Home care or long-term care facility: factors that influence the decision

In order to answer the research question--What factors determine if a long-term care client will be cared for at home or in a long-term care facility?--data were collected in five provinces in Canada in urban and rural sites, through focus groups with community care coordinators. A questionnaire provided information about the 89 participants and their workload. Factors are grouped under organizational, system, client, informal provider, formal provider, and case manager factors. Discussion focuses on changes needed to foster more long-term care in the home.     

Patient psychosocial factors and primary care consultation: a cohort study

BACKGROUND: The combined influence of psychological distress, family dysfunction and social support on primary care consultation (PCC) remains unclear. OBJECTIVE. To build an explanatory model of PCC concerning users' psychosocial factors. METHODS: We undertook a multicentre, prospective cohort study of a random sample of 1141 persons assigned to 113 GPs, belonging to 11 urban health centres in four Spanish cities (Seville, Malaga, Jaen and Granada), of whom 955 (84%) were interviewed in their homes. They were followed up for 1 year and then contacted again. After the second interview, 70 (7.3%) patients were excluded; accordingly, we measured the number of PCC of 885 valid patients using their medical charts. RESULTS: A multilevel analysis was developed. The null model with three levels showed that 93.29% of the variability was explained by the patients, 1.56% by the GPs and 5.15% by the health centres. We selected a two-level model (patients and health centres) with random effects. The variables used in the multilevel analysis explained 48% of PCC, 36% at the patient level and 12% at the health centre level. Poor mental health (GHQ-28, partial correlation coefficient=0.28) and family dysfunction (Family APGAR index, partial correlation coefficient=0.26) were the most predictive variables, whereas social support (Duke-UNC-11, partial correlation coefficient=-0.14) lost significance in the multivariate analysis. Chronic illness seemed less relevant in our study, and only two predisposing factors were included in the equation: age and satisfaction with their doctor. CONCLUSIONS: Mental health and family function were the most important psychosocial factors predicting PCC. More comprehensive identification of psychosocial factors may enhance our understanding of PCC.     

Primary care management of patients with pain complaints and the influence of physician training in mechanical diagnosis and therapy

Journal of Public Health - Chronic pain affects 20% of the adult population, and pain-related consultations comprise a significant amount of all primary care visits. The purpose of this study was...     

Patient gender differences in the diagnosis of depression in primary care

Our purpose was to explore why women are more likely than men to be diagnosed as depressed by their primary care physician. Women were found to have more depressive symptoms as self-reported on the Beck Depression Inventory (BDI). Women having high BDI scores (reflecting significant depression) were more likely than men with high BDI scores to be diagnosed by their primary care physician (p = 0.0295). Female patients made significantly more visits to the clinic than men. For both sexes, patients with greater numbers of primary care clinic visits were more likely to be diagnosed as depressed. Logistic regression revealed that gender has both a direct and indirect (through increased use) effect on the likelihood of being diagnosed as depressed. Patient BDI score, clinic use, educational level, and marital status were all significantly related to the diagnosis of depression. Controlling all other independent variables, women were 72% more likely than men to be identified as depressed, but this effect did not achieve statistical significance (p = 0.0981). In gender-specific analyses, BDI and clinic use were again significantly related to the diagnosis of depression for both sexes. However, educational and marital status predicted depression diagnosis only for women. Separated, divorced, or widowed women were almost five times as likely to be diagnosed as depressed as those who were never married, all other factors being equal. Clinic use and BDI scores were found to be important correlates of the diagnosis of depression. There was some evidence of possible gender bias in the diagnosis of depression.     

Do patient attitudes influence physician recognition of psychosocial problems in primary care?

Research has yielded consistent evidence of high levels of psychiatric morbidity and psychosocial problems among primary care patients, and recent studies have focused on improving physician recognition. These studies are based on the unexamined assumption that patients want their physicians to treat psychosocial disorders; thus, underrecognition is examined by analyzing characteristics of physicians and medical settings. Patient characteristics, particularly attitudes about the appropriateness of seeking help for psychosocial problems in primary care, have not been examined in relationship to underrecognition. This study directly focuses on patient attitudes about appropriateness of requesting care for psychosocial difficulties, the extent to which patients discuss difficulties with their physicians, and the degree to which physician recognition is explained by these patient characteristics. The study sample of 883 adult patients was drawn from 23 primary care practices. Over 70 percent of patients find it appropriate to turn to their primary care physicians for help with emotional distress, family problems, life stress, behavioral problems, and sexual dysfunction; however, only one fifth to one third of patients who have experienced difficulties have discussed these problems with their primary care providers. Attitudes about appropriateness are significantly related to physician recognition of psychiatric symptoms and family difficulties but account for limited variance in levels of recognition.     

Variables that influence diagnosis and treatment of the eating disorders within primary care settings: a vignette study

OBJECTIVE: This study examined the influence of clinical and nonclinical features of case presentation on the diagnosis and treatment of eating disorders in primary care. METHOD: Family physicians from a defined region of the UK were provided with two vignettes, characterizing eating disorder presentations in primary care. Case gender, ethnicity, weight status, and diabetes history were experimentally manipulated. Outcome variables included the primary diagnosis and the treatment course selected for each case. RESULTS: Female cases were more likely to receive an eating disorder diagnosis, even when their symptoms were identical to those of males. Nonclinical demographic variables also influenced treatment decisions. Weight status and physical comorbidity had a limited influence on treatment pathways. CONCLUSION: Nonclinical features of case presentations are used when making eating disorder diagnoses and in selecting treatment. Decision-making in primary care does not reflect recommendations from clinical guidance, and this disparity might increase the risk of complications in the care of sub-groups of eating-disordered patients.     

Prognostic occupational factors for persistent low back pain in primary care

Purpose

To reduce the socio-economic burden of persistent low back pain (LBP), factors influencing the progression of acute/subacute LBP to the persistent state must be identified at an early stage.

Methods

Prospective inception cohort study of patients attending a health practitioner for their first episode of acute/subacute or recurrent LBP. Patients were assessed at baseline addressing occupational, psychological, biomedical and demographic/lifestyle factors and followed up over 6 months. Multivariate logistic regression analysis was performed separately for the variables groups of the four different domains, controlling for age, gender and body mass index. The overall predictive value was calculated for the full regression models of the different domains. Finally, all significant variables from the different domains were combined into a final predictor model.

Results

The final four-predictor model predicted 51 % of variance of persistent LBP and included ‘resigned attitude towards the job’ (OR 1.73; 95 % CI 1.16–2.59), ‘social support at work’ (OR 0.54; 95 % CI 0.32–0.90), ‘functional limitation’ (OR 1.05; 95 % CI 1.01–1.10) and ‘duration of LBP’ (OR 1.04; 95 % CI 1.02–1.06). The accuracy of the model was 83 %, with 92 % of non-persistent and 67 % of persistent LBP patients correctly identified.

Conclusions

In this study of patients with acute/subacute LBP, ‘resigned attitude towards the job’ increased the likelihood of persistent LBP at 6 month. Addressing this factor with workplace interventions has the potential to modify the outcome. In patients experiencing ‘social support at work’, the development of persistent LBP was less likely and might therefore be considered as potential resource for prevention of persistent LBP.

     

Managed care and primary physician satisfaction

BACKGROUND: We examined whether physician compensation, financial incentives, and care management tools were associated with primary physician job and referral satisfaction. Our study was guided by a conceptual model of physician satisfaction derived from published evidence. METHODS: A cross-sectional survey was performed of 495 primary physicians (family practitioners, general practitioners, general internists) in the Seattle metropolitan area in 1997. RESULTS: Bivariate analyses revealed that salary compensation, productivity bonuses, and withholds for referrals were associated with job and referral dissatisfaction. However, after controlling for physician, practice, and office characteristics, only the association between salary payment and job dissatisfaction remained significant. Practice in offices with more physicians had the strongest association with physician job dissatisfaction. CONCLUSIONS: Although managed care features are correlated with physician job and referral dissatisfaction, the source of dissatisfaction may originate from being an employed physician in a large medical group with more physicians, which may be more likely to impose bureaucratic controls that limit physician autonomy.     

Program factors that influence utilization of adult day care.

Health planners, policymakers, and providers urgently require methods and information that explain the factors that affect health services utilization. This information is especially critical for planning programs that are effective in maintaining the burgeoning elderly population in community care. In this study, correlation and regression analyses examined the characteristics of adult day care (ADC) centers that were associated with utilization as operationalized by demand for and actual attendance in 822 centers. Community, client population, services and activities, and structural characteristics were associated with demand per center whereas the social environment of the ADC center was not. The attendance rate was most strongly affected by services and activities and structural characteristics. The significance of the study, its limitations, and future directions for research are discussed.     

Chronic pain in primary care. Identification and management of psychosocial factors

Chronic pain is a problem of great public health importance that is frequently seen in the primary care setting. Pain chronicity shows a strong association with psychosocial factors. Assessment of these factors should be composed of two parts: (1) psychological factors and (2) psychiatric illness. Psychological factors include all those pain-associated alterations in the patient's environment that reinforce illness behavior. Psychiatric illness includes those syndromes that retard recovery from illness or injury, such as depression, anxiety, substance abuse, and dementia. Psychiatric and psychological interventions can be successfully introduced in the context of a comprehensive rehabilitation effort. Usually these interventions can be accomplished by the family physician in concert with a consultant psychiatrist or psychologist. In severely disabled or resistant patients, referral to a multidisciplinary pain clinic will be necessary.