Physical limitations and self-rated overall health in family medicine patients

OBJECTIVE: To assess how physical limitations relate to self-rated health among family medicine patients after adjustment for severity of illness. DESIGN: A telephone survey of family medicine patients, linked with medical record information. SETTING: A large family medicine department in Rochester, Minnesota, USA. SUBJECTS: Self-ratings of health were linked to medical records for 804 adult patients. RESULTS: Adjusting for severity and other confounders using multiple logistic regression analysis revealed that having physical limitations was inversely and independently related to good self-rated health (adjusted odds ratio = 0.20, P<0.001). Odds ratios also were lower for high severity of illness (adjusted odds = 0.43). Morbidly obese patients and patients older than 65 years of age also had reduced odds of good self-rated health. CONCLUSIONS: In our sample of family medicine patients, part of the disparity in health status experienced by people with physical limitations is attributable to greater severity of illness, age and obesity.     

Understanding disparities in primary care patient experience

ObjectiveTo understand disparities in primary care patient experience.DesignA serial cross-sectional study was conducted to understand disparities in patient experience at 2 time points (2014 and 2016). Disparities related to age, gender, neighbourhood income, and self-rated health were explored using 3 analytic approaches: stratification, logistic regression, and relative comparison across multiple demographic variables.SettingA multisite family health team in Toronto, Ont.ParticipantsPatients in the family medicine practice who completed e-mail surveys in 2014 (n = 1171, 19% response rate) and 2016 (n = 1823, 15% response rate).Main outcome measuresPatient-reported access (timely access when sick, access after hours) and patient-centredness (opportunity to ask questions, involvement in care decisions, enough time with provider).ResultsPerformance for all measures improved between 2014 and 2016, with the greatest absolute improvement seen in access after hours (61% in 2014; 75% in 2016). Patients residing in low-income neighbourhoods reported worse patient experiences than those in high-income neighbourhoods did, as did patients with poor versus excellent self-rated health, even after adjustment for other variables. For example, in 2016, 60% of patients residing in low-income neighbourhoods reported timely access when sick versus 70% in high-income neighbourhoods (adjusted odds ratio of 0.67, 95% CI 0.47 to 0.95); 60% of patients with poor or fair self-rated health reported timely access when sick versus 72% with excellent self-rated health (adjusted odds ratio of 0.54, 95% CI 0.35 to 0.84). Comparing across demographic groups, patients with excellent self-rated health and poor or fair self-rated health reported the best and worst experiences, respectively, for all measures. In 2016, the average disparity between subgroups was largest for access after hours.ConclusionIn this setting, patient experience was worse for patients in lower-income neighbourhoods and those with poor or fair self-rated health. Access after hours demonstrated the greatest overall absolute improvement but also the greatest widening of disparities.     

Quality of life of cancer patients receiving inpatient and home-based palliative care

AIMS: This paper reports a comparative study of the symptom experience, physical and psychological health, perceived control of the effects of cancer and quality of life of terminally ill cancer patients receiving inpatient and home-based palliative care, and the factors that predict quality of life. BACKGROUND: Quality of life is a major goal in the care of patients with terminal cancer. In addition to symptom management, psychological care and provision of support, being cared for at home is considered an important determinant of patient well-being. A more comprehensive understanding of the impact of cancer on patients and their families will inform the delivery of palliative care services. METHODS: Fifty-eight patients with terminal cancer (32 inpatients, 26 home-based) were recruited from major palliative care centres in Australia in 1999. A structured questionnaire designed to obtain sociodemographic information, medical details and standard measures of symptoms, physical and psychological health, personal control and quality of life was administered by personal interview. RESULTS: The two groups were similar on most demographic measures, although more home-care patients were married, of Australian descent and had private health insurance cover. The most prevalent symptoms reported were weakness, fatigue, sleeping during the day and pain. Patients receiving home-based services had statistically significantly less symptom severity and distress, lower depression scores, and better physical health and quality of life than those receiving inpatient care. Home-care patients also reported statistically significantly more control over the effects of their illness, medical care and treatment received, and the course of the disease. Multiple regression analyses showed that better global physical health, greater control over the effects of cancer and lower depression scores were statistically significant predictors of higher quality of life. CONCLUSIONS: The main issues arising from the findings for nurses are the early detection and management of both physical and psychological symptoms, particularly fatigue, pain, anxiety and depression, and the need to use strategies that will empower patients to have a greater sense of control over their illness and treatment. Research is needed to identify other factors that may impact on quality of life, and to establish the extent to which inpatient and home-based care meets the needs of both the patient with terminal cancer and their family.     

Lack of ethnic disparities in adult immunization rates among underserved older patients in an urban public health system

BACKGROUND: In some settings, immunization rates for ethnic minorities are less than those of non-Hispanic white populations. This study examines demographic differences in the rate of pneumococcal and influenza immunization in an ethnically diverse older patient population seeking care at an urban primary care clinic system. METHODS: The setting is an integrated system of 11 federally qualified community health centers serving approximately 100,000 unduplicated patients annually. We linked data from chart audits performed in 2001-2003 for quality assurance purposes with patient registration data to evaluate vaccination rates in 740 patients age 66 years and older who had at least 3 primary care visits in the previous 2 years. RESULTS: Factors significantly associated with receipt of pneumococcal vaccination in multivariable analysis were Hispanic ethnicity (odds ratio [OR] 1.66-1.77, P = 0.01), medical comorbidities (OR 1.48, P = 0.03), psychiatric comorbidities (OR 2.0, P = 0.001), use of a family medicine versus internal medicine clinic (OR 2.3, P < 0.001), and age (OR 1.04 for 1 year increase, P = 0.004). Factors significantly associated with influenza vaccination were having insurance (OR 2.25, P = 0.014), medical comorbidities (OR 1.71, P = 0.036), age (OR 1.03 for 1 year increase, P = 0.045), later year of audit (OR 1.68-1.73, P = 0.015), and a greater number of clinic visits (OR 1.69, P = 0.006). CONCLUSIONS: Among older regular users of our public community health centers, minority populations have equal or higher immunization rates compared with non-Hispanic whites.     

Comparison of administrative data and medical records to measure the quality of medical care provided to vulnerable older patients

BACKGROUND: Administrative data are used to determine performance for publicly reported in health plan "report cards," accreditation status, and reimbursement. However, it is unclear how performance based on administrative data and medical records compare. METHODS: We compared applicability, eligibility, and performance on 182 measures of health care quality using medical records and administrative data during a 13-month period for a random sample of 399 vulnerable older patients enrolled in managed care. RESULTS: Of 182 quality indicators (QIs) spanning 22 conditions, 145 (80%) were applicable only to medical records and 37 (20%) to either medical records or administrative data. Among 48 QIs specific to geriatric conditions, all were applicable to medical records; 2 of these also were applicable to administrative data. Eligibility for the 37 QIs that were applicable to both medical records and administrative data was similar for both data sources (94% agreement, kappa = 0.74). With the use of medical records, 152 of the 182 the QIs that were applicable to medical records were triggered and yielded an overall performance of 55%. Using administrative data, 30 of the 37 QIs that were applicable to administrative data were triggered and yielded overall performance of 83% (P < 0.05 vs. medical records). Restricting to QIs applicable to both data sources, overall performance was 84% and 83% (P = 0.21) for medical records and administrative data, respectively. CONCLUSIONS: The number and spectrum of QIs that can be measured for vulnerable elderly patients is far greater for medical records than for administrative data. Although summary estimates of health care quality derived from administrative data and medical records do not differ when using identical measures, summary scores from these data sources vary substantially when the totality of care that can be measured by each data source is measured.     

Overall self-rated health as an outcome indicator in primary care

RATIONALE, AIMS AND OBJECTIVES: The ultimate goal of health care systems is to improve overall health from the patient's point of view. However, overall self-rated health is not routinely monitored as a performance indicator. The purpose of this study was to investigate the feasibility of using a measure normally employed in community health surveys as a quality indicator in primary care clinics. METHODS: In order to do so, we conducted a cross-sectional survey of community medicine patients treated in five clinics in Amarillo, Texas to test the theory that, in primary care patients, a single-item measure of self-rated health is significantly related to the usual risk factors found in community health surveys (environmental factors, demographic characteristics and health behaviours). RESULTS: Multiple logistic regression analysis revealed that age, race, frequent mental distress, current smoking and health confidence were independently related to the odds of reporting good health. CONCLUSION: Our results support using a single-item measure of self-rated health in primary care. Our data also suggest that encouragement of health confidence would appear to be in the best interests of patients.     

Asthma nurse practice improves outcomes and reduces costs in primary health care

OBJECTIVE: The aim of this study was to elucidate the care of patients with asthma in primary health care from medical, patient self-management, health, quality of life, and health economic perspectives. METHODS: Asthma nurse practice (ANP), an alternative asthma self-management strategy, was compared with traditional asthma care in primary health care in southern Sweden regarding medical history, lifestyle, self-management, symptoms caused by asthma, effects on sick leave, state of health, quality of life and health care costs. The first part of the investigation comprised a retrospective study of a randomly selected sample of patient records of asthmatics (n=152). The second part, lasting 3 months, was prospective and included consecutive patients visits (n=347). RESULTS: The ANP approach showed better results in most of the evaluated outcomes such as asthma quality documentation and self-management and the number of asthma symptoms was significantly lower. From a health economic perspective the results were encouraging with respect to ANP. CONCLUSION: This alternative asthma strategy, ANP, improved asthma care in primary health care and resulted in economic advantages in the health care sector. However the result may only be generalized to other practices working with asthma nurses in the same way.     

Patients and families experiences with video telehealth in rural/remote communities in Northern Canada

Aim. To explore patients’ and families’ experiences with video telehealth consultations as a method of health care delivery in rural/ remote communities in Northern Canada. Background. Accessing health services in isolated populations where human resources and infrastructure are constrained by vast geographical landmasses poses challenges and opportunities for nurses, health care providers, patients and families. Design. A qualitative approach was adopted with a purposeful sample of 10 patients and four family members representative of nine communities. Method. Selection criteria included patients receiving telehealth visits for a minimum of a year and willing to share their experiences. Data were collected during the winter of 2006 using semi‐structured video taped interviews and analysed using a qualitative thematic content analysis. Results. Patients and families experiences of their telehealth visits centered on three key themes: lessening the burden (costs of travel, accommodations, lost wages, lost time and physical limitations), maximising supports (access to family, friends, familiar home environment, nurses and other care providers), tailoring specific e‐health systems to enhance patient and family needs. Conclusion. The benefits of telehealth extend not only to patients and families but are linked to benefits for providers as well as the health care system. Relevance to clinical practice. This study indicates that video telehealth is an effective mechanism for delivering nursing and other health services to rural/remote communities and can impact positively on the quality of health care. The integration of telehealth practice can enhance the coordination, organisation and implementation of health care services.     

Impacts of patient characteristics on hospital care experience in 34,000 Swedish patients

ABSTRACT: BACKGROUND: Standardized patient surveys are widely used for assessing quality of healthcare from the patient perspective. An important purpose of such surveys is to identify disparities in care among different patient groups. The purpose of this study was to 1.) evaluate aspects of the validity of the adapted Swedish version of the Picker Patient Care Experience -15 (PPE-15) survey and 2.) examine the explanatory value of various socio-demographic and health characteristics in predicting patients' care experiences. METHODS: A retrospective cross-sectional study design was used. Patients discharged from internal medicine wards at regional and university hospitals in different parts of Sweden during 2010 were invited to participate in the regularly administered national care-experience survey for hospital care. The internal validity of the PPE-15 was assessed with Cronbach's alpha and item-scale correlations. Pearson product-moment correlation coefficients were used tocompare PPE-15 total scores with overall care satisfaction ratings and Spearman correlation coefficients were used to compare PPE-15 total scores with various patient characteristics. Multiple linear regression analysis was performed to examine the influence of various patient characteristics on PPE-15 scores. RESULTS: The response rate was 66% (n = 34 603). Cronbach's alpha was 0.87. The correlation between the PPE-15 total score and overall care satisfaction was high (0.62, p < 0.0001). Higher age, good self-rated health (SRH) and having Swedish as native language were associated with better care experiences and poorer experiences with greater healthcare utilization, functional impairment and being female. All examined characteristics, except language, were significant predictors in the regression model and SRH was the strongest predictor; however, the model explained only 7% of the total variance. Vulnerable patients (i.e. poor SRH and functional impairment) reported significantly less positive care experiences than did non-vulnerable patients (mean PPE-15 score 75 vs 85; p < 0.0001). CONCLUSIONS: Our results supported the internal validity of the Swedish adapted version of the PPE-15. The explanatory value of the examined patient socio-demographic and health characteristics was low, suggesting the need for exploring other patient-related determinants of care experiences. Our findings also suggest a care paradox: patients in greatest need of hospital care are least satisfied with the quality of the care they receive.     

Determinants of complementary alternative medicine (CAM) use

OBJECTIVE: The aim of this study was to describe the pattern of use of complementary alternative medicine (CAM) and identify the determinants of CAM use in a multi-ethnic Swedish primary health care practice population. METHODS: A questionnaire was handed out to 1433 patients aged 16 years and above who visited the Jordbro Health Centre (JHC) in Stockholm, Sweden, between 14 January and 30 June 2002. The results were linked to computerised medical records. RESULTS: Seventeen percent of respondents had consulted a CAM provider during the preceding year and many patients had consulted several types of CAM providers. The most frequently CAM used was massage, followed by acupuncture, chiropractic and naprapathy. In the logistic regression, when adjusting for the influence of possible confounders, chronic disease and physical activity were the most important predictors of consultations with CAM providers. Users of CAM had had a higher number of consultations with medical professionals than had non-users of alternative medicine. CONCLUSIONS: In our study population CAM, defined here as "manual therapy", was used in addition to traditional therapies and was related to high use of health care services. Chronic disease and physical activity were significantly and independently related to use of CAM.     

Overall self-rated health: a new quality indicator for primary care

RATIONALE, AIMS AND OBJECTIVES: Patient 'empowerment' gives patients choices about their own care and about the outcomes they would most prefer. Many patients can be presumed to regard overall self-rated health as an important outcome. Therefore, overall self-rated health can be considered a relevant and important outcome measure for a patient-centred medical clinic. The purpose of this study was to use this new outcome measure as a dependent variable and to test the hypothesis that patients who are confident about their ability to manage their health will have better health, in comparison to more dependent patients. METHODS: We conducted a randomized cross-sectional postal survey of 500 veteran patients from the Panhandle of Texas and the surrounding areas; and 302 participated in the study. Multiple logistic regression analysis was used to test the hypothesis that health confidence is positively related to self-rated health, controlling for obesity, cigarette smoking and participation in recreational activities. RESULTS: Veterans who strongly disagreed with the statement that they usually could overcome illnesses on their own were less likely to report good, very good or excellent self-rated health (adjusted odds ratio=0.25). CONCLUSIONS: Overall self-rated health as measured by a single question proved to be significantly related to behavioural risk factors in this sample of primary care patients, attesting to its validity as an outcome indicator. Furthermore, health confidence was associated with better health. Most primary providers believe that they can, through good communication and providing self-care tools, increase healthy behaviours in their patients. If we are indeed able to increase health confidence in our patients, this study would suggest that self-rated health would improve.     

Postacute care organizations: a solution for Medicare risk HMOs.

A postacute care organization is a company that contracts with HMOs and other types of insurers and risk-bearing groups to ensure the health plan's appropriate and cost-effective use of medical services available outside of the hospital setting. Through proactive and intensive case management of patients and postacute care providers, these organizations minimize inappropriate or unnecessary hospitalizations and deliver the following results to clients: reduced overall medical costs; higher quality postacute care services; increased plan retention of members through increased patient, family, and provider satisfaction. Postacute care organizations represent a solution for Medicare Risk HMOs and other health plans who are experiencing great difficulty in managing the financial risk and operational challenges related to their benefit plans for higher risk groups. Coordinated Care Solutions, Inc. (CCS) is an example of a company meeting the rapidly growing demand for postacute care management services. This article describes why there is a need for these services and studies CCS's model of delivering postacute care management services and value to its clients.     

EVIDENCE – BASED MEDICINE/PRACTICE IN SPORTS PHYSICAL THERAPY

A push for the use of evidence‐based medicine and evidence‐based practice patterns has permeated most health care disciplines. The use of evidence‐based practice in sports physical therapy may improve health care quality, reduce medical errors, help balance known benefits and risks, challenge views based on beliefs rather than evidence, and help to integrate patient preferences into decision‐making. In this era of health care utilization sports physical therapists are expected to integrate clinical experience with conscientious, explicit, and judicious use of research evidence in order to make clearly informed decisions in order to help maximize and optimize patient well‐being. One of the more common reasons for not using evidence in clinical practice is the perceived lack of skills and knowledge when searching for or appraising research. This clinical commentary was developed to educate the readership on what constitutes evidence‐based practice, and strategies used to seek evidence in the daily clinical practice of sports physical therapy.     

Dissatisfaction and insecurity of patients in domiciliary care

This paper is based on material from two domiciliary care studies undertaken in Finland. The purpose of this paper is to clarify on one hand the patient factors which relate to dissatisfaction and insecurity and on the other hand the significance of dissatisfaction and insecurity in patient care. The data were collected by interviewing patients (Helsinki: 129, Espoo: 215), by devising a care plan in Espoo and directing a questionnaire to the domiciliary care providers (Helsinki: 202, Espoo: 64). About one in 10 of the patients was dissatisfied and insecure. Correlation between dissatisfaction and insecurity was high (Helsinki: r = 0.63***, Espoo: r = 0.53***). The dissatisfaction was associated more with external factors, which appeared as a behaviour perceived by others. The quality of human relationships in care was the main predicting factor of the variance of dissatisfaction. Insecurity again was linked more with internal factors. The main factor which predicted the variance of insecurity was the quality of human relationships in care but also the well-planned goal-oriented care. A dissatisfied patient who actually feels insecure, can be perceived as being unco-operative, non-compliant and unpopular by care providers.     

Patient characteristics, practice activities, and one-month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medicine physicians: a practice-based feasibility study

BACKGROUND: Chronic low-back pain is a significant public health problem for which few therapies are supported by predictable outcomes. In this report, practice activities and 1-month outcomes data are presented for 93 chiropractic patients and 45 medical patients with chronic, recurrent low-back pain. DESIGN: A prospective, observational, community-based feasibility study involving chiropractors and family medicine physicians. SETTING: Forty private chiropractic clinics, the outpatient clinic of the Department of Family Medicine at Oregon Health Sciences University, and 5 other Portland area family medicine clinics. Outcomes Measures: The main outcome measures were pain severity, functional disability, sensory and affective pain quality at 1 month, and patient satisfaction assessed at 7 to 10 days and at 1 month. RESULTS: Although differences were noted in age, sex, education, and employment, the patients were closely matched at baseline with respect to frequency, severity, and type of low-back pain and the psychosocial dimensions of general health. The treatment of choice for chiropractors was spinal manipulation and physical therapy modalities; for medical physicians antiinflammatory agents were most frequently used. Chiropractic patients averaged 4 visits, and medical patients averaged 1 visit. On average, chiropractic patients showed improvement across all outcomes: 31% change in pain severity, 29% in functional disability, 36% in sensory pain quality, and 57% in affective pain quality. Medical patients showed minimal improvement in pain severity (6%) and functional disability (1%) and showed deterioration in the sensory (29%) and affective (26%) dimensions of pain quality. Satisfaction scores were higher for chiropractic patients. Outcomes for medical patients were heavily dependent on psychosocial status at baseline. CONCLUSION: Patients with chronic low-back pain treated by chiropractors show greater improvement and satisfaction at 1 month than patients treated by family physicians. Nonclinical factors may play an important role in patient progress. Findings from the Health Resources and Services Administration-funded project will include a report on the influence of practice activities, including more frequent visits by chiropractic patients, on the clinical course of low-back pain and patient outcomes. (J Manipulative Physiol Ther 2000;23:239-45).     

1例地震伤致植物生存状态患者的护理

探讨对植物生存状态患者实施整体护理后的效果.对一例由5.12汶川地震致植物生存状态患者从预防并发症、长期坚持促醒护理、家属健康教育并参与护理等方面对患者实施有针对性的整体护理,使患者得到最大程度的康复.经过近2年的治疗和护理,患者目前为止无尿路感染、肺部感染、褥疮等并发症发生,并且由最初的护理人员照顾模式成功转型为家属照顾模式,有利于患者更好地回归家庭、回归社会.对植物生存状态患者实施有针对性的整体护理,并对患者家属实施有效的心理护理及健康教育,有助于促进患者的全面康复,预防并发症,改善患者及家属的生活质量,维持家庭的社会功能,降低医疗消耗.     

1例地震伤致植物生存状态患者的护理

探讨对植物生存状态患者实施整体护理后的效果.对一例由5.12汶川地震致植物生存状态患者从预防并发症、长期坚持促醒护理、家属健康教育并参与护理等方面对患者实施有针对性的整体护理,使患者得到最大程度的康复.经过近2年的治疗和护理,患者目前为止无尿路感染、肺部感染、褥疮等并发症发生,并且由最初的护理人员照顾模式成功转型为家属照顾模式,有利于患者更好地回归家庭、回归社会.对植物生存状态患者实施有针对性的整体护理,并对患者家属实施有效的心理护理及健康教育,有助于促进患者的全面康复,预防并发症,改善患者及家属的生活质量,维持家庭的社会功能,降低医疗消耗.     

General practitioners' attitudes towards patients with disabilities: the need for training and support

PURPOSE: Some general practitioners (GPs) report discomfort in caring for people with disabilities. These feelings may impede the provision of quality health care to these patients. METHOD: A cross-sectional survey interviewed 600 GPs in southeastern France and assessed their personal and professional characteristics, their attitudes and opinions towards people with disabilities, and their knowledge and practices in this field. RESULTS: 21.3% of the GP reported discomfort in treating people with mental impairments and 8.2% people with physical impairments. Discomfort with either type of impairment was more frequent among GPs who perceived frequent communication problems with persons with disabilities (p < 0.05) or who did not belong to a professional network (p < 0.10). GPs who reported less experience with the disabled patients (p < 0.05), no medical training about disabilities (p = 0.04), a lack of assistance during consultations (p = 0.02), and inadequate consultation time (p = 0.09) expressed more discomfort in caring for patients with mental impairments. GPs' discomfort was associated with their assessment of the patient's level of disability among patients with physical impairments (p = 0.01). CONCLUSION: This study suggests that substantial obstacles related to GPs' attitudes impede the delivery of quality health care to patients with disabilities and that GPs need more support and guidance in dealing with them. These results raise also the issue of adequate time and remuneration for consultations with these patients.     

Measuring case-mix and outcome for older people in acute hospital care across Europe: the development and potential of the ACMEplus instrument

AIM: To identify case-mix variables measured shortly after admission to be included in a patient classification system (ACMEplus) that best explains hospital outcome for older people in different health care systems. DESIGN: Observational prospective cohort study collecting patient factors (sociodemographics, functional, mental, clinical, administrative and perceived health) at different time assessments. METHODS: Multicentre study involving eight hospitals in six European countries (United Kingdom, Spain, Italy, Finland, Greece and Poland). It included consecutive patients aged 65 years or older admitted to hospital for acute medical problems. Main outcome measures: discharge status, hospital readmission, mortality and length of stay. RESULTS: Of the 1667 included patients (mean age = 78.1 years; male gender = 43.5%) two-third had at least one 'Geriatric Giant' (immobility, confusion, incontinence or falls) on admission or shortly after. The most frequently affected system was cardiovascular (29.2%) and 31% of patients declared poor or very poor health. Mean length of stay was 17.9 days, 79% of patients were discharged to their usual residence; in-hospital and 1-month follow up mortality were 7.4% and 11.6%, respectively. Physical function explained the highest variation (between 8% and 21%), followed by cognitive status and number of Geriatric Giants, for almost all outcomes except readmission. CONCLUSION: Factors other than diagnosis (physical function, cognition and presenting problems) are important in predicting key outcomes of acute hospital care for older people and are consistent across countries. Their inclusion in a standardized system of measurement may be a way of improving quality and equity of medical care in older people.