respiratory complaints were most frequently seen, and these were more predominant in the winter months. Pediatric consultations varied according to month, likely due to population movements.

CONCLUSION

Dentistry was noted to be a gap in humanitarian response programming and accounted for the greatest need for specialist input with referrals for women and children accounting for a large proportion of referrals.

The Effects of the Health System Response to the COVID-19 Pandemic on Chronic Disease Management: A Narrative Review

BACKGROUND

Individuals with chronic conditions require ongoing disease management to reduce risks of adverse health outcomes. During the COVID-19 pandemic, health care for non-COVID-19 cases was affected due to the reallocation of resources towards urgent care for COVID-19 patients, resulting in inadequate ongoing care for chronic conditions.

METHODS

A keyword search was conducted in PubMed, Google Scholar, Science Direct, and Scopus for English language articles published between January 2020 and January 2021.

FINDINGS

During the COVID-19 pandemic, in-person care for individuals with chronic conditions have decreased due to government restriction of elective and non-urgent healthcare visits, greater instilled fear over potential COVID-19 exposure during in-person visits, and higher utilization rates of telemedicine compared to the pre-COVID-19 period. Potential benefits of a virtual-care framework during the pandemic include more effective routine disease monitoring, improved patient satisfaction, and increased treatment compliance and follow-up rates. However, more needs to be done to ensure timely and effective access to telemedicine, particularly for individuals with lower digital literacy. Capitation primary care models have been proposed as a more financially-robust approach during the COVID-19 pandemic than fee-for-service primary care models; however, the interplay between different primary models and the health outcomes is still poorly understood and warrants further investigation. Shortages of medication used to manage chronic conditions were also observed at the beginning of the COVID-19 pandemic due to global supply chain disruptions. Finally, patients with chronic conditions faced lifestyle disruptions due to the COVID-19 pandemic, specifically in physical activity, sleep, stress, and mental health, which need to be better addressed.

INTERPRETATION

Overall, this review elucidates the disproportionately greater barriers to primary and specialty care that patients with chronic diseases face during the COVID-19 pandemic and emphasizes the urgent need for better chronic disease management strategies moving forward.

"It's Difficult, There's No Formula": Qualitative Study of Stroke Related Communication Between Primary and Secondary Healthcare Professionals

Introduction:

Stroke survivors have complex health needs requiring long-term, integrated care. This study aimed to elicit generalists’ and specialists’ experience of stroke-related interprofessional communication, including perceived barriers and enablers.

Design and Setting:

Qualitative study involving generalist (primary care) and specialist services (acute and community) in England. Six focus groups (n = 48) were conducted.

Method:

Healthcare professionals were purposively selected and invited to participate. Audio-recordings were transcribed verbatim and analysed using Framework Analysis.

Results:

Four themes were identified: 1) Generalists and specialists have overlapping roles but are working in silos; 2) Referral decision-making process as influential to generalist-specialist communication; 3) Variable quality of communication; and 4) Improved dialogue between generalist and specialist services.

Conclusions:

Generalists and specialists recognise the need for better communication with each other. Current care is characterised by silo-based working that ignores the contribution of other sectors. Failure to bridge this communication gap will result in people with stroke continuing to experience unmet stroke needs and fragmented care.

How Do German General Practitioners Assess Medical Specialist Care Needs of Nursing Home Residents? Results of a Postal Survey in North-Western Germany

The frequency of contacts of nursing home residents with medical specialists is lower compared to the general population of the same age group in Germany. The aim of this study was to assess general practitioners’ (GPs) views on specialist care needs of nursing home residents, on questions of qualification and care coordination. A cross-sectional study was conducted with a postal questionnaire among a representative sample of 1121 GPs in north-western Germany in 2018. The perceptions of GPs about the relative importance of the type of specialist care that is required in nursing homes was assessed on a five-point Likert scale (0 = very low to 4 = very high). A total of 375 GPs (response 33.5%; mean age 54.4 years; 57.6% male) participated in the survey. GPs assessed care needs as highest for neurologists and psychiatrists (68.7%) and lowest for gynecologists (6.5%). Almost all respondents (96.2%) strongly agreed that medical care for nursing home residents should be coordinated by GPs and that GPs should initiate the referral for further specialist care when required (87.5%). A minority (25.7%) agreed that quality of medical care would improve when care for a nursing home was provided by only one GP practice. GPs perceive the needs of nursing home residents for specialist care as high only in relation to care by neurologists and psychiatrists. GPs consider their own coordination function for medical care in nursing homes as very important.

Cancer control in Africa: surgery

Surgery is the mainstay of cancer treatment and lack of surgical treatment is a major driver in holding back optimal cancer care. Surgery is essential for global cancer care in all resource settings. Of the estimated 18.1 million new cases of cancer in 2018, over 80% of cases will need surgery, some several times. Many patients throughout the world do not have access to cancer surgery. Many of the key adjunct treatment modalities for cancer surgery—e.g., anaesthesia, pathology and imaging—are also inadequate. Solutions are necessary and should include better-regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials and new approaches to improve quality and scale up cancer surgical systems through education and training. Delivery of safe, affordable and timely cancer surgery to all must be at the heart of global and national cancer-control planning.

Diagnosis and initial management in psoriatic arthritis: a qualitative study with patients

Objectives

PsA is an inflammatory condition that can cause pain, fatigue, swelling and joint stiffness. The consequences include impaired physical function, a high psychosocial burden, reduced quality of life and work disability. The presenting symptoms can be non-specific and varied, leading to delays in diagnosis or referral to specialist teams. The aim of this study was to explore patients' experiences of being diagnosed and the initial management of PsA.

Methods

The study used a qualitative design, with data collected in one-to-one, face-to-face semi-structured interviews.

Results

Fifteen newly diagnosed patients (<24 months) from three hospital sites in the southwest of England participated. Interviews were transcribed, anonymized and analysed using inductive thematic analysis. The following two main themes with sub-themes represent the data: symptom onset to specialist care: ‘it was the blind leading the blind’ (making sense of symptoms; mis-diagnosis and missed opportunities; and fast and easy access to expertise); and diagnosis as a turning point: ‘having somebody say you've got something wrong with you, I was euphoric’ (validation and reassurance; weighing up treatment options; taking on self-management; and acknowledging loss and change).

Conclusion

Participants were already dealing with functional limitations and were highly distressed and anxious by the time they received their diagnosis. Physical and mental outcomes could be improved by the implementation of existing psoriasis management guidelines and strategies for earlier referral from primary care to rheumatology and by the development of guidelines on educational, self-management and psychological support provision soon after diagnosis.

Early life adversity, use of specialist care and unmet specialist care need among children

Adverse childhood experiences (ACEs) are linked to increased utilization of health care among adults; however, the impact of ACEs on nonmental health specialist care has been largely overlooked. To address this, data from the 2011-2012 National Survey of Children's Health (n = 89,357) were used to assess the health of children aged 0-17 living with a parent or guardian. Use of specialist care among children in the past 12 months was the outcome of interest and experiencing any one of nine ACEs was the independent variable of interest. After adjusting for confounders in logistic regression modeling, children who experience specific ACEs had higher odds of receiving specialist care. All ACEs were associated with higher unmet need of specialist care, and each additional ACE was independently associated with higher odds of needing specialist care among those who had not received it. This study provides evidence of that experiencing specific ACEs lead to increased demand of nonmental health specialist services among children and adds to the growing body of research indicating that individual ACE items may be differentially associated with health-care utilization or not associated with health-care utilization at all.

Electronic Consultation Services Worldwide: Environmental Scan

BACKGROUND

Excessive wait times for specialist care pose a serious concern for many patients, leading to duplication of tests, patient anxiety, and poorer health outcomes. In response to this issue, many health care systems have begun implementing technological innovations designed to improve the referral-consultation process. Among these services is electronic consultation (eConsult), which connects primary care providers and specialists through a secure platform to facilitate discussion of patients' care.

OBJECTIVE

This study aims to examine different eConsult services available worldwide and compare the strategies, barriers, and successes of their implementation in different health care contexts.

METHODS

We conducted an environmental scan comprising 3 stages as follows: literature review; gray literature search; and targeted, semistructured key informant interviews. We searched MEDLINE and EMBASE (literature review) and Google (gray literature search). Upon completing the search, we generated a list of potential interview candidates from among the stakeholders identified. Potential participants included researchers, physicians, and decision makers. The maximum variation sampling was used to ensure sufficient breadth of participant experience. In addition, we conducted semistructured interviews by telephone using an interview guide based on the RE-AIM framework. Analyses of transcripts were conducted using a thematic synthesis approach.

RESULTS

A total of 53 services emerged from the published and gray literature. Respondents from 10 services participated in telephonic interviews. The following 4 major themes emerged from the analysis: service structure; benefits of eConsult; implementation challenges; and implementation enablers.

CONCLUSIONS

eConsult services have emerged in a variety of countries and health system contexts worldwide. Despite differences in structure, platform, and delivery of their services, respondents described similar barriers and enablers to the implementation and growth and reported improved access and high levels of satisfaction.

Symptom Distress Among Diverse Patients Referred for Community-Based Palliative Care: Sociodemographic and Medical Correlates

CONTEXT

Community-based palliative care programs are appearing in the U.S. Many of these programs, particularly those in large cities, serve highly diverse populations. Information about the sources of variation in the conditions that drive illness burden, like symptom distress, may be useful in program planning.

OBJECTIVES

To characterize variation in symptom distress among highly diverse patients referred for palliative care in an urban setting.

METHODS

This is a retrospective cross-sectional survey of data obtained from patients at the time of enrollment in a community-based palliative care program. Symptom distress was measured using the Condensed Memorial Symptom Assessment Scale. Severe distress was defined as reporting either "quite a bit"/"very much" or "frequently"/"almost constantly" for one or more symptoms. Multivariate analysis evaluated the associations between symptom distress and sources of patient variability.

RESULTS

Patients (n = 1532) were aged 72.2 years on average; 60.0% were women, 56.4% were African-American or Hispanic, and 30.8% were non-English speaking. Most had cancer or congestive heart failure (68.6%); 90.2% had a Karnofsky Performance Status score of 40-70. The most prevalent symptoms were fatigue (71.8%), pain (47.3%), and sadness (41.6%); the most distressing symptoms were fatigue (58.5%), worrying (54.8%), and weight loss (52.1%). In multivariate analyses, Caucasian race, non-Asian language, low Karnofsky Performance Status scores, and cancer diagnosis predicted severe symptom distress.

CONCLUSION

In a diverse urban population receiving community-based palliative care, symptoms were highly prevalent and distressing, and both sociodemographic and medical factors predicted severe distress. Program planning should consider the needs of subpopulations at risk for high symptom burden.

What proportion of paediatric specialist referrals originates from general practitioners?

AIM

To determine (i) the proportion of different referral sources for new referrals to paediatric specialist outpatient clinics and (ii) any association of referral source with utilisation of additional health services.

METHODS

Survey of parents presenting with their child at five paediatric specialist outpatient clinics at two Melbourne public hospitals.

RESULTS

Just over half (52%) of the respondents were referred by a general practitioner (GP). The remainder were referred by a paediatrician (27%) at hospital discharge (16%) or from the ED (6%). Most respondents (71%) reported that their child also has a referral to see another specialist for the same health concern but had not yet had the consultation; 44% had consulted another doctor for the same health concern between receiving the referral and the appointment. Paediatrician referrals were more likely to see another specialist for the same health concern compared to other referral sources (P = 0.032).

CONCLUSION

Only half of the referrals of new patients to paediatric specialist outpatient clinics come from GPs. Future research should investigate whether multiple referral sources have a negative impact on the co-ordination and cost of paediatric health care.

Girls and Boys Have a Different Cardiometabolic Response to Obesity Treatment

Background: Childhood obesity exposes individuals to cardiometabolic disturbances. We analyzed how family-based multidisciplinary obesity treatment influenced children's cardiometabolic health. Materials and methods: In this retrospective, two-year, follow-up study of 654 2- to 18-year-old children treated for obesity in three Finnish pediatric clinics in 2005-2012, blood pressure (BP), metabolic parameters, and the influence of sex, puberty and a change in body mass index standard deviation score (BMI SDS) were analyzed. Results: At baseline, at least one cardiovascular risk factor was present in 474 (80%) cases. Boys presented with more significant changes in cardiometabolic parameters than girls during the treatment. Boys' total cholesterol (TC) improved by 12 months (P = 0.009), and their low-density lipoprotein C (LDL-C) and glycosylated hemoglobin ameliorated by 12 months (P = 0.030 and 0.022, respectively) and 24 months (P = 0.043 and 0.025, respectively). Boys' triglycerides, insulin, homeostasis model assessment for insulin resistance (HOMA-IR) and systolic BP deteriorated at 24 months (P < 0.001, 0.004, 0.002, and 0.037, respectively). In all children, the number of acceptable TC, LDL-C, insulin, and HOMA-IR values increased if BMI SDS reduced 0.25 or more by 12 months. Conclusion: Minor cardiometabolic improvements were found during the obesity treatment. These findings indicate the need to assess treatment methods and focus on prevention.

Access to Medical Care for Individuals with Myalgic Encephalomyelitis and Chronic Fatigue Syndrome: A Call for Centers of Excellence

The current study sought to better understand the experience of individuals with myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS) in accessing care for their debilitating illness. Of 898 participants, less than half had ever seen an ME or CFS specialist, though 99% of participants were interested in specialist care. Participants cited geographic and financial barriers as most frequently precluding access to specialists. Furthermore, satisfaction with specialist care greatly exceeded satisfaction with non-specialist care. These findings suggested that individuals with ME and CFS represent a medically-underserved population, due to lack of available care. The CFS Advisory Committee and NIH Pathways to Prevention Working Group recommended the creation of ME and CFS Centers of Excellence to improve the healthcare access of patients with ME and CFS. The current study documents the need for these centers, as they would ameliorate geographic and financial barriers to quality care.

General practice and specialist palliative care teams: an exploration of their working relationship from the perspective of clinical staff working in New Zealand

With the future focus on palliative and end-of-life care provision in the community, the role of the general practice team and their relationship with specialist palliative care providers is key to responding effectively to the projected increase in palliative care need. Studies have highlighted the potential to improve co-ordination and minimise fragmentation of care for people living with palliative care need through a partnership between generalist services and specialist palliative care. However, to date, the exact nature of this partnership approach has not been well defined and debate exists about how to make such partnerships work successfully. The aim of this study was to explore how general practice and specialist palliative care team (SPCT) members view their relationship in terms of partnership working. Five focus group discussions with general practices and SPCT members (n = 35) were conducted in 2012 in two different regions of New Zealand and analysed using a general inductive approach. The findings indicate that participants' understanding of partnership working was informed by their identity as a generalist or specialist, their existing rules of engagement and the approach they took towards sustaining the partnership. Considerable commitment to partnership working was shown by all participating teams. However, their working relationship was based primarily on trust and personal liaison, with limited formal systems in place to enable partnership working. Tensions between the cultures of 'generalism' and 'specialism' also provided challenges for those endeavouring to meet palliative care need collaboratively in the community. Further research is required to better understand the factors associated with successful partnership working between general practices and specialist palliative care in order to develop robust strategies to support a more sustainable model of community palliative care.

Barriers and facilitators influencing self-management among COPD patients: a mixed methods exploration in primary and affiliated specialist care

Self-management is becoming increasingly important in COPD health care although it remains difficult to embed self-management into routine clinical care. The implementation of self-management is understood as a complex interaction at the level of patient, health care provider (HCP), and health system. Nonetheless there is still a poor understanding of the barriers and effective facilitators. Comprehension of these determinants can have significant implications in optimizing self-management implementation and give further directions for the development of self-management interventions. Data were collected among COPD patients (N=46) and their HCPs (N=11) in three general practices and their collaborating affiliated hospitals. Mixed methods exploration of the data was conducted and collected by interviews, video-recorded consultations (N=50), and questionnaires on consultation skills. Influencing determinants were monitored by 1) interaction and communication between the patient and HCP, 2) visible and invisible competencies of both the patient and the HCP, and 3) degree of embedding self-management into the health care system. Video observations showed little emphasis on effective behavioral change and follow-up of given lifestyle advice during consultation. A strong presence of COPD assessment and monitoring negatively affects the patient-centered communication. Both patients and HCPs experience difficulties in defining personalized goals. The satisfaction of both patients and HCPs concerning patient centeredness during consultation was measured by the patient feedback questionnaire on consultation skills. The patients scored high (84.3% maximum score) and differed from the HCPs (26.5% maximum score). Although the patient-centered approach accentuating self-management is one of the dominant paradigms in modern medicine, our observations show several influencing determinants causing difficulties in daily practice implementation. This research is a first step unravelling the determinants of self-management leading to a better understanding.

Healthcare personnel's experiences using video consultation in primary healthcare in rural areas

BACKGROUND

Patients living in rural areas often need to travel long distances for access to specialist care. To increase access to specialist care, video consultation between patients in primary healthcare and specialist care has been used. In order for this new method to be developed and used to the fullest, it is important to understand healthcare personnel's experiences with this intervention.

OBJECTIVE

The aim of this study was to describe healthcare personnel's experiences using video consultation in their work in primary healthcare.

METHOD

A mixed methods design was used, and the data were analysed using qualitative and quantitative analysis methods. Interviews were conducted with eight general practitioners and one district nurse, all of whom had conducted a video consultation with a patient and a specialist physician or a cardiac specialist nurse. After each video consultation, the participants completed a consultation report/questionnaire.

RESULTS

Healthcare personnel considered video consultation to provide quicker access to specialist care for the patient, and greater security when the video consultation encounter was conducted at their own primary healthcare centre. They considered video consultation an opportunity to provide education and for the patients to ask questions.

CONCLUSION

Video consultation is a satisfactory tool for healthcare personnel, and the technology is a new, useful method, especially for the district nurses. Further, video consultation is an opportunity for healthcare personnel to learn. However, for it to work as an accepted method, the technology must function well and be user friendly. It must also be clear that it is beneficial for the patients and the healthcare personnel.

A High-Touch Model of Community-Based Specialist Palliative Care: Latent Class Analysis Identifies Distinct Patient Subgroups

CONTEXT

Community-based palliative care may support seriously ill homebound patients. Programs vary widely, and few studies have described the heterogeneity of the populations served or service delivery models.

OBJECTIVES

To evaluate a diverse population served by an interdisciplinary model of community-based specialist palliative care and the variation in service delivery over time and identify subgroups with distinct illness burden profiles.

METHODS

A retrospective cohort study evaluated longitudinal electronic health record data from 894 patients served during 2010-2013. Illness burden was defined by measures of performance status (Karnofsky Performance Status scale), symptom distress (Condensed Memorial Symptom Assessment Scale), palliative care needs (Palliative Outcome Scale), and quality of life (Spitzer Quality of Life Index). Service utilization included the frequency of visits received and calls made or received by patients. Latent class analysis identified patient subgroups with distinct illness burden profiles, and mixed-effects modeling was used to evaluate associations between patient characteristics and service utilization.

RESULTS

The mean age was 72.3 years (SD = 14.0); 56.2% were women; 67.5% were English speaking; and 22.2% were Spanish speaking. Most had congestive heart failure (36.4%) or cancer (30.4%); 98.0% had a Karnofsky Performance Status score of 40-70. Four patient subgroups were identified: very low illness burden (26.2%); low burden (39.5%); moderate burden (13.5%); and high burden (20.8%). The subgroups differed in both baseline characteristics and palliative care service utilization over time.

CONCLUSION

The population served by a community-based specialist palliative care program manages patients with different levels of illness burden, which are associated with patient characteristics and service utilization.

How Well Is CHIP Addressing Health Care Access and Affordability for Children?

OBJECTIVE

We examine how access to care and care experiences under the Children's Health Insurance Program (CHIP) compared to private coverage and being uninsured in 10 states.

METHODS

We report on findings from a 2012 survey of CHIP enrollees in 10 states. We examined a range of health care access and use measures among CHIP enrollees. Comparisons of the experiences of established CHIP enrollees to the experiences of uninsured and privately insured children were used to estimate differences in children's health care.

RESULTS

Children with CHIP coverage had substantially better access to care across a range of outcomes, other things being equal, particularly compared to those with no coverage. Compared to being uninsured, CHIP enrollees were more likely to have specialty and mental health visits and to receive prescription drugs; and their parents were much more likely to feel confident in meeting the child's health care needs and were less likely to have trouble finding providers. CHIP enrollees were less likely to have unmet needs, but 1 in 4 had at least 1 unmet need. Compared to being privately insured, CHIP enrollees had generally similar health care use and unmet needs. Additionally, CHIP enrollees had lower financial burden related to their health care needs. The findings were generally robust with respect to alternative specifications and subgroup analyses, and they corroborated findings of previous studies.

CONCLUSIONS

Enrolling more of the uninsured children who are eligible for CHIP improved their access to a range of care, including specialty and mental health services, and reduced the financial burden of meeting their health care needs; however, we found room for improvement in CHIP enrollees' access to care.

A systematic review of contemporary models of shared HIV care and HIV in primary care in high-income settings

HIV shared care is uncommon in the UK although shared care could be a beneficial model of care. We review the literature on HIV shared care to determine current practice and clinical, economic and patient satisfaction outcomes. We searched MEDLINE, EMBASE, NICE Evidence, Cochrane collaboration, Google and websites of the British HIV Association, Aidsmap, Public Health England, World Health Organization and Terrence Higgins Trust using relevant search terms in August 2014. Studies published after 2000, from healthcare settings comparable to the UK that described links between primary care and specialised HIV services were included and compared using principles of the Critical Appraisal Skills Programme and Authority, Accuracy, Coverage, Objectivity, Date, Significance frameworks. Three of the nine included models reported clinical or patient satisfaction outcomes but data collection and analyses were inadequate. None reported economic outcomes although some provided financial costings. Facilitators of shared care included robust clinical protocols, training and timely communication. Few published examples of HIV shared care exist and quality of evidence is poor. There is no consistent association with improved clinical outcomes, cost effectiveness or acceptability. Models are context specific, driven by local need, although some generalisable features could inform novel service delivery. Further evaluative research is needed to determine optimal components of shared HIV care.

Access to Specialist Care in Rural Saskatchewan: The Saskatchewan Rural Health Study

The role of place has emerged as an important factor in determining people’s health experiences. Rural populations experience an excess in mortality and morbidity compared to those in urban settings. One of the factors thought to contribute to this rural-urban health disparity is access to healthcare. The objective of this analysis was to examine access to specialized medical care services and several possible determinants of access to services in a distinctly rural population in Canada. In winter 2010, we conducted a baseline mail survey of 11,982 households located in rural Saskatchewan, Canada. We obtained 4620 completed household surveys. A key informant for each household responded to questions about access to medical specialists and the exact distance traveled to these services. Correlates of interest included the location of the residence within the province and within each household, socioeconomic status, household smoking status, median age of household residents, number of non-respiratory chronic conditions and number of current respiratory conditions. Analyses were conducted using log binomial regression for the outcome of interest. The overall response rate was 52%. Of households who required a visit to a medical specialist in the past 12 months, 23% reported having difficulty accessing specialist care. The magnitude of risk for encountering difficulty accessing medical specialist care services increased with the greatest distance categories. Accessing specialist care professionals by rural residents was particularly difficult for persons with current respiratory conditions.

Patient related factors for optimal blood pressure control in patients with hypertension

BACKGROUND

Patient related factors hindering optimal blood pressure (BP) control in patients with hypertension are unclear.

OBJECTIVES

To investigate the barriers to optimal hypertension management.

METHODS

A survey on the awareness and management of hypertension was conducted in 556 patients (365 males, mean age 60.9 ± 10.1) from a rural community.

RESULTS

Of the 556 patients who had a clinical diagnosis of hypertension, 127 (22.8%) were unaware the existence of the condition and received no therapy. In the 429 patients who were aware the presence of hypertension, 206 (48.0%) did not receive any antihypertensive medication at the time of this study. Fifty-four (12.5%) had a BP of less than 140/90 mm Hg. Only 21 (4.9%) received formal counselling or education from health professionals and 74 (17.2%) were aware of the optimal level of BP. Difficulty in accessing a specialist doctor was reported by 126 (29.4%). In 279 (65.0%), missing regular antihypertensive medications was reported in the 4-week period prior to this study. Omitting prescribed antihypertensive drugs due to the costs was reported by 169 (39.4%).

CONCLUSION

Inadequate counselling, lack of understanding on the disease, difficulties in accessing specialist care and poor medication adherence are the barriers to optimal BP control.

Access granted! barriers endure: determinants of difficulties accessing specialist care when required in Ontario, Canada

BACKGROUND

In the Canadian context, health care services are governed by the Canada Health Act, which ensures that primary care doctors, specialists, hospitals and dental surgeries are covered through provincial health insurance plans. This ensures access to medically necessary health care services for all Canadians regardless of ability to pay. Despite this important piece of legislation, research has shown persistent inequalities in access between and within socio-demographic groups, and geographic areas. To date, most research has focused on access to primary care, with much less attention paid to specialist care as an important component of the health care continuum. Thus, the objectives of this research are to address this gap in knowledge by examining the factors associated with difficulty accessing specialist services, and the reasons why particular subpopulation groups report experiencing difficulties.

METHODS

This research uses multivariate logistic regression to analyze data from the Canadian Community Health Surveys' optional content from the province of Ontario (n=21,526) related to accessing specialist health care services. The multivariate logistic regression model identifies several subpopulation groups that are more likely to report difficulty accessing specialist care when required. Cross-tabulations are subsequently used to establish the main reasons why difficulties are faced.

RESULTS

Over 26% of respondents required a specialist visit in the 12 months preceding administration of the survey. Of these, 22% reported difficulty accessing specialist care. Those with difficulties were more likely to be immigrants, post-secondary educated, and have one or more chronic conditions. People living in urban health regions were also more likely to report difficulties accessing care. Primarily wait times were cited as reasons for these difficulties, followed by a perceived lack of availability.

CONCLUSIONS

There are difficulties faced by the general population as a whole (e.g., wait times) as well as particular difficulties experienced more frequently by certain groups (e.g., transportation, language, and cost barriers for newcomers). These issues are important, as they may discourage individuals from using necessary health care services, and may contribute to feelings of dissatisfaction with the health care system.

Surgically correctable morbidity from male circumcision: indications for specialist surgical care in lagos

AIM/OBJECTIVE

To determine the pattern of morbidity and outcome among patients referred to the Pediatric Surgery Unit of the Lagos University Teaching Hospital (LUTH) following circumcision.

MATERIALS AND METHODS

Retrospective descriptive study of all patients with complications of circumcision who were managed in LUTH between 2008 and 2010.

RESULTS

There were 36 patients. The age range was between 2 days and 9 years (median-3 months). Fifteen cases (42.9%) were due to urethro-cutaneous fistula while there were six cases (16.7%) of postcircumcision bleeding. There were four cases (11.1%) each of partial penile amputation and buried penis. There were also cases of meatal stenosis, penile implantation cyst and glanulo-preputial skin bridge. With respect to the treatment offered, eleven (30.6%) patients had urethroplasty for the urethro-cutaneous fistulae while seven (19.4%) patients had penile refashioning for the buried penis and penile amputation. Appropriate surgical treatments were performed for the other complications.

CONCLUSION

Urethrocutaneous fistula and penile amputation are the commonest complications of circumcision for which referral is made to LUTH. Treatment outcome was satisfactory. Health education and legislation to ensure procedure is performed by qualified medical and paramedical staff may reduce the morbidity.

Universal health insurance and equity in primary care and specialist office visits: a population-based study

PURPOSE

Universal coverage of physician services should serve to reduce socioeconomic disparities in care, but the degree to which a reduction occurs is unclear. We examined equity in use of physician services in Ontario, Canada, after controlling for health status using both self-reported and diagnosis-based measures.

METHODS

Ontario respondents to the 2000-2001 Canadian Community Health Survey (CCHS) were linked with physician claim files in 2002-2003 and 2003-2004. Educational attainment and income were based on self-report. The CCHS was used for self-reported health status and Johns Hopkins Adjusted Clinical Groups was used for diagnosis-based health status.

RESULTS

After adjustment, higher education was not associated with at least 1 primary care visit (odds ratio [OR] = 1.05; 95% confidence interval [CI], 0.87-1.24), but it was inversely associated with frequent visits (OR = 0.77; 95% CI, 0.65-0.88). Higher education was directly associated with at least 1 specialist visit (OR = 1.20; 95% CI, 1.07-1.34), with frequent specialist visits (OR = 1.21; 95% CI, 1.03-1.39), and with bypassing primary care to reach specialists (OR = 1.23, 95% CI 1.02-1.44). The largest inequities by education were found for dermatology and ophthalmology. Income was not independently associated with inequities in physician contact or frequency of visits.

CONCLUSIONS

After adjusting for health status, we found equity in contact with primary care for educational attainment but inequity in specialist contact, frequent visits, and bypassing primary care. In this setting, universal health insurance appears to be successful in achieving income equity in physician visits. This strategy alone does not eliminate education-related gradients in specialist care.

Deficiencies in the quality of diabetes care: comparing specialist with generalist care misses the point

The quality of diabetes care delivered to patients falls below the expectations of practice guidelines and clinical trial evidence. Studies in many jurisdictions with varying health care systems have shown that recommended processes of care occur less often than they should; hence, outcomes of care are inadequate. Many studies comparing care between specialists and generalists have found that specialists are more likely to implement processes of care. However, this provides little insight into improving quality of care, as the difference between specialists and generalists in these studies is small compared to the overall deficiency in quality. Therefore, future research should instead focus on ways to implement high quality care, regardless of specialty. To date, few methodologically rigorous studies have uncovered interventions that can improve quality of care. The development of such interventions to help all physicians implement better quality care could greatly benefit people with diabetes.

[Analysis of a programme of direct referral between primary and specialist care in potential surgery patients]

OBJECTIVE

To describe the results of a programme of direct referral of potential surgery patients between primary and specialist care, designed to lessen waiting-times.Design. Prospective, longitudinal and descriptive study.

SETTING

Health Area N. masculine 19 (Valencian Health Service): Surgery Service of Elche Hospital and 6 Health Centres.

PARTICIPANTS

Patients with pathologies that do not need special techniques for diagnosis except examination and who have a clear irrefutable indication of surgery without risk factors (ASA I-II).Intervention. The referral protocol consists of: a) diagnosis of pathology and pre-operative study in primary care (PC); b) appointment made by phone for the surgery clinic at the hospital, where diagnosis and pre-operative study are confirmed; c) referral and operation in the unit of non-hospital major surgery (UCMA); d) monitoring post-operation by the home hospitalisation unit (HHU) or preferably by the health centre, and e) check-up at the surgery clinic. Main measurements. The degree of agreement between PC and the specialist, assessment of the pre-operative study, and waiting time.

RESULTS

86 patients were referred (average age, 35; 76% male) by 28 doctors. The most common pathologies were hernia (36%), pilonidal sinus (23.2%) and miscellaneous (32.5%). There was general agreement in diagnosis in 90.7% of cases. 89.5% of patients brought the proper pre-operative study. Mean waiting time between the primary care consultation in the different procedures and the first hospital consultation was 19 days; with 44 more days elapsing till the surgical operation.

CONCLUSIONS

This new programme is effective and economic, in that there is <<adequate referral>> of patients, waiting time is reduced by over 7 months for pilonidal sinus and by over 2 years for hernia pathology, and the procedure can be used for a large number of patients, as the pathologies involved are very common.