A Mobile Health Intervention Supporting Heart Failure Patients and Their Informal Caregivers: A Randomized Comparative Effectiveness Trial

Background

Mobile health (mHealth) interventions may improve heart failure (HF) self-care, but standard models do not address informal caregivers’ needs for information about the patient’s status or how the caregiver can help.

Objective

We evaluated mHealth support for caregivers of HF patients over and above the impact of a standard mHealth approach.

Methods

We identified 331 HF patients from Department of Veterans Affairs outpatient clinics. All patients identified a “CarePartner” outside their household. Patients randomized to “standard mHealth” (n=165) received 12 months of weekly interactive voice response (IVR) calls including questions about their health and self-management. Based on patients’ responses, they received tailored self-management advice, and their clinical team received structured fax alerts regarding serious health concerns. Patients randomized to “mHealth+CP” (n=166) received an identical intervention, but with automated emails sent to their CarePartner after each IVR call, including feedback about the patient’s status and suggestions for how the CarePartner could support disease care. Self-care and symptoms were measured via 6- and 12-month telephone surveys with a research associate. Self-care and symptom data also were collected through the weekly IVR assessments.

Results

Participants were on average 67.8 years of age, 99% were male (329/331), 77% where white (255/331), and 59% were married (195/331). During 15,709 call-weeks of attempted IVR assessments, patients completed 90% of their calls with no difference in completion rates between arms. At both endpoints, composite quality of life scores were similar across arms. However, more mHealth+CP patients reported taking medications as prescribed at 6 months (8.8% more, 95% CI 1.2-16.5, P=.02) and 12 months (13.8% more, CI 3.7-23.8, P<.01), and 10.2% more mHealth+CP patients reported talking with their CarePartner at least twice per week at the 6-month follow-up (P=.048). mHealth+CP patients were less likely to report negative emotions during those interactions at both endpoints (both P<.05), were consistently more likely to report taking medications as prescribed during weekly IVR assessments, and also were less likely to report breathing problems or weight gains (all P<.05). Among patients with more depressive symptoms at enrollment, those randomized to mHealth+CP were more likely than standard mHealth patients to report excellent or very good general health during weekly IVR calls.

Conclusions

Compared to a relatively intensive model of IVR monitoring, self-management assistance, and clinician alerts, a model including automated feedback to an informal caregiver outside the household improved HF patients’ medication adherence and caregiver communication. mHealth+CP may also decrease patients’ risk of HF exacerbations related to shortness of breath and sudden weight gains. mHealth+CP may improve quality of life among patients with greater depressive symptoms. Weekly health and self-care monitoring via mHealth tools may identify intervention effects in mHealth trials that go undetected using typical, infrequent retrospective surveys.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00555360","term_id":"NCT00555360"}}NCT00555360; https://clinicaltrials.gov/ct2/show/{"type":"clinical-trial","attrs":{"text":"NCT00555360","term_id":"NCT00555360"}}NCT00555360 (Archived by WebCite at http://www.webcitation.org/6Z4Tsk78B).     

SimQ: Real-Time Retrieval of Similar Consumer Health Questions

Background

There has been a significant increase in the popularity of Web-based question-and-answer (Q&A) services that provide health care information for consumers. Large amounts of Q&As have been archived in these online communities, which form a valuable knowledge base for consumers who seek answers to their health care concerns. However, due to consumers’ possible lack of professional knowledge, it is still very challenging for them to find Q&As that are closely relevant to their own health problems. Consumers often repeatedly ask similar questions that have already been answered previously by other users.

Objective

In this study, we aim to develop efficient informatics methods that can retrieve similar Web-based consumer health questions using syntactic and semantic analysis.

Methods

We propose the “SimQ” to achieve this objective. SimQ is an informatics framework that compares the similarity of archived health questions and retrieves answers to satisfy consumers’ information needs. Statistical syntactic parsing was used to analyze each question’s syntactic structure. Standardized Unified Medical Language System (UMLS) was employed to annotate semantic types and extract medical concepts. Finally, the similarity between sentences was calculated using both semantic and syntactic features.

Results

We used 2000 randomly selected consumer questions to evaluate the system’s performance. The results show that SimQ reached the highest precision of 72.2%, recall of 78.0%, and F-score of 75.0% when using compositional feature representations.

Conclusions

We demonstrated that SimQ complements the existing Q&A services of Netwellness, a not-for-profit community-based consumer health information service that consists of nearly 70,000 Q&As and serves over 3 million users each year. SimQ not only reduces response delay by instantly providing closely related questions and answers, but also helps consumers to improve the understanding of their health concerns.     

Cognitive Factors of Using Health Apps: Systematic Analysis of Relationships Among Health Consciousness,Health Information Orientation,eHealth Literacy,and Health App Use Efficacy

Background

Interest in smartphone health apps has been increasing recently. However, we have little understanding of the cognitive and motivational factors that influence the extent of health-app use.

Objective

This study aimed to examine the effects of four cognitive factors—health consciousness, health information orientation, eHealth literacy, and health-app use efficacy—on the extent of health-app use. It also explored the influence of two different use patterns—information and information-behavior use of health apps—with regard to the relationships among the main study variables.

Methods

We collected and analyzed 765 surveys in South Korea. According to the results, there was a negligible gender difference: males (50.6%, 387/765) and females (49.4%, 378/765). All participants were adults whose ages ranged from 19 to 59. In order to test the proposed hypotheses, we used a path analysis as a specific form of structural equation modeling.

Results

Through a path analysis, we discovered that individuals’ health consciousness had a direct effect on their use of health apps. However, unlike the initial expectations, the effects of health information orientation and eHealth literacy on health-app use were mediated by health-app use efficacy.

Conclusions

The results from the path analysis addressed a significant direct effect of health consciousness as well as strong mediating effects of health-app use efficacy. These findings contribute to widening our comprehension of the new, digital dimensions of health management, particularly those revolving around mobile technology.     

Can an Internet-Based Health Risk Assessment Highlight Problems of Heart Disease Risk Factor Awareness? A Cross-Sectional Analysis

Background

Health risk assessments are becoming more popular as a tool to conveniently and effectively reach community-dwelling adults who may be at risk for serious chronic conditions such as coronary heart disease (CHD). The use of such instruments to improve adults’ risk factor awareness and concordance with clinically measured risk factor values could be an opportunity to advance public health knowledge and build effective interventions.

Objective

The objective of this study was to determine if an Internet-based health risk assessment can highlight important aspects of agreement between respondents’ self-reported and clinically measured CHD risk factors for community-dwelling adults who may be at risk for CHD.

Methods

Data from an Internet-based cardiovascular health risk assessment (Heart Aware) administered to community-dwelling adults at 127 clinical sites were analyzed. Respondents were recruited through individual hospital marketing campaigns, such as media advertising and print media, found throughout inpatient and outpatient facilities. CHD risk factors from the Framingham Heart Study were examined. Weighted kappa statistics were calculated to measure interrater agreement between respondents’ self-reported and clinically measured CHD risk factors. Weighted kappa statistics were then calculated for each sample by strata of overall 10-year CHD risk. Three samples were drawn based on strategies for treating missing data: a listwise deleted sample, a pairwise deleted sample, and a multiple imputation (MI) sample.

Results

The MI sample (n=16,879) was most appropriate for addressing missing data. No CHD risk factor had better than marginal interrater agreement (κ>.60). High-density lipoprotein cholesterol (HDL-C) exhibited suboptimal interrater agreement that deteriorated (eg, κ<.30) as overall CHD risk increased. Conversely, low-density lipoprotein cholesterol (LDL-C) interrater agreement improved (eg, up to κ=.25) as overall CHD risk increased. Overall CHD risk of the sample was lower than comparative population-based CHD risk (ie, no more than 15% risk of CHD for the sample vs up to a 30% chance of CHD for the population).

Conclusions

Interventions are needed to improve knowledge of CHD risk factors. Specific interventions should address perceptions of HDL-C and LCL-C. Internet-based health risk assessments such as Heart Aware may contribute to public health surveillance, but they must address selection bias of Internet-based recruitment methods.     

Predictors for Assessing Electronic Messaging Between Nurses and General Practitioners as a Useful Tool for Communication in Home Health Care Services: A Cross-Sectional Study

Background

Nurses providing home health care services are dependent on access to patient information and communicating with general practitioners (GPs) to deliver safe and effective health care to patients. Information and communication technology (ICT) systems are viewed as powerful tools for this purpose. In Norway, a standardized electronic messaging (e-messaging) system is currently being established in health care.

Objective

The aim of this study was to explore home health care nurses’ assessments of the utility of the e-messaging system for communicating with GPs and identify elements that influence the assessment of e-messaging as a useful communication tool.

Methods

The data were collected using a self-developed questionnaire based on variables identified by focus group interviews with home health care nurses (n=425) who used e-messaging and existing research. Data were analyzed using logistic regression analyses.

Results

Over two-thirds (425/632, 67.2%) of the home health care nurses returned the questionnaire. A high proportion (388/399, 97.2%) of the home health care nurses who returned the questionnaire found the e-messaging system to be a useful tool for communication with GPs. The odds of reporting that e-messaging was a useful tool were over five times higher (OR 5.1, CI 2.489-10.631, P<.001) if the nurses agreed or strongly agreed that e-messaging was easy to use. The odds of finding e-messaging easy to use were nearly seven times higher (OR 6.9, CI 1.713-27.899, P=.007) if the nurses did not consider the system functionality poor. If the nurses had received training in the use of e-messaging, the odds were over six times higher (OR 6.6, CI 2.515-17.437, P<.001) that they would consider e-messaging easy to use. The odds that a home health care nurse would experience e-messaging as easy to use increased as the full-time equivalent percentage of the nurses increased (OR 1.032, CI 1.001-1.064, P=.045).

Conclusions

This study has shown that technical (ease of use and system functionality), organizational (training), and individual (full-time equivalent percentage) elements had an impact on home health care nurses’ assessments of using e-messaging to communicate with GPs. By identifying these elements, it is easier to determine which interventions are the most important for the development and implementation of ICT systems in home health care services.     

GPs asking patients to self-rate their health: a qualitative study

Background

In epidemiological research, self-rated health is an independent predictor of mortality, cardiovascular diseases, and other critical outcomes. It is recommended for clinical use, but research is lacking.

Aim

To investigate what happens in consultations when the question ‘How would you assess your general health compared with others your own age?’ is posed.

Design and setting

Authentic consultations with GPs at health centres in Sweden.

Method

Thirty-three planned visits concerning diabetes, pain, or undiagnosed symptoms were voice-recorded. Dialogue regarding self-rated health was transcribed verbatim and analysed using a systematic text condensation method. Speaking time of patients and doctors was measured and the doctors’ assessment of the value of the question was documented in a short questionnaire.

Results

Two overarching themes are used to describe patients’ responses to the question. First, there was an immediate reaction, often expressing strong emotions, setting the tone of the dialogue and influencing the continued conversation. This was followed by reflection regarding their functional ability, management of illnesses and risks, and/or situation in life. The GPs maintained an attitude of active listening. They sometimes reported a slight increase in consultation time or feeling disturbed by the question, but mostly judged it as valuable, shedding additional light on the patients’ situation and making it easier to discuss difficulties and resources. The patients’ speaking time increased noticeably during this part of the consultation.

Conclusion

Asking patients to comparatively self-rate their health is an effective tool in general practice.     

Introducing genetic testing for cardiovascular disease in primary care: a qualitative study

Background

While primary care systematically offers conventional cardiovascular risk assessment, genetic tests for coronary heart disease (CHD) are increasingly commercially available to patients. It is unclear how individuals may respond to these new sources of risk information.

Aim

To explore how patients who have had a recent conventional cardiovascular risk assessment, perceive additional information from genetic testing for CHD.

Design and setting

Qualitative interview study in 12 practices in Nottinghamshire from both urban and rural settings.

Method

Interviews were conducted with 29 adults, who consented to genetic testing after having had a conventional cardiovascular risk assessment.

Results

Individuals’ principal motivation for genetic testing was their family history of CHD and a desire to convey the results to their children. After testing, however, there was limited recall of genetic test results and scepticism about the value of informing their children. Participants dealt with conflicting findings from the genetic test, family history, and conventional assessment by either focusing on genetic risk or environmental lifestyle factors. In some participants, genetic test results appeared to reinforce healthy behaviour but others were falsely reassured, despite having an ‘above-average’ conventional cardiovascular risk score.

Conclusion

Although genetic testing was acceptable, participants were unclear how to interpret genetic risk results. To facilitate healthy behaviour, health professionals should explore patients’ understanding of genetic test results in light of their family history and conventional risk assessment.     

Online Prediction of Health Care Utilization in the Next Six Months Based on Electronic Health Record Information: A Cohort and Validation Study

Background

The increasing rate of health care expenditures in the United States has placed a significant burden on the nation’s economy. Predicting future health care utilization of patients can provide useful information to better understand and manage overall health care deliveries and clinical resource allocation.

Objective

This study developed an electronic medical record (EMR)-based online risk model predictive of resource utilization for patients in Maine in the next 6 months across all payers, all diseases, and all demographic groups.

Methods

In the HealthInfoNet, Maine’s health information exchange (HIE), a retrospective cohort of 1,273,114 patients was constructed with the preceding 12-month EMR. Each patient’s next 6-month (between January 1, 2013 and June 30, 2013) health care resource utilization was retrospectively scored ranging from 0 to 100 and a decision tree–based predictive model was developed. Our model was later integrated in the Maine HIE population exploration system to allow a prospective validation analysis of 1,358,153 patients by forecasting their next 6-month risk of resource utilization between July 1, 2013 and December 31, 2013.

Results

Prospectively predicted risks, on either an individual level or a population (per 1000 patients) level, were consistent with the next 6-month resource utilization distributions and the clinical patterns at the population level. Results demonstrated the strong correlation between its care resource utilization and our risk scores, supporting the effectiveness of our model. With the online population risk monitoring enterprise dashboards, the effectiveness of the predictive algorithm has been validated by clinicians and caregivers in the State of Maine.

Conclusions

The model and associated online applications were designed for tracking the evolving nature of total population risk, in a longitudinal manner, for health care resource utilization. It will enable more effective care management strategies driving improved patient outcomes.     

Accessing primary care: a simulated patient study

Background

Simulated patient, or so-called ‘mystery-shopper’, studies are a controversial, but potentially useful, approach to take when conducting health services research.

Aim

To investigate the construct validity of survey questions relating to access to primary care included in the English GP Patient Survey.

Design and setting

Observational study in 41 general practices in rural, urban, and inner-city settings in the UK.

Method

Between May 2010 and March 2011, researchers telephoned practices at monthly intervals, simulating patients requesting routine, but prompt, appointments. Seven measures of access and appointment availability, measured from the mystery-shopper contacts, were related to seven measures of practice performance from the GP Patient Survey.

Results

Practices with lower access scores in the GP Patient Survey had poorer access and appointment availability for five out of seven items measured directly, when compared with practices that had higher scores. Scores on items from the national survey that related to appointment availability were significantly associated with direct measures of appointment availability. Patient-satisfaction levels and the likelihood that patients would recommend their practice were related to the availability of appointments. Patients’ reports of ease of telephone access in the national survey were unrelated to three out of four measures of practice call handling, but were related to the time taken to resolve an appointment request, suggesting responders’ possible confusion in answering this question.

Conclusion

Items relating to the accessibility of care in a the English GP patient survey have construct validity. Patients’ satisfaction with their practice is not related to practice call handling, but is related to appointment availability.     

Effectiveness of general practice-based health checks: a systematic review and meta-analysis

Background

A recent review concluded that general health checks fail to reduce mortality in adults.

Aim

This review focuses on general practice-based health checks and their effects on both surrogate and final outcomes.

Design and setting

Systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

Method

Relevant data were extracted from randomised trials comparing the health outcomes of general practice-based health checks versus usual care in middle-aged populations.

Results

Six trials were included. The end-point differences between the intervention and control arms in total cholesterol (TC), systolic and diastolic blood pressure (SBP, DBP), and body mass index (BMI) were −0.13 mmol/l (95% confidence interval [CI] = −0.19 to −0.07), −3.65 mmHg (95% CI = −6.50 to −0.81), −1.79 mmHg (95% CI = −2.93 to −0.64), and −0.45 kg/m² (95% CI = −0.66 to −0.24), respectively. The odds of a patient remaining at ‘high risk’ with elevated TC, SBP, DBP, BMI or continuing smoking were 0.63 (95% CI = 0.50 to 0.79), 0.59 (95% CI = 0.28 to 1.23), 0.63 (95% CI = 0.53 to 0.74), 0.89 (95% CI = 0.81 to 0.98), and 0.91 (95% CI = 0.82 to 1.02), respectively. There was little evidence of a difference in total mortality (OR 1.03, 95% CI = 0.90 to 1.18). Higher CVD mortality was observed in the intervention group (OR 1.30, 95% CI = 1.02 to 1.66).

Conclusion

General practice-based health checks are associated with statistically significant, albeit clinically small, improvements in surrogate outcome control, especially among high-risk patients. Most studies were not originally designed to assess mortality.     

MRCGP CSA: are the examiners biased,favouring their own by sex,ethnicity, and degree source?

Background

Concern exists regarding differential performance of candidates in postgraduate clinical assessments by ethnicity, sex, and country of primary qualification. Could examiner bias be responsible?

Aim

To explore whether candidate demographics affect examiners’ judgements, by investigating candidates’ case performances by candidates’ and examiners’ demographics.

Design and setting

Data on 4000 candidates (52 000 cases) sitting the MRCGP clinical skills assessment in 2011–2012.

Method

Univariate analyses were undertaken of subgroup performance (male/female, white/black and minority ethnic (BME), UK/non-UK graduates) by parallel examiner demographics. Due to confounding of variables, these were complemented by multivariate ANOVA and multiple regression analyses.

Results

Univariate analysis showed some differences between outcomes between the same-group and other-group examiners: these were contradictory regarding examiners ‘favouring their own’, for example, males received higher marks from female examiners than from males: maximum effect size was 3.6%. A six-way ANOVA confirmed all three candidate and examiner variables as having significant effects individually, identifying one significant interaction (examiner sex by examiner ethnicity). Stepwise regression showed candidate variables predicting 12% of score variance, parallel examiner demographics adding little (approximately 0.2% of variance). One ‘transactional’ variable proved significant, explaining 0.06% of score variance.

Conclusion

Examiners show no general tendency to ‘favour their own kind’. With confounding between variables, as far as the impact on candidates’ case scores, substantial effects relate to candidate and not examiner characteristics. Candidate–examiner interaction effects were inconsistent in their direction and slight in their calculated impact.     

Identifying depression among adolescents using three key questions: a validation study in primary care

Background

Depression in adolescents is a serious psychiatric illness. GPs play an important role in identifying adolescents with depression and those at risk of developing depression. Few validated tools are suitable for identifying adolescent depression in general practice.

Aim

To determine if three verbally asked key questions are valid for identifying depression in adolescents.

Design and setting

A cross-sectional, general practice multicentre, validation study was conducted in Oslo, Norway, and Aarhus, Denmark.

Method

A total of 294 adolescents answered three verbally asked key questions followed by a Composite International Diagnostic Interview (CIDI) for psychiatric diagnosis. Inclusion criteria were age (14–16 years) and fluency in the Norwegian or Danish language. The primary outcome was ROC curve statistics in terms of sensitivity and specificity, predictive values, and likelihood ratios of the three key questions. Secondary outcomes were Loevinger’s H, Cronbach’s α, and prevalence of depression.

Results

The three key questions met the criteria for construct and criterion validity for detecting depression among the adolescents. ROC curve statistics for the three key questions demonstrated an AUC of 0.79 for the answer ‘yes’ to either screening question and of 0.73 for the answer ‘yes’ to the help question. The positive predictive value was 31% and the negative predictive value was 97%.

Conclusion

The three key questions are useful for identifying depression in adolescents in primary health care.     

Electronic Versus Paper-Based Assessment of Health-Related Quality of Life Specific to HIV Disease: Reliability Study of the PROQOL-HIV Questionnaire

Background

Electronic patient-reported outcomes (PRO) provide quick and usually reliable assessments of patients’ health-related quality of life (HRQL).

Objective

An electronic version of the Patient-Reported Outcomes Quality of Life-human immunodeficiency virus (PROQOL-HIV) questionnaire was developed, and its face validity and reliability were assessed using standard psychometric methods.

Methods

A sample of 80 French outpatients (66% male, 52/79; mean age 46.7 years, SD 10.9) were recruited. Paper-based and electronic questionnaires were completed in a randomized crossover design (2-7 day interval). Biomedical data were collected. Questionnaire version and order effects were tested on full-scale scores in a 2-way ANOVA with patients as random effects. Test-retest reliability was evaluated using Pearson and intraclass correlation coefficients (ICC, with 95% confidence interval) for each dimension. Usability testing was carried out from patients’ survey reports, specifically, general satisfaction, ease of completion, quality and clarity of user interface, and motivation to participate in follow-up PROQOL-HIV electronic assessments.

Results

Questionnaire version and administration order effects (N=59 complete cases) were not significant at the 5% level, and no interaction was found between these 2 factors (P=.94). Reliability indexes were acceptable, with Pearson correlations greater than .7 and ICCs ranging from .708 to .939; scores were not statistically different between the two versions. A total of 63 (79%) complete patients’ survey reports were available, and 55% of patients (30/55) reported being satisfied and interested in electronic assessment of their HRQL in clinical follow-up. Individual ratings of PROQOL-HIV user interface (85%-100% of positive responses) confirmed user interface clarity and usability.

Conclusions

The electronic PROQOL-HIV introduces minor modifications to the original paper-based version, following International Society for Pharmacoeconomics and Outcomes Research (ISPOR) ePRO Task Force guidelines, and shows good reliability and face validity. Patients can complete the computerized PROQOL-HIV questionnaire and the scores from the paper or electronic versions share comparable accuracy and interpretation.     

A Web-Based Interactive Diabetes Registry for Health Care Management and Planning in Saudi Arabia

Background

Worldwide, eHealth is a rapidly growing technology. It provides good quality health services at lower cost and increased availability. Diabetes has reached an epidemic stage in Saudi Arabia and has a medical and economic impact at a countrywide level. Data are greatly needed to better understand and plan to prevent and manage this medical problem.

Objective

The Saudi National Diabetes Registry (SNDR) is an electronic medical file supported by clinical, investigational, and management data. It functions as a monitoring tool for medical, social, and cultural bases for primary and secondary prevention programs. Economic impact, in the form of direct or indirect cost, is part of the registry’s scope. The registry’s geographic information system (GIS) produces a variety of maps for diabetes and associated diseases. In addition to availability and distribution of health facilities in the Kingdom, GIS data provide health planners with the necessary information to make informed decisions. The electronic data bank serves as a research tool to help researchers for both prospective and retrospective studies.

Methods

A Web-based interactive GIS system was designed to serve as an electronic medical file for diabetic patients retrieving data from medical files by trained registrars. Data was audited and cleaned before it was archived in the electronic filing system. It was then used to produce epidemiologic, economic, and geographic reports. A total of 84,942 patients were registered from 2000 to 2012, growing by 10% annually.

Results

The SNDR reporting system for epidemiology data gives better understanding of the disease pattern, types, and gender characteristics. Part of the reporting system is to assess quality of health care using different parameters, such as HbA1c, that gives an impression of good diabetes control for each institute. Economic reports give accurate cost estimation of different services given to diabetic patients, such as the annual insulin cost per patient for type 1, type 2, and gestational diabetes, which are 1155 SR (US $308), 1406 SR (US $375), and 1002 SR (US $267), respectively. Of this, 72.02% of the total insulin cost is spent on type 2 patients and 55.39% is in the form of premixed insulin. The SNDR can provide an accurate assessment of the services provided for research purposes. For example, only 27.00% of registered patients had an ophthalmic examination and only 71.10% of patients with proliferative retinopathy had laser therapy.

Conclusions

The SNDR is an effective electronic medical file that can provide epidemiologic, economic, and geographic reports that can be used for disease management and health care planning. It is a useful tool for research and disease health care quality monitoring.     

Users' reports and evaluations of out-of-hours health care and the UK national quality requirements: a cross sectional study

Background

National standards for delivery of out-of-hours services have been refined. Health service users'' preferences, reports, and evaluations of care are of importance in a service that aims to be responsive to their needs.

Aim

To investigate NHS service users'' reports and evaluations of out-of-hours care in the light of UK national service quality requirements.

Design

Cross sectional survey.

Setting

Three areas (Devon, Cornwall, Sheffield) of England, UK.

Method

Participants were 1249 recent users of UK out-of-hours medical services. Main outcome measures were: users'' reports and evaluations of out-of-hours services in respect of the time waiting for their telephone call to the service to be answered; the length of time from the end of the initial call to the start of definitive clinical assessment (‘call back time’); the time waiting for a home visit; and the waiting time at a treatment centre.

Results

UK national quality requirements were reported as being met by two-thirds of responders. Even when responders reported that they had received the most rapid response option for home visiting (waiting time of ‘up to an hour’), only one-third of users reported this as ‘excellent’. Adverse evaluations of care were consistently related to delays encountered in receiving care and (for two out of four measures) sex of patient. For 50% of users to evaluate their care as ‘excellent’, this would require calls to be answered within 30 seconds, call-back within 20 minutes, time spent waiting for home visits of significantly less than 1 hour, and treatment centre waiting times of less than 20 minutes.

Conclusion

Users have high expectations of UK out-of-hours healthcare services. Service provision that meets nationally designated targets is currently judged as being of ‘good’ quality by service users. Attaining ‘excellent’ levels of service provision would prove challenging, and potentially costly. Delivering services that result in high levels of user satisfaction with care needs to take account of users'' expectations as well as their experience of care.     

Incidence of Online Health Information Search: A Useful Proxy for Public Health Risk Perception

Background

Internet users use search engines to look for information online, including health information. Researchers in medical informatics have found a high correlation of the occurrence of certain search queries and the incidence of certain diseases. Consumers’ search for information about diseases is related to current health status with regard to a disease and to the social environments that shape the public’s attitudes and behaviors.

Objective

This study aimed to investigate the extent to which public health risk perception as demonstrated by online information searches related to a health risk can be explained by the incidence of the health risk and social components of a specific population’s environment. Using an ecological perspective, we suggest that a population’s general concern for a health risk is formed by the incidence of the risk and social (eg, media attention) factors related with the risk.

Methods

We constructed a dataset that included state-level data from 32 states on the incidence of the flu; a number of social factors, such as media attention to the flu; private resources, such as education and health insurance coverage; public resources, such as hospital beds and primary physicians; and utilization of these resources, including inpatient days and outpatient visits. We then explored whether online information searches about the flu (seasonal and pandemic flu) can be predicted using these variables. We used factor analysis to construct indexes for sets of social factors (private resources, public resources). We then applied panel data multiple regression analysis to exploit both time-series and cross-sectional variation in the data over a 7-year period.

Results

Overall, the results provide evidence that the main effects of independent variables—the incidence of the flu (P<.001); social factors, including media attention (P<.001); private resources, including life quality (P<.001) and health lifestyles (P=.009); and public resources, such as hospital care utilization (P=.008) and public health funds (P=.02)—have significant effects on Web searches for queries related to the flu. After controlling for the number of reported disease cases and Internet access rate by state, we estimate the contribution of social factors to the public health risk perception levels by state (R²=23.37%). The interaction effects between flu incidence and social factors for our search terms did not add to the explanatory power of our regression models (R²<1%).

Conclusions

Our study suggests a practical way to measure the public’s health risk perception for certain diseases using online information search volume by state. The social environment influences public risk perception regardless of disease incidence. Thus, monitoring the social variables can be very helpful in being ready to respond to the public’s behavior in dealing with public health threats.     

Patients’ assessments of the continuity of primary care in Finland: a 15-year follow-up questionnaire survey

Background

Continuity of care is an essential aspect of quality in general practice. This study is the first systematic follow-up of Finnish primary care patients’ assessments with regard to personal continuity of care.

Aim

To ascertain whether patient-reported longitudinal personal continuity of care is related to patient characteristics and their consultation experiences, and how this had changed over the study period.

Design and setting

A 15-year follow-up questionnaire survey that took place at Tampere University Hospital catchment area, Finland.

Method

The survey was conducted among patients attending health centres in the Tampere University Hospital catchment area from 1998 until 2013. From a sample of 363 464 patients, a total of 157 549 responded. The responses of patients who had visited a doctor during the survey weeks (n = 97 468) were analysed. Continuity of care was assessed by asking the question: ‘When visiting the health centre, do you usually see the same doctor?’; patients could answer ‘yes’ or ‘no’.

Results

Approximately half of the responders had met the same doctor when visiting the healthcare centre. Personal continuity of care decreased by 15 percentage points (from 66% to 51%) during the study years. The sense of continuity was linked to several patients’ experiences of the consultation. The most prominent factor contributing to the sense of continuity of care was having a doctor who was specifically appointed (odds ratio 7.28, 95% confidence interval = 6.65 to 7.96).

Conclusion

Continuity of care was proven to enhance the experienced quality of primary care. Patients felt that continuity of care was best realised when they could consult a doctor who had been specifically appointed to them. Despite efforts of the authorities, over the past 15 years patient-reported continuity of care has declined in Finland.