Worry: a particular determinant of consultation illuminated.

In this study, exploring the worry experienced by patients in the GP waiting room and the reasons for being worried, 791 patients completed a structured questionnaire just before they consulted their GP, and afterwards. The perceptions of the patients concerning the complaint and the need for more information about the complaint played an important role in the degree of worry. Patients who wanted more information about the complaint were more worried than the patients who did not feel they needed more information. Not surprisingly, the more serious the patients perceived the complaint to be and the greater the perceived chance of serious disease, the more worried they were. General health status and frequency of consultations per year were related to the degree of general worry. According to the patient self-reports, worry was almost never due to information from the mass media or from other persons, or to a concern for the consultation itself. Patients generally evaluated the consultation as positive with respect to the way their worry was discussed. The decrease in worry after consulting the GP, in patients who were positive about the consultation was significantly higher than that in patients who were less positive. The theoretical and practical implications of this study are discussed.     

Beliefs About the Causes of Health Complaints: A Study in Primary Care

In public and interpersonal health communication, a need exists to explore the nature of lay beliefs about health complaints to achieve effective communication. Beliefs of patients visiting their family physician/general practitioner (GP) may give insight into this matter. The aim of this study was to investigate the spectrum of causes attributed to different categories of health complaints presented at the GP office. Before visiting their GP, 2,253 individuals completed a questionnaire about their health complaint and the cause they attributed to this complaint. The spectrum of causes attributed to all health complaints was compared between distinct categories of health complaints. Sixty-two percent of the GP patients attributed at least 1 cause to health complaints they presented at the GP office. Thirty-eight percent of GP patients did not attribute a cause to the health complaint they presented at the GP office. Patient beliefs differed across distinct health problems. Lay beliefs seemed to differ from basic notions of illness because patients attributed different causes to different health complaints. These differences in beliefs, when patients choose to share them with their GP, may serve as a starting point for the communication between the patients and the GP to achieve an effective communication. A need seems to emerge to discriminate between lay beliefs regarding the nature of specific illnesses and those regarding basic notions. GPs are therefore advised to attend to, or at least ask for, their patients' views specifically.     

Do patients want to disclose psychological problems to GPs?

BACKGROUND: GPs are an accessible health care provider for most patients with mental disorders and are gatekeepers to specialist care. The extent to which patients consider their primary care team as relevant to their mental health problems needs to be explored. OBJECTIVES: To explore reasons why patients choose not to disclose psychological problems to GPs, and to discuss the implications for the provision of primary mental health care. METHODS: A cross-sectional survey of consecutive patients attending general practices in New Zealand (part of the MaGPIe study). Patients were screened using the GHQ-12 and a stratified sample participated in a structured in-depth interview to assess their psychological health. Non-disclosure of psychological problems was explored. GPs assessed patients' psychological health using a 5-point scale of severity. RESULTS: Seventy GPs (90%) and 775 patients (70%) participated. Overall, 29.8% of all patients and 36.9% of patients with current symptoms reported non-disclosure of self-perceived psychological problems. Younger patients, those consulting more frequently and those with greater psychiatric disability were more likely to report non-disclosure. The most frequently given reasons were beliefs that a GP is not the 'right' person to talk to (33.8%) or that mental health problems should not be discussed at all (27.6%). CONCLUSIONS: Interventions such as screening and GP education may be ineffective in improving primary mental health care unless accompanied by educational programmes for the general public to increase mental health literacy, de-stigmatise mental illness and increase awareness of general practice as an appropriate and effective source of health care.     

Familiarity with a GP and patients' evaluations of care. A cross-sectional study

BACKGROUND: Personal continuity is considered a core feature of general practice care. Nowadays, another important concept for general practice may be patients' familiarity with a GP. OBJECTIVES: We studied the extent to which patients see a familiar GP, and how this matches their preferences. Furthermore we studied the impact of knowing the GP on patients' evaluations of consultations. METHODS: A cross-sectional design was used and 2400 patients visiting 17 general practices (30 GPs) in The Netherlands for a consultation were approached; 2152 patients completed the questionnaire. The main outcome measures were: i) the extent to which patients saw a familiar GP in relation to the reason for encounter, perceived seriousness of symptoms, and concern about symptoms; and ii) the impact of 'knowing the GP' on patients' overall satisfaction with the consultation, feeling of being helped to move forwards, trust in the GP, and perceived clearness of treatment plans. RESULTS: Patients saw a familiar GP to a high extent, regardless of the reason for encounter, perceived seriousness of symptoms and worries. Higher levels of familiarity with a GP were associated with higher levels of satisfaction, with increased feelings of being helped forward, with more trust in the GP, and with the perception of clearer treatment plans made. A multivariate model including the variable 'knowing the GP' explained 11% of the observed variance in patients' evaluations of consultations. CONCLUSION: Familiarity with a GP improves patients' assessment of general practice care. Also in the future, personal continuity should be promoted.     

Why do patients want to have their blood tested? A qualitative study of patient expectations in general practice

Background

While in general practice chronic non-specific abdominal complaints are common, there is insufficient data on the clinical course and the management of these complaints. Aim of this study was to present a primary care based profile of these chronic complaints including health care involvement, health status and clinical course.

Methods

Thirty general practitioners (GPs) and patients from their practices participated in a prospective follow-up study. All patients and GPs were asked to complete questionnaires at baseline and at 6, 12 and 18 months of follow-up. The GPs provided information on diagnostic and therapeutic management and on referral concerning 619 patients with chronic non-specific abdominal complaints, while 291 patients provided information about health status and clinical course of the complaints.

Results

When asked after 18 months of follow-up, 51,7% of the patients reported an equal or worsened severity of complaints. General health perception was impaired and patients had high scores on SCL-anxiety and SCL-depression scales. Diagnostic tests other than physical examination and laboratory tests were not frequently used. Medication was the most frequent type of treatment. The persistence of chronic non-specific abdominal complaints was quite stable.

Conclusion

Once non-specific chronic abdominal complaints have become labelled as chronic by the attending physician, little improvement can be expected. The impact on patients' physiological and psychological well-being is large. GPs use a variety of diagnostic and therapeutic strategies. Research into the evidence base of currently applied management strategies is recommended.     

Association between perceived health status and satisfaction with quality of care: evidence from users of primary health care in Oman

OBJECTIVE: Our aim was to assess the influence of perceived health status, as measured by SF-12, on the client's views of service quality. METHODS: A structured interview of patients was carried out in six primary health care centres in Adh Dhahira region health authority in the Sultanate of Oman. A total of 1226 patients aged 15 and over attending the different health care services within the health centres took part in the study. The main outcome measures were patients' satisfaction with the different aspects of health care and their perceived physical and mental health status. RESULTS: When adjusted for the relevant background factors such as age and gender, poor perceived health status has been found to predict less positive judgements of various aspects of health care quality. Poor mental health status, for example, predicts less positive judgements of aspects that are linked to the accessibility of the service and interpersonal aspects of care such as the working hours of the centre, GP's attitude and time spent with the GP (P < 0.05, <0.05 and <0.01, respectively). Poor physical health status, on the other hand, predicts less positive judgements of aspects such as cleanliness of the building, confidentiality of consultation with the GP, explanation about the visit to the antenatal clinic and standard of antenatal clinic in general (P < 0.05, <0.05, <0.05 and <0.05, respectively). CONCLUSION: Users' perceived health status has to be evaluated concurrently with assessing satisfaction with the quality of health care services. This would provide more valid results with regard to the patients' views on their level of satisfaction with health care quality.     

Patients' experience of epilepsy and health care

OBJECTIVE: The aim of this study was to assess the severity of epilepsy and its effect on patients lives, and to describe patients' use of and attitudes to health care. METHOD: A questionnaire was sent to 595 people with epilepsy identified from 14 general practices in north-west Bristol. All patients aged 16 years and over receiving anti-epileptic medication for their epilepsy were included in the study. Areas investigated included severity of epilepsy and its effect on quality of life, anti-epileptic medication and its perceived effect, health care utilization and preferences for health care. RESULTS: Seizure frequency was strongly associated with adverse effects of epilepsy. Attacks of epilepsy were experienced at least monthly by 20.4% (95% confidence intervals (Cl) 17.0-23.7%) of patients, 29.4% (25.4-33.4%) took more than one anti-epileptic drug, 56.1% (50.1-62.2%) reported drug side effects, 74.1% (70.3-77.8%) would prefer to receive all or most of their epilepsy care in a general practice setting, and 69.8% (63.5- 76.2%) would like contact with a primary care-based epilepsy specialist nurse. During the previous year 42.4% (35.9-48.8%) of patients had not seen a doctor about their epilepsy. Of patients who had attended the general practice only 13.4% (9.6-17.2%) had regular arrangements to see their GP about epilepsy. Patients receiving both primary and secondary care had the greatest needs and wants for improved care. CONCLUSIONS: Structured care, including regular appointments, co-ordination of primary and secondary care, and increased monitoring and discussion, may improve the quality of life of people with epilepsy, but requires evaluation.      

Moroccans' opinions about general practitioners: analyzing reasons for consultation

OBJECTIVE: To determine whether there is a difference in the extent to which the GP succeeds in establishing the reasons for consultation of Moroccans and those of the Dutch; and whether the opinion of Moroccans about the GP's consultation differs from that of the Dutch. DESIGN: Analysis of patient interviews and GP's consultations. METHOD: In 11 general practices in Amsterdam and The Hague in May 1997, 50 Moroccan adults and 50 Dutch individuals were asked for their reasons to attend before the consultation and in the mother language; a distinction was made between the actual complaint and the expectations with regard to the consultation. The GPs recorded these data after every consultation. The complaints were coded by organ system and by nature of complaint, following which agreement of the assessments was scored on a scale ranging from 0 to 100. RESULTS: Both groups comprised 20 men and 30 women. The mean age of the Moroccans was 38.6 years (SD: 13.8), that of the Dutch 56.4 years (SD: 16.7). The GPs established complaints of Moroccan patients not as well as those of Dutch patients (score: 73.9 versus 87.3); the difference was more pronounced where patients with only elementary education were concerned (67.0 as against 86.1). The GPs were able to establish the expectations with regard to the consultation nearly as often for the Moroccan as for the Dutch patients (58.5 versus 55.9). Moreover, the Moroccans were as positive about the course of the consultation as the Dutch. Except for communication problems among the lower educated, none of the problems indicated appeared to be experienced more often by the Moroccans than by the Dutch. CONCLUSION: A large part of the complaints presented by lower educated Moroccan patients were interpreted differently by the GP. For Moroccans with a higher education, the care was comparable with that among the Dutch.     

Content analysis of patient complaints

OBJECTIVE: To develop a standard taxonomy for inpatient complaints that could be adopted in a wide array of health service institutions. DESIGN: A taxonomy was developed by merging the coding schemes from eight prior studies of patient complaints, and then by revising the received coding scheme in light of the codes and clarifications that emerged from a content analysis of patient complaints. SETTING: Two Boston area hospitals. PARTICIPANTS: Stratified random sample of 1216 complaints from patients in 2004. INTERVENTION: s) None. Main outcome measure(s) Patient complaints codes, provider codes and inter-rater reliability. RESULTS: A taxonomy comprising 22 patient complaint codes and five provider codes was developed. Inter-rater agreement for complaint codes was good (median Kappa statistic 0.66, interquartile range 0.55-0.80). Four codes were each used in more than 10% of the patient complaints filed: unprofessional conduct (19%); poor provider-patient communication (17%); treatment and care of patient (16%); and, having to wait for care (11%). Of the coding for the profession of the person complained about, 47% of the patient complaints were about staff in general or did not specify a particular profession; 22% identified a physician or dentist; 12% nursing staff; 11% administrative or support staff and 8% allied clinical health professionals. CONCLUSIONS: Standardized coding of patient complaint data may provide an opportunity for quality improvement, patient satisfaction and changes in patient care.     

Measuring the severity of upper gastrointestinal complaints: does GP assessment correspond with patients' self-assessment?

BACKGROUND: Questionnaires are frequently used to measure the severity of gastrointestinal (GI) complaints. These questionnaires can either be filled out by the physicians or by the patients, but it is not clear whether these scores correspond. This study aimed to investigate the interrater agreement between physician-reported severity and patient-reported severity concerning the patients' upper GI complaints. METHODS: In a prospective observational study, the severity of eight GI complaints was registered by both patients and GPs independently on a seven-point scale (n = 316) before and after treatment with esomeprazole. Weighted kappa values for the agreement on the severity and simple kappa values for the agreement on the absence or presence of symptoms were calculated. RESULTS: The weighted kappa values ranged from 0.14 to 0.68 indicating poor to moderate agreement. The agreement on the presence or absence of symptoms was similar. Several systematic differences in scoring were found: the GPs tended to underestimate the severity of belching, nausea, early satiety, vomiting and upper and lower abdominal pain. Furthermore, the treatment effect for belching and lower abdominal pain was more often overestimated, while the treatment effect for nausea was more often underestimated by the GP. CONCLUSION: The agreement between GP and patient is low. The differences in scoring should be kept in mind when comparing physician-reported outcomes with patient-reported outcomes.     

Use of general practice, diagnostic investigations and hospital services before and after cancer diagnosis - a population-based nationwide registry study of 127,000 incident adult cancer patients

ABSTRACT: BACKGROUND: Knowledge of patterns in cancer patients' health care utilisation around the time of diagnosis may guide health care resource allocation and provide important insights into this groups' demand for health care services. The health care need of patients with comorbid conditions far exceeds the oncology capacity and it is therefore important to elucidate the role of both primary and secondary care. The aim of this paper is to describe the use of health care services amongst incident cancer patients in Denmark one year before and one year after cancer diagnosis. METHODS: The present study is a national population-based case-control (1:10) registry study. All incident cancer patients (n=127,210) diagnosed between 2001 and 2006 aged 40 years or older were identified in the Danish Cancer Registry. Data from national health registries were provided for all cancer patients and for 1,272,100 controls. Monthly consultation frequencies, monthly proportions of persons receiving health services and three-month incidence rate ratios for one year before and one year after the cancer diagnosis were calculated. Data were analysed separately for women and men. RESULTS: Three months before their diagnosis, cancer patients had twice as many general practitioner (GP) consultations, ten to eleven times more diagnostic investigations and five times more hospital contacts than the reference population. The demand for GP services peaked one month before diagnosis, the demand for diagnostic investigations one month after diagnosis and the number of hospital contacts three months after diagnosis. The proportion of cancer patients receiving each of these three types of health services remained more than 10% above that of the reference population from two months before diagnosis until the end of the study period. CONCLUSIONS: Cancer patients' health service utilisation rose dramatically three months before their diagnosis. This increase applied to all services in general throughout the first year after diagnosis and to the patients' use of hospital contacts in particular. Cancer patients' heightened demand for GP services one year after their diagnosis highlights the importance of close coordination and communication between the primary and the secondary healthcare sector.     

Unexplained non-cardiac chest pain; its prevalence and natural course

OBJECTIVE: (a) To assess whether data on prevalence and natural course of unexplained chest pain are similar to previous results reported for patients with unexplained chest pain in foreign literature; (b) to find biographical or medical record variables predictive of continuing pain. DESIGN: Retrospective research of medical records. SETTING: University Medical Centre and Diaconessenhuis (peripheral hospital), Leiden, the Netherlands. METHOD: Medical records of patients who had been newly referred between 1992 and 1995 to the cardiac outpatient clinic were screened on the discharge diagnosis: unexplained chest pain. Patients were approached by mail with a questionnaire, inquiring about duration, frequency, intensity, functional limitations and medical consumption with regard to their unexplained chest pain. RESULTS: In 39.8% (1053/2648) of the patients, no explanation was found for their complaints. After 12 and 24 months, 72% and 56% respectively reported still having complaints. 37% experienced limitations in daily activities at the time of the investigation. Sex and duration of pain before visiting the cardiologist were predictors of the persistence of chest pain. 31% of the patients did consult their general practitioner at least once more after the discharge by the cardiologist. CONCLUSION: Unexplained chest pain is a common complaint of patients visiting an outpatient clinic for cardiology and often persists. The present results are largely similar to those reported in foreign literature.     

Randomised controlled trial of a shared care programme for newly referred cancer patients: bridging the gap between general practice and hospital

Objective: To determine the effect of a shared care programme on the attitudes of newly referred cancer patients towards the healthcare system and their health related quality of life and performance status, and to assess patients' reports on contacts with their general practitioner (GP).     

Comparing patients with depressive complaints and patients with chronic medical conditions on their functioning and medical consumption

BACKGROUND: Several studies have found that depressive complaints are associated with limitations in functioning that are at least comparable with those of chronic medical conditions, such as diabetes or lung diseases. However, the consequences of these associations for the utilization of general health care services are not known, certainly not for health care settings outside the United States. AIMS OF THE STUDY: To investigate the association of depressive complaints with functioning and health care utilization, comparing this with the association of chronic medical conditions with functioning and health care utilization. METHODS: In a community-based sample of Dutch adults (N=9428), chronic conditions (21 types) and depressive complaints were assessed by self-report. Only active conditions and depressive complaints, for which treatment was taking place, were selected for the analyses. Health status and disabilities were also assessed by self-report. Information on the utilization of health care services was based on self-report as well as on data extracted from a claims database. This database also provided information on the use of psychoactive medications. The associations between chronic conditions, depressive complaints and dependent variables were determined by analysis of variance or regression analysis, adjusting for possibly confounding factors (gender, age, living conditions). RESULTS: Depressive complaints, more than any chronic condition (except back problems), were associated with fatigue, poor subjective health and days spent in bed. Those having depressive complaints visited their general practitioner (GP) more often than the others. They also contacted a medical specialist more often than other patient categories, apart from patients with heart diseases. The combination of depressive complaints and chronic medical conditions was not associated with increased utilization or lower functioning. CONCLUSION: Depressive complaints are not only connected to functioning, but also to the utilization of general health care services. The strength of these associations is comparable with that of chronic medical conditions. This study stresses the pertinence of (research on) the management and treatment of patients with depressive complaints in general health care settings.     

Hospital patients'' responses to dissatisfaction

Hospitalized patients' responses to dissatisfaction in the provision of services are analysed as a function of their perceptions of the severity of the service failure and their relative social power. The analysis is based on the responses of 384 patients in a general hospital who reported experiencing at least one disturbing problem in the receipt of hospital services. Three binary dependent variables were constructed based on three dimensions of intensity of complaint behaviours: passive vs. active, non-directed vs. directed, non-formal vs. formal. The four possible response combinations created an ordinal scale of intensity of response. The set of independent variables included: perceived severity of the problem, general measures of satisfaction with services, structural po wer discrepancies, personal and situational resources of social power, and self perception of social power. The results of multivariate analyses indicate that the perceived severity of the problem best explains the intensity of response. Personal and situational social power resources and self perception of power add to the explanation. Structural power discrepancies, however, do not relate to the intensity of patients' responses to dissatisfaction.     

Prospective study of the relationship between musculoskeletal and psychological complaints and electromyographic activity during isometric muscular contractions in a working population

OBJECTIVES: This study focused on determining whether musculoskeletal and psychological complaints reported monthly over a 4-month period predicted muscular activity during and immediately after standardized worktasks and whether muscular activity during and immediately after these tasks predicted changes in complaint severity in the following 12 months. METHODS: Surface electromyography (EMG) was recorded bilaterally from the upper trapezius, middle deltoid, and forearm extensor muscles of 45 postal workers (30 women) during sustained submaximal (25% of peak force) isometric contractions (wrist extension and shoulder abduction). Self-reported health complaints were recorded monthly. Musculoskeletal and psychological complaint-severity indices (MSI and PI, respectively) were computed from complaint-severity scores (intensity score x duration score). The history of complaints over the previous 4 months was included in adjusted regression models to predict muscular activity during and immediately after submaximal contractions. Muscular activity was included in adjusted models to predict changes in the complaint severity over the subsequent 12-month period. RESULTS: A higher MSI predicted a lower EMG level in the trapezius muscle during submaximal contractions (P<0.014), whereas the PI did not predict the level of EMG in any of the muscles studied (P > 0.194). The EMG activity did not predict changes in the complaint severity over the subsequent 12 months. CONCLUSIONS: These findings may support the hypotheses of pain adaptation or the dysfunction of synergistic muscular control in relation to musculoskeletal complaints. However, the findings did not indicate that increased or decreased muscular activity is a risk factor for heightened levels of complaints in the subsequent 12 months.     

Elderly patients' and GPs' views on different methods for patient involvement: an international qualitative interview study

BACKGROUND: Elderly patients' interaction with the GP may be improved through patient involvement techniques, and there is a variety of such techniques which improve patients' involvement in their own care, although little is known about their acceptability. OBJECTIVES: The aim of this study was to identify barriers and facilitators for using patient information leaflets and patient satisfaction questionnaires as methods for increasing elderly patients' involvement in general practice care by comparing their views with the GPs' views on these two types of methods. METHODS: In seven countries (Austria, Denmark, Germany, The Netherlands, Portugal, Slovenia and Switzerland) 146 GPs and 284 patients aged 70 and over were interviewed about the use and the acceptability of these two methods. Interviewers followed a semi-structured interview guide, and all interviews were tape-recorded and transcribed verbatim. RESULTS: The arguments for using patient satisfaction questionnaires were that they would provide the GP with more information, function as a basis for change, increase patients' self-confidence and make them more conscious of what to expect. Barriers for their use were cognitive impairment among patients, fear that they would not answer honestly and opposition to written material. The arguments for patient information leaflets were that they could support patients' memories, educate patients and promote their self-responsibility. The barriers were cognitive impairment among patients and fear that they would give them false impressions of what to expect. CONCLUSION: Both instruments were generally well accepted by both GPs and patients. Their use seemed to be dependent upon the individual GP's attitude and the patients' cognitive capacities.     

The importance of job characteristics in determining medical care-seeking in the Dutch working population, a longitudinal survey study

ABSTRACT: BACKGROUND: The working population is ageing, which will increase the number of workers with chronic health complaints, and, as a consequence, the number of workers seeking health care. It is very important to understand factors that influence medical care-seeking in order to control the costs. I will investigate which work characteristics independently attribute to later care-seeking in order to find possibilities to prevent unnecessary or inefficient care-seeking. METHODS: Data were collected in a longitudinal two-wave study (n = 2305 workers). The outcome measures were visits (yes/no and frequency) to a general practitioner (GP), a physical therapist, a medical specialist and/or a mental health professional. Multivariate regression analyses were carried out separately for men and women for workers with health complaints. RESULTS: In the Dutch working population, personal, health, and work characteristics, but not sickness absence, were associated with later care-seeking. Work characteristics independently attributed to medical care-seeking but only for men and only for the frequency of visits to the GP. Women experience more health complaints and seek health care more often than men. For women, experiencing a work handicap (health complaints that impede work performance) was the only work characteristic associated with more care-seeking (GP). For men, work characteristics that led to less care-seeking were social support by colleagues (GP frequency), high levels of decision latitude (GP frequency) and high levels of social support by the supervisor (medical specialist). Other work characteristics led to more care-seeking: high levels of engagement (GP), full time work (GP frequency) and experiencing a work handicap (physical therapist). CONCLUSIONS: We can conclude that personal and health characteristics are most important when explaining medical care-seeking in the Dutch working population. Work characteristics independently attributed to medical care-seeking but only for men and only for the frequency of visits to the GP. The association between work characteristics and later medical care-seeking differed between health care providers and between men and women. If we aim at reducing health care costs for workers by preventing unnecessary or inefficient care, it is important to reduce the number of workers that report that health complaints impede their work performance. The supervisor could provide more social support, closely monitor workload in combination with work pressure and decision latitude, and when possible help to adjust working conditions. Health care providers could reduce medical costs by taking the work relatedness of health complaints into account and act accordingly, by decreasing the time to referral and waiting lists, and by providing appropriate care and avoiding unnecessary or harmful care.