Health Care Provider Contacts Research Articles

Accessibility from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments

The operational definition of first-contact accessibility is "the ease with which a person can obtain needed care (including advice and support) from the practitioner of choice within a time frame appropriate to the urgency of the problem"; accommodation is "the way healthcare resources are organized to accommodate a wide range of patients' abilities to contact healthcare providers and reach healthcare services, that is to say telephone services, flexible appointment systems, hours of operation, and walk-in periods." To compare how well accessibility is measured in validated subscales that evaluate primary healthcare from the patient's perspective. 645 adults with at least one healthcare contact in the previous 12 months responded to six instruments that evaluate primary healthcare with four subscales that measure accessibility: the Primary Care Assessment Survey (PCAS), the Primary Care Assessment Tool - Short Form (PCAT-S, two subscales) and the first version of the EUROPEP (EUROPEP-I). Scores were normalized to a 0-to-10 scale for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analysis examined fit to operational definition, and item response theory analysis examined item performance on common constructs. The subscales demonstrate similar psychometric measures to those reported by developers. The PCAT-S First-Contact Utilization subscale does not fit the accessibility construct. The remaining three subscales load reasonably onto a single factor, presumed to be accessibility, but the best-fitting model has two factors: "timeliness of obtaining needed care" (PCAT-S First-Contact Access, some EUROPEP-I items) and "how resources are organized to accommodate clients" (PCAS Organizational Access and most of EUROPEP-I organization of care). Items in the PCAS and PCAT-S subscales have good discriminability. Only three of the four subscales measure accessibility; all are appropriate for use in Canada. The PCAT-S First-Contact Access subscale is the best measure for first-contact accessibility, and PCAS Organizational Accessibility has good metric properties and measures for accommodation.

The association between childhood overweight and obesity and otitis media

The objective of this study was to examine the association between otitis media and childhood obesity in a population-based sample of elementary school children in the Canadian province of Nova Scotia. The study design is a prospective cohort study, linking data from a population-based survey of Grade 5 students (aged 10-11 years) in the Canadian province of Nova Scotia in 2003 with Nova Scotia administrative health data. Measured body mass index was used to define weight status based on the age- and gender-specific cut-off points of the International Obesity Task Force. Health administration data for each child was linked via Health Card numbers. The primary outcome was healthcare utilization (physician visits and costs) for suppurative otitis media (International Classification of Diseases [ICD]9: 382; ICD10: H65-66) with no previous diagnosis of otitis in the last 30 days. Relative to normal weight children, obese children had more healthcare provider contacts for otitis media (adjusted incidence rate ratio 2.03, 95% confidence interval [CI] 1.66-2.49), incurred more costs per otitis media-related visit ($47 vs. $24, P = 0.0001) and had higher odds to have repeated otitis media (adjusted odds ratio 2.27, 95% CI 1.54-3.35). Socioeconomic factors, a history of breastfeeding, presence of an allergic disorder or chronic adenoid/tonsil disorder did not change the association between obesity and otitis media. There is a clear association between childhood obesity and otitis media that cannot be explained by confounding by socioeconomic factors or clinically associated disorders.

Measuring Use of Health Services for At-Risk Drinkers: How Brief Can You Get?

This study examines the validity, utility, and costs of using a brief telephone-administered instrument, the Brief Health Services Questionnaire (BHSQ), for self-reported health care provider contacts relative to collection and abstraction of complete medical records. The study sample was 441 community-dwelling at-risk drinkers who participated in an 18-month longitudinal study. Agreement between BHSQ self-reports and abstracted provider contacts was good to very good for general medical (79% agreement, kappa = .50) and specialty mental health contacts (93% agreement, kappa = .62), but low for "other" miscellaneous health contacts (61% agreement, kappa = .04). Average cost to collect and abstract complete medical records was 424 US dollars per study participant, whereas average cost to administer only the BHSQ was 31 US dollars per participant. Although it is not possible to conduct a formal cost-effectiveness analysis, results suggest the BHSQ is a viable option for collecting self-reported health provider contacts in a sample of at-risk drinkers, with definite cost advantages over more elaborate data collection methods.

Providing longitudinal health care information with the new German Health Card—a pilot system to track patient pathways

The paper describes an application system that employs the new German Health Card to provide a technical solution for tracking patient pathways. The aim is to improve the flow and availability of health care information. We used standard software components and technologies in order to facilitate interoperability with multiple system platforms and allow for customizing as the specification process for the German Health Card is not yet completed. Every health care provider contact is recorded on the card and associated medical documents are stored in a central database and can be retrieved via Web Services running on a central application server. The patient pathway can thus be chronologically tracked by the clinician and relevant longitudinal information is made accessible quickly. Our system for tracking patient pathways with the new German Health Card can be regarded as a first example of its great future potential.

Cost Effectiveness of Budesonide/Formoterol for Maintenance and Reliever Therapy versus Salmeterol/Fluticasone plus Salbutamol in the Treatment of Asthma

Budesonide/formoterol (Symbicort) Maintenance And Reliever Therapy (SMART) is an effective and well tolerated treatment option for patients with asthma. We compared the cost effectiveness from a societal perspective of this one-inhaler regimen with that of maintenance salmeterol/fluticasone propionate (Seretide) plus salbutamol (albuterol) as needed (Seretide) Fixed Combination [SFC]). A cost-effectiveness analysis was performed based on effectiveness and resource-utilisation data collected prospectively in a randomised, 12-month study performed in 2143 patients in 16 countries. Resource utilisation data were pooled and unit costs (euro, year 2003 values) from Italy, France, the UK and Germany were used to generate estimates of direct and total costs per patient per year and cost per severe exacerbation avoided. Adolescents and adults with asthma (n = 2143; mean forced expiratory volume in 1 second [FEV(1)] 73% predicted; mean inhaled corticosteroid [ICS] dose 884 microg/day) were randomised to SMART or SFC. The effectiveness measure used was the number of severe exacerbations per patient per year. Direct costs included medication use (budesonide/formoterol 160microg/4.5microg or salmeterol/fluticasone 50microg/100microg, 50microg/250microg or 50microg/500microg plus salbutamol) and nonmedication-related resource use, including days in hospital, emergency room visits, specialist or primary care physician visits and other healthcare provider contacts. Indirect costs, including the number of days when the patient or their carer was unable to attend to their normal daily activities, were also assessed. The study assumed a European societal perspective (i.e. including direct and indirect costs). Treatment with SMART resulted in significantly fewer severe exacerbations per patient per year compared with SFC (0.24 vs 0.31 events per patient per year; p = 0.0025). Resource use was low in both groups. Medication costs accounted for the majority of the total costs. The increased effectiveness of SMART was achieved at a reduced or similar cost compared with SFC. SMART dominated when German unit costs were applied (i.e. there was a statistically significant reduction in both costs and number of exacerbations). In all other countries, the incremental cost-effectiveness ratios showed that there was a reduction in mean total cost per exacerbation avoided; however, this difference was not statistically significant. This analysis demonstrates that, compared with SFC, SMART may be cost effective from a societal perspective for the treatment of patients with asthma in Italy, Germany, France and the UK. SMART provided a reduction in the number of severe exacerbations per patient per year, at no statistically significant increase in cost - or even at a lower cost - compared with SFC plus as-needed reliever salbutamol.

Technical standards and guidelines: Prenatal screening for open neural tube defects: This new section on “Prenatal Screening for Open Neural Tube Defects,” together with the new section on “Prenatal Screening for Down Syndrome,” replaces the previous Section H of the American College of Medical Genetics Standards and Guidelines for Clinical Genetics Laboratories

Technical standards and guidelines: Prenatal screening for open neural tube defects: This new section on “Prenatal Screening for Open Neural Tube Defects,” together with the new section on “Prenatal Screening for Down Syndrome,” replaces the previous Section H of the American College of Medical Genetics Standards and Guidelines for Clinical Genetics Laboratories *

Improving the quality of pain treatment by a tailored pain education programme for cancer patients in chronic pain

Educational interventions, aiming to increase patients' knowledge and attitude regarding pain, can affect pain treatment. The purpose of this study was to evaluate the effects of a Pain Education Programme (PEP), on adequacy of pain treatment, and to describe characteristics predicting change in adequacy. The PEP consists of a multi-method approach in which patients are educated about the basic principles regarding pain, instructed how to report pain in a pain diary, how to communicate about pain, and how to contact healthcare providers. The effects of the PEP were evaluated taking into consideration the lack of well-established outcome measures to evaluate adequacy of pain treatment, the lack of long-term follow-up, and the influence of missing data.A prospective, randomized study was utilized in which 313 chronic cancer patients were followed-up until 8 weeks postdischarge. Adequacy of pain treatment was evaluated by means of the Amsterdam Pain Management Index (APMI), consisting of an integrated score of patients' Present Pain Intensity, Average Pain Intensity, and Worst Pain Intensity, corrected for patients' Tolerable Present Pain, with the analgesics used by the patient.At pretest, 60% of the patients in the hospital were treated inadequately for their pain. Postdischarge, the control group patients were significantly more inadequately treated at 2 weeks after discharge (56%vs 41%), at 4 weeks after discharge (62%vs 42%) and at 8 weeks after discharge (57%vs 51%) than the intervention group patients. While the level of inadequacy in the control groups remained relatively stable at all assessment points, a slight increase in the percentage of patients being treated inadequately was found in the intervention group patients over time. A beneficial effect of the PEP was found for patients both with and without district nursing. Variables predicting an improvement in adequacy of pain treatment consisted of the PEP, the APMI score at baseline, patients' level of physical functioning, patients' level of social functioning, the extent of adherence to pain medication, patients' pain knowledge, and the amount of analgesics used.These findings suggest that quality of pain treatment in cancer patients with chronic pain can be enhanced by educating patients about pain and improving active participation in their own pain treatment. The benefit from the PEP, however, decreases slightly over time, pointing at a need for ongoing education.

A Pain Education Program for chronic cancer pain patients: follow-up results from a randomized controlled trial

The effectiveness of a Pain Education Program in cancer patients with chronic pain offered by nurses was investigated in a randomized controlled clinical trial. A multi-method approach was used in which verbal instruction, written material, an audio cassette tape, and the use of a pain diary were combined to inform and instruct patients about pain and pain management. The Pain Education Program was tailored to the needs of the individual patient and consisted of three elements: (1) educating patients about the basic principles regarding pain and pain management; (2) instructing patients how to report their pain in a pain diary; and (3) instructing patients how to communicate about pain and how to contact health care providers. Following pretesting in 313 patients, patients who needed district nursing and who did not need district nursing at home were randomly assigned to a control or intervention group. Intervention group patients received the Pain Education Program in the hospital, and 3 and 7 days postdischarge by telephone; this was done by nurses who were specially trained as pain counselors. Follow-up assessments were at 2, 4 and 8 weeks postdischarge. Results of the pretest showed that many patients lacked knowledge about pain and pain management. The majority of pain topics had to be discussed. The Pain Education Program proved to be feasible: 75.0% of the patients had read the entire pain brochure, 55.7% had listened to the audio cassette, and 85.6% of pain scores were completed in the pain diary. Results showed a significant increase in pain knowledge in patients who received the Pain Education Program and a significant decrease in pain intensity. However, pain relief was mainly found in the intervention group patients without district nursing. It can be concluded that the tailored Pain Education Program is effective for cancer patients in chronic pain. The use of the Pain Education Program by nurses should be seriously considered on oncology units.

Re-Engineering Process in a Community Hospital: The Transition to Patient-Focused Care

LEARNING OBJECTIVE: Provide an overview of the inpatient care re-engineering process and role of the Food and Nutrition Service in a community hospital setting. Shortly after the merger of two community hospitals, a re-engineering project was undertaken to examine the delivery of inpatient care. A interdisciplinary team was given the goals to: 1.) establishing standardized systems at both facilitates; 2.) improve patient care; 3.) improve work efficiency; 4) limit the number of health care provider contacts for each patient; and 5.) reduce cost of care. Data developed for the team by the Food and Nutrition Service included: 1.) work flows and task analysis for all service staff; and 2.) food and non-food supplies used by the units. The team developed a model of patient -focused care utilizing a multi-skilled service worker. Responsibilities of the new position, titled Service Associate, included tasks previously assigned to Food and Nutrition Service, Environmental Services and Transport Department. Service Associates, now deployed to specific nursing units under the supervision of nurse managers, perform the following food service functions: 1.) patient tray delivery and pick-up; 2.) assisting patients with menu selection; 3.) delivery of patient nourishments; 4.) documentation of intake; and 5.) ordering of food and non-food supplies. As part of the implementation process, the Food and Nutrition Service was responsible for: 1.) development of job descriptions, including competency assessment; 2.) recruitment and selection of internal and external candidates; and 3.) training and education of personnel selected for the role. The development of quality monitors to be used in the evaluation of the patient care model include satisfaction and quality indicators related to Food and Nutrition Services at both sites.

Health care triage alternatives and the influence of health insurance, education and race

The relationship between one of Andersen's enabling factors, health insurance status and the choice of a pharmacist as the initial contact in the health care system was examined via telephone surveys. Eighty-seven percent of the sample reported having some form of health insurance. Of all intended health care provider contacts, pharmacists were selected as the initial contact 21% of the time. Logistic regression identified insurance status, education and race as significant (alpha < 0.05) covariates in the model. The odds ratios generated from the logit model indicated that non-whites, persons with less education and no health insurance were more likely to select a pharmacist for triage. The study concluded that uninsured persons were nearly twice as likely to seek pharmacist triage than insured individuals. Pharmacists may be filling an important triage gap for individuals who have limited financial access to traditional sources of physician care.

Symptom reporting during physician consultation. Results of a health diary study.

Most studies of physician consultation focus on decisions to contact health care providers. In this article, the authors examine decisions regarding which symptoms to report once people contact physicians. Data for the analysis were gathered through interviews and health diaries completed by a probability sample of 667 elderly people, based on a subsample of 152 respondents who consulted physicians during the 3-week reporting period. A qualitative analysis produced behavioral patterns underlying decisions to report some but not other symptoms experienced on the day of physician contact. Logistic regression was used to explore the extent to which predispositions of individuals that precede the onset of symptoms and the type of symptom experience explain the distribution of these reporting patterns. Variation in the percentages of people reporting particular symptoms indicates that these reporting patterns cannot be explained solely by the type of symptoms people experience. The decisions regarding which symptoms to report reflect respondents' attribution of cause, the impact of symptoms on their daily lives, and the broader health and social context in which they confront particular symptoms.