Patients' perceptions and experiences of transitions in diabetes care: a longitudinal qualitative study

Objective  To examine patients' perceptions and experiences over time of the devolvement of diabetes care/reviews from secondary to primary health-care settings.
Design  Repeat in-depth interviews with 20 patients over 4 years.
Participants and setting  Twenty type 2 diabetes patients recruited from primary- and secondary-care settings across Lothian, Scotland.
Results  Patients' views about their current diabetes care were informed by their previous service contact. The devolvement of diabetes care/reviews to general practice was presented as a 'mixed blessing'. Patients gained reassurance from their perception that receiving practice-based care/reviews signified that their diabetes was well-controlled. However, they also expressed resentment that, by achieving good control, they received what they saw as inferior care and/or less-frequent reviews to others with poorer control. While patients tended to regard GPs as having adequate expertise to conduct their practice-based reviews, they were more ambivalent about nurses taking on this role. Opportunities to receive holistic care in general practice were not always realized due to patients seeing health-care professionals for diabetes management to whom they would not normally present for other health issues.
Conclusions  It is important to educate patients about their care pathways, and to reassure them that frequency of reviews depends more on clinical need than location of care and that similar care guidelines are followed in hospital clinics and general practice. A patients' history of service contact may need to be taken into account in future studies of service satisfaction.     

What patients know about their rights in Turkey

Patients' rights issues are currently being discussed in health care at both the private and public levels in Turkey. In this study, 317 patients were interviewed upon hospital discharge and asked what they knew about their "rights" as patients. According to the collected data, 63% of the patients were not aware that they had any rights in receiving health care services at all. Since this is the first study of its type in Turkey, further research in this area is needed. In closing, it is recommended that hospitals in Turkey adapt routine policies similar to those in the United States for informing customers about their rights for safe, effective and efficient health care provision.     

Weight management: what patients want from their primary care physicians

OBJECTIVE: The researchers wanted to determine the weight management experiences of patients in primary care, and what those patients want from their physicians. STUDY DESIGN: Patients completed a survey in a primary care waiting room. Afterward they were measured for body mass index (BMI). POPULATION: A total of 410 consecutive adult patients in 2 primary care practices at the University of California, San Francisco, were approached, and 366 (89%) completed the survey. OUTCOMES MEASURED: The primary outcomes were patient attitudes about weight loss, previous weight management experiences with their current physicians, and future preferences for weight management within the primary care relationship. RESULTS: Ninety-seven percent of the obese patients (BMI > 30), 84% of the overweight patients (BMI=25-30), and 39% of the non-overweight patients (BMI < 25) thought they needed to lose weight. Forty-nine percent of the obese patients, 24% of the overweight patients, and 12% of the non-overweight patients had discussed weight with their current physicians. The types of weight management assistance that patients most wanted from their physicians were: (1) dietary advice, (2) help with setting realistic weight goals, and (3) exercise recommendations. CONCLUSIONS: Although most patients believe they should lose weight, this is often not discussed during office visits. Most patients (especially those who are overweight or obese) want more help with weight management than they are getting from their primary care physicians.     

Indicators of quality of in-patient psychiatric treatment: the patients' view.

OBJECTIVES: The object of this study was to find out from psychiatric in-patients which aspects of care and treatment they considered important and how satisfied they were with these. DESIGN: One hundred and ninety-four in-patients were asked to rate the importance of, and their satisfaction with, 22 different aspects of in-patient care and treatment. The questionnaire, developed for the purpose of the study after a pilot phase including professional care givers and patients, contained 92 items and was returned by 52% of all discharged patients from the Psychiatric university hospital during a 3-month period. RESULTS: Patients made a clear distinction between aspects of treatment they considered important and aspects they were satisfied with. Ranked of highest importance were various therapeutic relationships, and respect for their rights and privileges. They were satisfied with their relationships with clinical staff but dissatisfied with medication. CONCLUSION: A well differentiated assessment of importance and satisfaction has implications for the evaluation of the quality of psychiatric care, for specific methods of treatment, and for the improvement of in-patient psychiatric care.     

Do active patients seek higher quality prenatal care?: A panel data analysis from Nairobi,Kenya

Despite poverty and limited access to health care, evidence is growing that patients in low-income countries are taking a more active role in their selection of health care providers. Urban areas such as Nairobi, Kenya offer a rich context for studying these “active” patients because of the large number of heterogeneous providers available. We use a unique panel dataset from 2015 in which 402 pregnant women from peri-urban (the “slums” of) Nairobi, Kenya were interviewed three times over the course of their pregnancy and delivery, allowing us to follow women's care decisions and their perceptions of the quality of care they received. We define active antenatal care (ANC) patients as those women who switch ANC providers and explore the prevalence, characteristics and care-seeking behavior of these patients. We analyze whether active ANC patients appear to be seeking out higher quality facilities and whether they are more satisfied with their care. Women in our sample visit over 150 different public and private ANC facilities. Active patients are more educated and more likely to have high risk pregnancies, but have otherwise similar characteristics to non-active patients. We find that active patients are increasingly likely to pay for private care (despite public care being free) and to receive a higher quality of care over the course of their pregnancy. We find that active patients appear more satisfied with their care over the course of pregnancy, as they are increasingly likely to choose to deliver at the facility providing their ANC.     

Why are newly qualified doctors unprepared to care for patients at the end of life?

Medical Education 2011: 45 : 389–399 Context Death and dying occur in almost all areas of medicine; it is essential to equip doctors with the knowledge, skills and attitudes they need to care for patients at the end of life. Little is known about what doctors learn about end‐of‐life care while at medical school and how they learn to care for dying patients in their first year as doctors. Methods We carried out a qualitative study using face‐to‐face interviews with a purposive sample of 21 newly qualified doctors who trained in different medical schools. Results Data were analysed using a constant comparative approach. Two main groups of themes emerged. The first pertained to medical school experiences of end‐of‐life care, including: lack of exposure; a culture of ‘clerking and signs’; being kept and keeping away from dying patients; lack of examinations; variable experiences, and theoretical awareness. The second group of themes pertained to the experiences of recently qualified doctors and included: realising that patients really do die; learning by doing; the role of seniors; death and dying within the hospital culture; the role of nursing staff, and the role of the palliative care team. Conclusions Undergraduate medical education is currently failing to prepare junior doctors for their role in caring for dying patients by omitting to provide meaningful contact with these patients during medical school. This lack of exposure prevents trainee doctors from realising their own learning needs, which only become evident when they step onto the wards as doctors and are expected to care for these patients. Newly qualified doctors perceive that they receive little formal teaching about palliative or end‐of‐life care in their new role and the culture within the hospital setting does not encourage learning about this subject. They also report that they learn from ‘trial and error’ while ‘doing the job’, but that their skills and knowledge are limited and they therefore seek advice from those outside their usual medical team, mainly from nursing staff and members of palliative care teams.     

Commitment to a regular physician: how long will patients wait to see their own physician for acute illness?

BACKGROUND: Continuity of care with a physician is associated with better health outcomes and greater patient satisfaction. Having a "regular doctor" could lead to greater continuity of care, but only if the patient consistently seeks care from this physician. How long will a patient wait for care if their usual physician is not available? Our study explored factors related to a patient's decision to seek care from another professional. METHODS: We analyzed the results of a statewide random digit dialing telephone survey of 658 Kentucky adults. Our study focused on the 466 adults who indicated they usually seek care from the same physician. Respondents were asked about seeing an alternate provider if they had an acute, non-life-threatening condition and their usual physician was not available. RESULTS: Of the respondents, 48.6% indicated they would seek care from another professional the same day, 41.6% would wait 1 day or more, and 9.8% would not see another professional. Patients with asthma were significantly more likely to wait for care from their regular physician (P <.05), as were patients who usually visited a physician's office instead of a clinic (P <.05). In a multivariate model, seeking alternate care the same day was significantly more likely among patients who were older, nonwhite, and who would seek alternate care at their usual site of care (P <.05). CONCLUSIONS: Maintaining continuity of care with their usual physician is important to patients. Patient and practice characteristics may influence the decision to wait for care in an effort to maintain continuity.     

Family physician involvement in cancer care follow-up: the experience of a cohort of patients with lung cancer

PURPOSE There has been little research describing the involvement of family physicians in the follow-up of patients with cancer, especially during the primary treatment phase. We undertook a prospective longitudinal study of patients with lung cancer to assess their family physician’s involvement in their follow-up at the different phases of cancer.METHODS In 5 hospitals in the province of Quebec, Canada, patients with a recent diagnosis of lung cancer were surveyed every 3 to 6 months, whether they had metastasis or not, for a maximum of 18 months, to assess aspects of their family physician’s involvement in cancer care.RESULTS Of the 395 participating patients, 92% had a regular family physician but only 60% had been referred to a specialist by him/her or a colleague for the diagnosis of their lung cancer. A majority of patients identified the oncology team or oncologists as mainly responsible for their cancer care throughout their cancer journey, except at the advanced phase, where a majority attributed this role to their family physician. At baseline, only 16% of patients perceived a shared care pattern between their family physician and oncologists, but this proportion increased with cancer progression. Most patients would have liked their family physician to be more involved in all aspects of cancer care.CONCLUSIONS Although patients perceive that the oncology team is the main party responsible for the follow-up of their lung cancer, they also wish their family physicians to be involved. Better communication and collaboration between family physicians and the oncology team are needed to facilitate shared care in cancer follow-up.     

The nurse and patient's nudity

This is a qualitative study about the relationship among nurses of a university hospital and their patients when they need to undress those patients to take care. The purpose was to analyze speech of seven nurses in this situation. The information was taken by transcribing the semi-structured interviews which were analyzed according Michel Foucault's thought. The results demonstrated that the relationship among nurses and patients at the time when nudity is needed to perform nursing care is full of power, to which the nurses don't feel always prepared. Also the nurses don't think that, acting as they act, they exert power over the patients. It is suggested to Nursing schools to perform seminars about the care with the naked body.     

Expenditures on health care in the last year of life.

18-26% of public expenditure on health care is devoted to care of patients in their last year of life. 60% of this expenditure is on patients in somatic nursing homes. The figures do not tell directly whether too much or too little money in Norwegian health care is spent on people in the end stage of life. In order to answer this question, one must look at the quality of terminal care and assess the share of patients having a reasonable benefit of the care they receive.     

Preliminary Assessment of Appropriateness of Emergency Care Service Use: Actions Taken and Consultations Obtained Before Emergency Care Presentation

Inappropriate use of emergency care services can increase hospital readmissions and related costs. This pilot, cross-sectional survey project determined whether home health care patients who receive emergency care services during a Medicare-approved home care episode sought consultation from health care professionals before they made the emergency care visit. The two research questions were: (a) What actions were taken by the patient before making an emergency care visit?; (b) If prior consultation was obtained, what were the suggestions? Preliminary data were obtained from a Michigan-based, Medicare-certified, not-for-profit home health agency affiliated with a university health system. A two-page questionnaire recorded up to three emergency care visits. Volunteer participants were Medicare patients who had no cognitive deficits and were able to communicate with home health care providers (HHCPs) by themselves. Thirty-five emergency care visits were reported; 31 (88.6%) Medicare patients participated and 4 (11.4%) of them had two emergency care visits. Before the patients made an emergency care visit, they most often called their primary care physicians (PCPs; N = 20, 57.1%), followed by the HHCPs (N = 10, 28.6%). All 20 patients who contacted their PCPs and 7 patients who contacted their HHCPs were advised to seek emergency care services. In 20 emergency care visits the patient was admitted for an acute hospital stay; the other 15 patients went home. Most patients contacted their PCPs or HHCPs before they went to an emergency department or urgent care facility. These results implied that PCPs and HHCPs seemed to perceive that the need for emergency care should be determined at an emergency room or urgent care facility. This study was unable to differentiate the need for emergency care services or the appropriateness of the advice given by PCPs or HHCPs when the home care patients were under the care of a medical team.     

Preliminary assessment of appropriateness of emergency care service use: actions taken and consultations obtained before emergency care presentation

Inappropriate use of emergency care services can increase hospital readmissions and related costs. This pilot, cross-sectional survey project determined whether home health care patients who receive emergency care services during a Medicare-approved home care episode sought consultation from health care professionals before they made the emergency care visit. The two research questions were: (a) What actions were taken by the patient before making an emergency care visit?; (b) If prior consultation was obtained, what were the suggestions? Preliminary data were obtained from a Michigan-based, Medicare-certified, not-for-profit home health agency affiliated with a university health system. A two-page questionnaire recorded up to three emergency care visits. Volunteer participants were Medicare patients who had no cognitive deficits and were able to communicate with home health care providers (HHCPs) by themselves. Thirty-five emergency care visits were reported; 31 (88.6%) Medicare patients participated and 4 (11.4%) of them had two emergency care visits. Before the patients made an emergency care visit, they most often called their primary care physicians (PCPs; N = 20, 57.1%), followed by the HHCPs (N = 10, 28.6%). All 20 patients who contacted their PCPs and 7 patients who contacted their HHCPs were advised to seek emergency care services. In 20 emergency care visits the patient was admitted for an acute hospital stay; the other 15 patients went home. Most patients contacted their PCPs or HHCPs before they went to an emergency department or urgent care facility. These results implied that PCPs and HHCPs seemed to perceive that the need for emergency care should be determined at an emergency room or urgent care facility. This study was unable to differentiate the need for emergency care services or the appropriateness of the advice given by PCPs or HHCPs when the home care patients were under the care of a medical team.     

General practitioners' knowledge of functional and social factors in patients with rheumatoid arthritis

The care of people with chronic physical disease is an important part of the work of general practitioners (GPs). Knowledge of social and functional factors, and good teamwork with other health and social care professionals, are necessary to provide high quality general practice care. This study investigated functional disability, social situation and the involvement of health and social care professionals in patients with rheumatoid arthritis, and their GPs' knowledge of these factors. Questionnaires were sent to all patients aged 15-74 with rheumatoid arthritis in two general practices, and similar questionnaires were given to their GPs. Functional disability was assessed using the health assessment questionnaire (HAQ), on a scale of 0-3. The GP consultation rate for patients with rheumatoid arthritis in the previous year was 6.9 compared to 3.7 for all patients in the practices, and increased with increasing disability. Sixty-five per cent of patients had a moderate (HAQ > 1 but 2) disabiltiy. There was an average difference between patient and GP scores for functional disability on the HAQ of 0.49 (95% confidence interval 0.36-0.62), with GPs scoring lower than patients and the difference increased with increasing disability. Seventy-one per cent of patients had seen a rheumatologist or orthopaedic surgeon in the previous year, but there was little involvement by other members of the primary health care team (PHCT). General practitioners had good levels of knowledge of their patients' employment status and who they lived with, but poor knowledge of most of the welfare benefits they were receiving, and of other health and social care professionals involved. It is concluded that GPs see their patients with rheumatoid arthritis frequently, but are often lacking the knowledge about their patients to provide high quality care. They often only know about aspects of their patients' care in which they are directly involved. Ways are suggested for how this situation could be improved.     

Changing the nature of physician referral relationships in the US: the impact of managed care

Prior to the era of managed care in the US, health care delivery was managed by the professional activities of physicians. Managed care replaces management by profession with bureaucratic management structures and oversight, such as utilization review and gatekeeping (required referrals to specialty care). Practically, this means that physicians cannot use the professional relationships that typified practice under fee-for-service medicine, potentially changing not only what physicians do (e.g., order test or not, refer or not), but also how they do what they do. In this paper I look at just one of the changes brought about by managed care: contractual arrangements that require primary care providers to refer patients to a closed panel of specialist physicians. Through an in-depth case study of 45 primary care providers' in the USA who face restricted specialist panels for their managed care patients, but not for their fee-for-service patients, I investigate how the practice of referring is changed by this requirement. First, I use interview data to describe primary care providers general preferences for referral consultants, as well as their views of the referral process and potential barriers in it. Next I present data from all referrals over a four-week period to analyze the extent of referral relationships in actual referrals. Finally, I conclude by discussing some ways that managed care entities can facilitate rather than diminish referral relationships among physicians.     

Access to Spanish-speaking physicians in California: supply, insurance, or both

BACKGROUND: National studies report patients with limited English proficiency (LEP) have difficulty finding bilingual physicians; however, it is unclear whether this situation is primarily a result of an inadequate supply of bilingual physicians or a lack of the insurance coverage necessary to gain access to bilingual physicians. In California, 12% of urban residents are Spanish-speaking with some limited proficiency in English. The majority of these residents (67%) are uninsured or on Medicaid. METHODS: In 2001, we performed a mailed survey of a probability sample of primary care and specialist physicians practicing in California. We received 1364 completed questionnaires from 2240 eligible physicians (61%). Physicians were asked about their demographics, practice characteristics, whether they were fluent in Spanish, and whether they had Medicaid or uninsured patients in their practice. RESULTS: Twenty-six percent of primary care and 22% of specialist physicians in the 13 urban study counties reported that they were fluent in Spanish. This represented 146 primary care and 66 specialist physicians who spoke Spanish for every 100,000 Spanish-speaking LEP residents. In contrast to the general population, there were only 48 Spanish-speaking primary care and 29 specialist physician equivalents available for every 100,000 Spanish-speaking LEP patients on Medicaid and even fewer (34 primary care and 4 specialist) Spanish-speaking physician equivalents for every 100,000 Spanish-speaking physician equivalents for uninsured Spanish-speaking LEP patients. CONCLUSION: Although the supply of Spanish-speaking physicians in California is relatively high, the insurance status of LEP Spanish-speaking patients limits their access to the physicians. Addressing health insurance-related barriers to care for those on Medicaid and the uninsured is critical to improving health care for Spanish-speaking LEP patients.     

Requiring influenza vaccination for health care workers: seven truths we must accept

In this paper we outline the seven primary truths supporting the call for requiring influenza immunization of all health care workers. We view this as a serious patient safety issue, given the clear and compelling data regarding the frequency and severity of influenza infection. In addition, clear-cut safety, efficacy, economic, legal, and ethical platforms support the use of influenza vaccine. Unfortunately health care workers have demonstrated, over almost 25 years that they are unwilling to comply with voluntary influenza immunization programs utilizing a variety of education and incentive programs, at rates sufficient to protect the patients in their care. We suggest that an annual influenza immunization should be required for every health care worker with direct patient contact, unless a medical contraindication or religious objection exists, or an informed declination is signed by the health care worker. High rates of health care worker immunization will benefit patients, health care workers, their families and employers, and the communities within which they work and live.     

Patients' priorities for ambulatory hospital care centres. A survey and discrete choice experiment among elderly and chronically ill patients of a Dutch hospital

Objective  This study established patients' preferences regarding the facilities in an adjacent centre for ambulatory hospital care. It also identified determinants of patients' choice to visit this centre instead of the regional hospital.
Methods  A questionnaire survey among 1477 elderly and chronically ill people (response 72%) assessed patients' expectations regarding (a) quality of hospital care, (b) facilities in centres for ambulatory hospital care, and (c) future use of these centres. Additionally, 75 patients participated in discrete choice experiments about their decision to visit a centre for ambulatory hospital care or the regional hospital.
Results  Respondents prioritized facilities for examination and medical consultations in the ambulatory care centres. Half of the respondents also valued paramedic care, information desks and pharmacies as centre facilities. Most patients living near a future centre for ambulatory care would rather visit this centre than the regional hospital. However, they favoured seeing their familiar physician, short waiting lists and appointments scheduled consecutively on 1 day. If these aspects were not guaranteed at the adjacent centres, more patients chose to visit the hospital.
Conclusions  Although patients value most facilities, they set clear priorities. Furthermore, this study showed three important conditions in the decision to visit an ambulatory care centre; (1) the possibility to see their familiar physician, (2) to have consecutive appointments, and (3) a short waiting list. These three factors were more important to patients than proximity. Thus, when choosing between a hospital and an adjacent centre for ambulatory care, quality aspects matter.     

General practitioners’ perceptions of their role in cancer follow-up care: A qualitative study in the Netherlands

Background: In the last few decades there has been a considerable increase in the number of cancer survivors. Health policy makers would like to see cancer follow-up care moved from secondary to primary care. Method: Between 2008 and 2010, a qualitative study among primary health care professionals was performed to get more insight into the way they care for cancer survivors. Analysed was whether a coordinating role in cancer survivorship care would fit in with the practical logic underlying the way the general practitioners work. Results: In their everyday work, general practitioners are used to provide care in a reactive way. Based on this habitus, they classify their patients into ‘not special’ and ‘special’ ones. Since general practitioners label cancer survivors as ‘not special,’ they expect these patients to take the initiative to ask for help and present their complaints in a clear and complete way. Their habitus as a gatekeeper implies that they are reticent about referring patients to other primary health care professionals. In regard to ‘not special’ patients, such as cancer survivors, general practitioners appear to build on the patients’ own strengths.

Conclusion: The emphasis on a wait-and-see attitude in contemporary Dutch general practice, as well as the general practitioners’ role as a gatekeeper are at odds with the proactive and holistic approach inherent to a coordinating role in cancer follow-up. Therefore, we assume that it will be difficult for general practitioners to shape a pivotal role in this care.     

Knowledge of patient's method of payment by physicians in a group practice.

Physicians generally know how patients pay for their medical care. At the Marshfield Clinic, however, a group practice in Marshfield, Wis., physicians did not know the source of payment for the vast majority of their patients (79.3 percent). Also, even for the approximately one-fifth of the patients whose payment status they reported knowing, the information was incorrect for a small proportion. The patient''s age and sex, length of time the physician had provided care, patient''s place of employment, reason for patient''s visit, and whether the physician was in the medical or surgical department apparently affected the physician''s knowledge of the patient''s payment status. Twenty-five of the 49 physicians studied reported they knew the payment status of none of their patients about whom they were asked; 24 knew the status of at least one patient. Only one physician in seven, however, reported having this knowledge about all the patients about whom he was asked. Physicians in medicine were more likely than those in surgical sub-specialties to know the patient''s payment status. About one physician in five said such knowledge would be helpful for at least one patient; about one in seven said it would be helpful for all patients about whom they were asked. The Marshfield Clinic physicians, who receive salaries, emphasize comprehensive care and increased access to care, rather than maximization of income. The clinic offers medical care to patients in a prepayment health plan while continuing to serve other patients on a fee-for-service basis. Arrangements like this may help ease the transition to repayment if health-maintenance organizations become predominant in the delivery of health services in the United States.