Work stress of primary care physicians in the US,UK and German health care systems

Work-related stress among physicians has been an issue of growing concern in recent years. How and why this may vary between different health care systems remains poorly understood. Using an established theoretical model (effort–reward imbalance), this study analyses levels of work stress among primary care physicians (PCPs) in three different health care systems, the United States, the United Kingdom and Germany. Whether professional autonomy and specific features of the work environment are associated with work stress and account for possible country differences are examined.     

Designing a mixed methods study in primary care

BACKGROUND Mixed methods or multimethod research holds potential for rigorous, methodologically sound investigations in primary care. The objective of this study was to use criteria from the literature to evaluate 5 mixed methods studies in primary care and to advance 3 models useful for designing such investigations.     

Pediatric immunization-related safety incidents in primary care: A mixed methods analysis of a national database

BackgroundChildren are scheduled to receive 18–20 immunizations before their 18th birthday in England and Wales; this approximates to 13 million vaccines administered per annum. Each immunization represents a potential opportunity for immunization-related error and effective immunization is imperative to maintain the public health benefit from immunization. Using data from a national reporting system, this study aimed to characterize pediatric immunization-related safety incident reports from primary care in England and Wales between 2002 and 2013.MethodsA cross-sectional mixed methods study was undertaken. This comprised reading the free-text of incident reports and applying codes to describe incident type, potential contributory factors, harm severity, and incident outcomes. A subsequent thematic analysis was undertaken to interpret the most commonly occurring codes, such as those describing the incident, events leading up to it and reported contributory factors, within the contexts they were described.ResultsWe identified 1745 reports and most (n = 1077, 61.7%) described harm outcomes including three deaths, 67 reports of moderate harm and 1007 reports of low harm. Failure of timely vaccination was the potential cause of three child deaths from meningitis and pneumonia, and described in a further 113 reports. Vaccine administration incidents included the wrong number of doses (n = 476, 27.3%), wrong timing (n = 294, 16.8%), and wrong vaccine (n = 249, 14.3%). Documentation failures were frequently implicated. Socially and medically vulnerable children were commonly described.ConclusionThis is the largest examination of reported contributory factors for immunization-related patient safety incidents in children. Our findings suggest investments in IT infrastructure to support data linkage and identification of risk predictors, development of consultation models that promote the role of parents in mitigating safety incidents, and improvement efforts to adapt and adopt best practices from elsewhere, are needed to mitigate future immunization-related patient safety incidents. These priorities are particularly pressing for vulnerable patient groups.     

Empowering patients with diabetes: a qualitative primary care study focusing on South Asians in Leicester, UK

OBJECTIVES: We aimed to explore the experience and attitudes of primary care patients with diabetes living in a UK community with a high proportion of South Asian patients of Indian origin, with particular reference to patient empowerment. METHODS: Semi-structured interviews were conducted with patients with diabetes attending two general practices in Leicester, UK. Patients were interviewed in English, Gujarati or Punjabi and interviews were transcribed with translation into English where necessary. Broad themes were identified and Framework charting was used to organise data for analysis. RESULTS: Interviews were conducted with 15 South Asian and 5 white patients. We identified both similar and culturally specific elements within the experience, attitudes and barriers in the two ethnic groups. High regard for education, particularly in South Asians, was associated with a positive attitude to empowerment through knowledge, but also sometimes led to low motivation to become partners in diabetes management. High prevalence of diabetes and strong family networks meant that families were an important source of knowledge for South Asians and that these patients generally had good emotional support. Practical considerations such as the need for a convenient venue for educational initiatives were common to both ethnic groups, but some cultural preferences were also identified, for example for appropriate language provision and separate gender sessions. CONCLUSIONS: Educational initiatives aimed at promoting self-management in chronic diseases such as diabetes need to be designed with an awareness of the complexity of social and cultural experiences and attitudes in target communities.     

Developing research management and governance capacity in primary care organizations: transferable learning from a qualitative evaluation of UK pilot sites

BACKGROUND: The capacity and capabilities for undertaking primary care research have increased both within and outside of the UK in recent years. The UK Department of Health aims to facilitate this further by establishing a national network of primary care organizations (PCOs) ready to act as hosts for shared research governance systems. However, it is unclear which models offer the most effective option. In addition, there is confusion over new processes and concern that researchers may be deterred from addressing important questions. OBJECTIVES: The research ascertains how PCOs selected as pilot sites have organized research management and governance (RM&G). METHODS: We adopted a case study approach involving interviews with key informants in a purposive sample of eight pilot PCO (RM&G) sites. RESULTS: Motivating factors for PCOs to host RM&G included the possibility of additional resources and more effective use of research to improve service delivery. A range of organizational models were adopted, often reflecting existing strategic alliances. It is envisaged that it will not be effective or cost-effective for many PCOs to make individual arrangements for RM&G, and so models are already developing among groups of PCOs and partner organizations. The extent of partnerships between PCOs varied with concern over critical mass and dilution of expertise in larger groupings. The development and implementation of systems in pilot sites was facilitated by the support of the wider PCO in recognizing research as a valued and integral part of the organization; the effective management of relationships and the establishment of equal partnership arrangements for RM&G, and the effective use of existing R&D infrastructure and expertise. CONCLUSIONS: RM&G partnerships vary according to local circumstances. It is likely that groupings will develop in the future with increasing co-terminosity and across wider health organization boundaries, such as Strategic Heath Authorities (in the UK) or primary care research networks. Critical mass of RM&G arrangements is likely to be linked to levels of research activity. There are real concerns over the levels of bureaucracy associated with the implementation of research governance; however, those PCOs that develop as RM&G sites have the opportunity to enrich their organizations and expand clinically relevant R&D. Partnership working within PCOs and with primary care research networks, academic departments or acute trusts, may be the key to success. Those undertaking research within primary care settings outside of the UK can learn important lessons from the UK experience and ensure development of high quality research that informs improvements in patient care.     

An empirical analysis of US and Japanese health insurance using age-period-cohort decomposition

Aggregate data on household health insurance expenditure in the US and Japan that are classified by period and age are decomposed into age, period, and cohort effects by using the Bayesian cohort models. These models are developed to overcome the identification problem involved in cohort analysis. Despite the differences between the health insurance systems of the two countries, three interesting empirical findings are obtained. First, in both the countries, the age effects are the most influential, and the cohort effects have negligible influence. The latter provides a striking policy implication since the generational imbalance in social security expenditures is widely recognized in developed countries. Second, in both the countries, the period effects show a roughly upward trend. Finally, the age effects exhibit a roughly upward movement for all age groups in the US; however, in Japan, these effects show a downward movement for the 55-59 age group due to the changes in the health insurance system on retirement.     

Stories from frequent attenders: a qualitative study in primary care

PURPOSE Patients who make frequent office visits (frequent attenders) in primary care are often considered a major burden on resources, yet we know little about their perceptions and expectations. We wanted to explore how these patients viewed their rates of consultation, what they expected from the consultation, and how they perceived their relationship with the primary health care team.     

An analysis of computerization in primary care practices

To remain profitable, primary care practices, the front-line health care providers, must provide excellent patient care and reduce expenses while providing payers with accurate data. Many primary care practices have turned to computer technology to achieve these goals. This study examined the degree of computerization of primary care providers in the Augusta, Georgia, metropolitan area as well as the level of awareness of the Health Insurance Portability and Accountability Act (HIPAA) by primary care providers and its potential effect on their future computerization plans. The study's findings are presented and discussed as well as a number of recommendations for practice managers.     

Satisfaction with primary health care and confidence in general practitioners: an exploratory comparison of US and UK students.

This paper explores attitudes of university students towards two differently organised health services, ie the National Health Service in the UK and the more market oriented system in the US and analyses the level of confidence placed in primary care providers (GPs/family physicians) in both systems. Although major differences in the perception of the two health care systems are identified, hardly any differences emerge between the two countries in terms of the confidence patients place in their primary care providers.     

A cost-effectiveness analysis of domestic radon remediation in four primary care trusts located in Northamptonshire, UK

The paper considers how primary care trusts (PCTs), which are relatively new organisations in the UK health service, might respond to the health hazards associated with radon in domestic properties. To this end, the cost-effectiveness of radon remediation programmes in four primary care trusts is calculated and compared with those of other interventions that can avert and treat lung cancer. The results suggest remediation programmes in the primary care trusts are cost-effective on various criteria. Policy recommendations that follow for the primary care trusts include encouraging remediation among their populations and identifying those most at risk from radon's effects.     

Spatial accessibility of primary care: concepts,methods and challenges

Primary care is recognized as the most important form of healthcare for maintaining population health because it is relatively inexpensive, can be more easily delivered than specialty and inpatient care, and if properly distributed it is most effective in preventing disease progression on a large scale. Recent advances in the field of health geography have greatly improved our understanding of the role played by geographic distribution of health services in population health maintenance. However, most of this knowledge has accrued for hospital and specialty services and services in rural areas. Much less is known about the effect of distance to and supply of primary care on primary care utilization, particularly in the U.S.     

A qualitative study of medication-taking behaviour in primary care

BACKGROUND: Prescribed medication is a mainstay of primary care but it is clear that a large proportion of treatment is not taken correctly. Such 'non-compliance' is considered to be a major problem, but research to date has provided few solutions. There have been increasing calls for a change in approach in order to gain a deeper understanding of why the problem remains and new ways of addressing it. OBJECTIVES: We aimed to investigate how adult primary care patients perceived medication- taking using a Grounded Theory methodology. METHOD: Fifty general practice patients without major current mental health or recreational drug abuse problems were interviewed at home using a flexible interview schedule. Subjects' accounts of taking prescribed treatments were verified where possible by tablet counts or case-record review, six interviews being excluded as unreliable. Medication use was discussed for 159 prescribed treatments of which 34 were reportedly not taken as directed. RESULTS: The analysis is presented as a model of decision making which suggests that: (i) knowledge (about disease and treatment) combined with faith in the doctor produces the motivation to start using medicines; (ii) most patients test a medicine before accepting it fully; (iii) three types of medicine user exist: those who (a) passively accept treatment advice, i.e. try to take the medicine as they perceive the doctor wants them to, (b) actively use medicines, i.e. take it as they decide they want to, and (c) reject medication altogether; (iv) the process of accepting a treatment is closely linked to accepting the illness; and (v) practical problems are a late obstacle which only play a small part in the process. CONCLUSIONS: These concepts have been organized within a comprehensive model of the decision-making process, which is discussed with reference to other current theories of medication use. Researchers and clinicians must move beyond compliance when assessing or trying to improve medication use. Making the medication-testing process explicit is proposed as one way of assisting patients to use treatments better.      

Factors related to inappropriate referral between primary and specialized care: qualitative study among primary care physicians

OBJECTIVE: To characterise the factors that, from a primary care physician's point of view, are related to inappropriate referral from primary to specialised health care. METHODS: We conducted two focus groups and two semi-structured interviews with primary care physicians. Each of the participant's profiles was defined according to variables related to inappropriate referral found in previous studies. Discussions were recorded on audio tape and later transcribed verbatim onto paper. We analysed the factors related to inappropriate referral according to frequency and capacity for generating discussion. RESULTS: Primary care physicians have different concepts regarding inappropriate referral, besides health problems that can be solved in primary care. Inappropriate referral is usually justified. Factors related to inappropriate referral can be divided into four groups: 1) related to the patient and patient/doctor relationship: pressure exerted on the primary care physician, caused by a belief in specialists' greater competence, the right of the patient to specialist referral and mass media pressure; 2) related to the health system: lack of coordination between care levels, consultancy time pressure, lack of equipment and distance to the specialist; 3) related to primary care physicians: lack of training and defensive medical practise; 4) related to specialists: professional competence and behaviour with patients. CONCLUSIONS: A notable gap can clearly be seen between primary and specialised care, and this generates problems in the health system. It is difficult to implement prevention and control measures with the factors related to inappropriate referral. Primary care physicians form opinions that are not based on available evidence. Further research is needed in both qualitative and quantitative fields.     

Incidence of fatigue symptoms and diagnoses presenting in UK primary care from 1990 to 2001

Little is known about whether the incidence of symptoms of fatigue presented in primary care, and the consequent diagnoses made, change over time. The UK General Practice Research Database was used to investigate the annual incidence of both fatigue symptoms and diagnoses recorded in UK primary care from 1990 to 2001. The overall incidence of all fatigue diagnoses decreased from 87 per 100 000 patients in 1990 to 49 in 2001, a reduction of 44%, while postviral fatigue syndromes decreased from 81% of all fatigue diagnoses in 1990 to 60% in 2001. Chronic fatigue syndrome (CFS) and myalgic encephalomyelitis (ME) together increased from 9% to 26% of all fatigue diagnoses. The incidence of fibromyalgia increased from less than 1 per 100 000 to 35 per 100 000. In contrast, there was no consistent change in the incidence of all recorded symptoms of fatigue, with an average of 1503 per 100 000, equivalent to 1.5% per year. CFS/ME and fibromyalgia were rarely diagnosed in children and were uncommon in the elderly. All symptoms and diagnoses were more common in females than in males. The overall incidence of fatigue diagnoses in general has fallen, but the incidence rates of the specific diagnoses of CFS/ME and fibromyalgia have risen, against a background of little change in symptom reporting. This is likely to reflect fashions in diagnostic labelling rather than true changes in incidence.