Comparison of patients' and general practitioners' evaluations of general practice care

Objectives: To compare patients' and general practitioners' (GPs') evaluations of the quality of general practice care.

Design: Written surveys among patients and GPs.

Setting: General practice in the Netherlands.

Subjects: 1772 patients (from 45 GPs) and a random sample of 315 GPs.

Main outcome measures: Patients' and GPs' evaluations of 23 aspects of general practice care and GPs' perceptions of patients' evaluations using a 5 point scale.

Results: The response rate was 88% in the patient sample and 63% in the GP sample. The patients' ratings of care were significantly more positive (mean 4.0) than those of the GPs (mean 3.7) as well as GPs' perceptions of patients' evaluations (mean 3.5) (p<0.001). The overall rank order correlations between the patients' evaluations, GPs' evaluations, and GPs' perceptions of the patients' evaluations were 0.75 or higher (p<0.001). Patients and practitioners gave the most positive evaluations of specific aspects of the doctor-patient relationship ("keeping patients' records and data confidential", "listening to patients", and "making patients feel they had enough time during consultations") and aspects of the organisation of care ("provide quick service for urgent health problems" and "helpfulness of the staff (other than the doctor)"). The aspects of care evaluated least positively by patients as well as by GPs were other organisational aspects ("preparing patients for what to expect from specialist or hospital care" and "getting through to practice on the telephone").

Conclusions: GPs and patients have to some extent a shared perspective on general practice care. However, GPs were more critical about the quality of care than patients and they underestimated how positive patients were about the care they provide. Furthermore, specific aspects of care were evaluated differently, so surveys and other consultations with patients are necessary to integrate their perspective into quality improvement activities.

     

Comparison of health care professionals' self-assessments of standards of care and patients' opinions on the care they received in hospital: observational study

Objectives: To compare the views of healthcare professionals and patients regarding compliance with standards of care concerning patient information.

Design: Self-rated questionnaire survey.

Setting: Nine wards in short stay French hospitals.

Participants: 939 patients and 359 healthcare professionals (physicians, nurses, assistants and other professionals).

Main outcome measure: Patients' and healthcare professionals' views of compliance with 20 standards of patient care described in the French accreditation manual. Comparison of the rank order of the standards within the two samples.

Results: The response rate was 61.5% in the patient group and 85.8% in the healthcare professionals. The rank orders for the 20 items were similar in both groups (Spearman rank order correlation 0.6, p = 0.004). The two items ranked highest by healthcare professionals ("consent request for a surgical procedure" and "the doctors ask the visitors to leave the room before examining a patient") were also the two ranked highest by the patients. Three items were ranked low by both groups: "consent request for students to be present", "health education given to patients", and "possibility to express satisfaction during discharge". Patients were more satisfied with their pain management than were healthcare providers. Professionals were more satisfied with the social services than the patients.

Conclusion: There are both similarities and differences between patients' and healthcare professionals' views of care. Accurate assessments of quality performed during the accreditation procedure require that both patients' and professionals' views be taken into account.

     

Patient and nurse assessment of quality of care in postoperative pain management

Objective: To describe and compare patient and nurse assessments of the quality of care in postoperative pain management, to investigate differences between subgroups of patients, and to compare patient assessments in different departments.

Design: Patient and nurse questionnaires.

Setting: Five surgical wards in general surgery, orthopaedics, and gynaecology in a central county hospital in Sweden.

Sample: Two hundred and nine inpatients and 64 registered nurses. The response rates were 96% for the patients and 99% for the nurses; there were 196 paired patient-nurse assessments.

Method: The Strategic and Clinical Quality Indicators in Postoperative Pain Management patient questionnaire was used which comprises14 items in four subscales (communication, action, trust, and environment). The items were scored on a 5 point scale with higher values indicating a higher quality of care. Five complementary questions on levels of pain intensity and overall satisfaction with pain relief were scored on an 11 point scale. Twelve of the 14 items in the patient questionnaire and two of the complementary questions were adjusted for use in the nurse questionnaire.

Results: The patients' mean (SD) score on the total scale (scale range 14–70) was 58.6 (8.9) and the nurses' mean (SD) score (scale range 12–60) was 48.1 (6.2). The percentage of patients who scored 1 or 2 for an individual item (disagreement) ranged from 0.5% to 52.0%, while for nurses the percentage ranged from 0.0% to 34.8%. Forty two patients (24%) reported more pain than they expected; these patients assessed the quality of care lower. There were differences between patient and nurse assessments concerning the environment subscale, the question on overall satisfaction, and patients' experience of worst possible pain intensity.

Conclusion: The results provided valuable baseline data and identified important areas for quality improvement in postoperative pain management.

     

Patients' Evaluation of the Quality of Diabetes Care (PEQD): development and validation of a new instrument

Objectives: To develop a brief measure of patients' evaluation of the quality of diabetes care and to study predictors of consumers' rating of the quality of diabetes care.

Design: A prospective design.

Subjects: 176 adults with type 1 (39%) or type 2 (61%) diabetes.

Main measures: Demographic variables, HbA_1c, number of diabetes complications, satisfaction with diabetes care, diabetes related distress, and fear of hypoglycaemia were assessed by self-report. In addition, satisfaction with diabetes care and evaluations about quality of the care were measured at 16 month follow up. Statistical analysis comprised principal component analyses, Cronbach's alpha, t tests, Pearson's correlation, and linear regression analyses.

Results: Results in the literature were used to develop the 14 items of the Patients' Evaluation of the Quality of Diabetes Care (PEQD) scale, assessing the most important aspects of the quality of diabetes care as delivered by the specialist in internal medicine (internist) and the diabetes nurse specialist (DNS). Two principal components analyses (internist/DNS) both yielded one 14 item factor with a high internal consistency. Satisfaction with diabetes care, fewer diabetes related complications, fewer treatment related problems, and a low level of worries about hypoglycaemia were predictors of a more positive evaluation of diabetes care delivered by the internist. Sociodemographic variables were not related to the patients' evaluations of the quality of diabetes care.

Conclusions: The PEQD comprises different aspects of quality of diabetes care and can be regarded as a suitable instrument for evaluating patients' judgements about the quality of their care.

     

The effectiveness, acceptability and costs of a hospital-at-home service compared with acute hospital care: a randomized controlled trial

OBJECTIVE: To compare the safety, effectiveness, acceptability and costs of a hospital-at-home programme with usual acute hospital inpatient care. METHOD: Patients aged 55 years or over being treated for an acute medical problem were randomized to receive either standard inpatient hospital care or hospital-at-home care. Follow-up was for 90 days after randomization. Health outcome measures included physical and mental function, self-rated recovery, health status as assessed by the SF-36, adverse events and readmissions to hospital. Acceptability was assessed using satisfaction surveys and the Carer Strain Index. Costs comprised hospital care, care in the home, community services, general practitioner services and personal health care expenses. RESULTS: In all, 285 people were randomized with a mean age of 80 years. There were no significant differences in health outcome measures between the two randomized groups. Significantly more patients receiving care at home reported high levels of satisfaction, as did more of their relatives. Relatives of the care-at-home group also reported significantly lower scores on the Carer Strain Index. However, the mean cost per patient was almost twice for patients treated at home (NZ 6524 dollars) as for standard hospital care (NZ 3525 dollars). A sensitivity analysis indicated that, if the service providing care in the home had been operating at full capacity, the mean cost per patient episode would have been similar for both modes of care. CONCLUSIONS: This hospital-at-home programme was found to be more acceptable and as effective and safe as inpatient care. While caring for patients at home was significantly more costly than standard inpatient care, this was largely due to the hospital-at-home programme not operating at full capacity.     

QUOTE-HIV: an instrument for assessing quality of HIV care from the patients' perspective

Background: An HIV-specific version of the QUOTE questionnaire was developed to measure the quality of care of patients infected with HIV from the patients' perspective. The consistency and validity of the questionnaire was assessed.

Methods: Focus group discussions were held to select aspects for inclusion in the questionnaire that are important to patients with HIV. Item and inter-item analysis, factor analysis, and reliability analysis were performed to test the internal consistency and validity of the questionnaire.

Results: Twenty seven items (13 generic and 14 HIV specific) were used in the QUOTE-HIV questionnaire. Separate factor analyses of the generic and HIV specific aspects indicated that each loaded onto a single factor. The internal consistency of the total questionnaire was good (Cronbach's alpha &ge;0.80). Feasibility of the questionnaire was shown by the diversity of importance and performance scores for general practitioners as well as for HIV specialists and AIDS nursing consultants.

Conclusion: The QUOTE-HIV questionnaire is a useful instrument for measuring the quality of care from the perspective of HIV infected patients.

     

Team structure, team climate and the quality of care in primary care: an observational study

Objectives: To determine whether practice structure (for example, list size, number of staff) predicts team processes and whether practice structure and team process in turn predict team outcomes

Design: Observational study using postal questionnaires and medical note audit. Team process was assessed through a measure of "climate" which examines shared perceptions of organisational policies, practices, and procedures.

Setting: Primary care.

Subjects: Members of the primary health care team from 42 practices.

Main outcome measures: Objective measures of quality of chronic disease management, patients' evaluations of practices, teams' self-reported ratings of effectiveness, and innovation.

Results: Team climate was better in singlehanded practices than in partnerships. Practices with longer booking intervals provided superior chronic disease management. Higher team climate scores were associated with superior clinical care in diabetes, more positive patient evaluations of practice and self-reported innovation and effectiveness.

Conclusions: Although the conclusions are preliminary because of the limited sample size, the study suggests that there are important relationships between team structure, process, and outcome that may be of relevance to quality improvement initiatives in primary care. Possible causal mechanisms that might underlie these associations remain to be determined.

     

Influence of length of stay on patient satisfaction with hospital care in Japan.

OBJECTIVE: The objective of this study was to identify specific patient satisfaction items related to overall satisfaction by different length of stay (LOS) for patients in Japanese hospital settings. METHODS: This cross-sectional study involved a participant sample, drawn from 77 voluntarily participating hospitals throughout Japan, of in-patients discharged to the community. Older patients and psychiatric, pediatric, obstetric and gynecologic patients were excluded. The 1050 respondents analyzed (response rate > or = 5l.1%) were divided into three groups based on their LOS: group 1, LOS < or = 1 week; group 2, LOS < or = 1 month; and group 3, LOS > 1 month. Using stepwise multiple regression analysis, we explored for each LOS group the relationship between overall patient satisfaction and satisfaction with 33 individual items, including three regarding perceived reputation of the hospital in question. RESULTS: Some unique satisfaction items for each group (e.g. 'skill of nursing care' in group 1, 'Recovery of physical health', 'skill of nursing care', and 'respect for patients opinions and feelings' in group 2, and 'relief from pain' and 'respect for patients' opinions and feelings' in group 3) were significantly associated with overall satisfaction. In all three groups, common items (e.g. 'recovery from distress and anxiety' and 'doctor's clinical competence') also related significantly to overall satisfaction. Two items pertaining to the hospital reputation dimension (e.g. 'family member's evaluation of the hospital' and 'hospital reputation among other patients') were also significant predictors of overall satisfaction in all three groups. CONCLUSION: The findings show that according to LOS, unique items could determine significantly the achievement of overall satisfaction, while some common predictors across all three LOS groupings also seemed to be indispensable for inpatient's assessment of hospital care. It was also confirmed in this study that a positive perception of hospital reputation might have an important role in patient satisfaction in Japan.     

Quality Ratings of a Hospital Foodservice Department by Inpatients and Postdischarge Patients

Objectives To examine quality of food and nutrition services using the ratings of inpatients and patients who had been discharged (postdischarge patients).Design Questionnaires were used to collect perceptions of inpatients and postdischarge patients on the quality of food and nutrition services. A 5-point scale allowed subjects to rate quality from very poor to very good.Subjects Questionnaires were completed by 252 inpatients and 437 postdischarge patients of a midwestern teaching hospital.Statistical analysis Analysis of variance was used to assess differences in quality ratings on the basis of demographic variables. Stepwise regression was used to determine variables that best predicted overall satisfaction. Paired t tests were conducted to compare matched inpatient and postdischarge ratings.Results Ratings of food and nutrition services indicated that patients were satisfied; few differences were found in ratings on the basis of patient demographics. Food quality was the best predictor of overall satisfaction for both inpatients and postdischarge patients. As patient expectations were increasingly met or exceeded, patient ratings of quality increased. The majority of patients in the matched sample gave the same ratings on the inpatient and postdischarge questionnaires.Applications Foodservice managers who desire to improve patient satisfaction should focus attention on meeting or exceeding patient expectations for food quality. J Am Diet Assoc. 1998;98:1303–1307.     

Public hospital admissions for treating complications of clinical care: incidence,costs and funding strategy

Objective: To quantify the frequency of, and the costs and payments associated with, admissions for treatment of injuries and illnesses that are consequences of care. Data sources: Routinely‐coded 2005/06 public hospital inpatient data from Victoria, Australia (1.25 million admissions) and corresponding patient‐level cost data (1.04 million admissions). Payments reflected DRG‐based prospective rates. Study design: Retrospective analysis of admissions with principal diagnoses that specify adverse events arising as a direct consequence of healthcare. Results: 1.5% (15,336) of the costed admissions specifically treat an injury or illness arising from medical or surgical care, consuming 2.74% of hospital prospective payments and representing $89.3 m (2.84%) of total reported costs. 1.4% (17,429) of all public hospital admissions and 2.82% of hospital prospective payments (estimated cost‐$101.5 m per year) are committed to treating complications of care. Private residences or aged care facilities are the source of 84.9% (14,804) of these admissions. Inpatient death was the outcome in 0.7% (118) of these admissions. Implications: Admissions for treating complications of care represent a small, relatively expensive, proportion of hospital admissions, which account for disproportionate levels of hospital costs and funding. A policy option providing incentives to reduce the incidence and costs of complications arising from care includes allocating all costs arising from transferred (re)admissions back to the original episode of care and developing a suite of specific DRGs to fund admissions for treatment of complications.     

Patient judgment of the quality of ambulatory care in a Japanese setting

OBJECTIVE: To assess patient satisfaction with a hospital-based ambulatory service in Japan and define the determinants of satisfaction and the patient's intention to return to the service. DESIGN: A questionnaire was developed to measure overall satisfaction, intention to return to the service, patient judgment about the structure/process of the service, patient perception about the global reputation of the service, and other health-related items. The questionnaire was mailed to patients attending the ambulatory service. SETTING AND PATIENTS: All non-psychiatric patients who used the ambulatory service of a 350-bed general hospital in Tokyo in the sampling days were asked to participate. The response rate was 77.2% (1,307 responses). Of these, 1,074 non-proxy and non pediatric responses were used for the main analysis. RESULTS: Based on content analysis and factor analysis, scores for the service components were constructed and found to have high internal consistency and reliability. The results indicated several important points regarding the use of patients' evaluation of ambulatory services as a quality monitoring tool. It was shown that patients' overall satisfaction and intention to return to the same physician were determined primarily by their evaluation of their doctor's conduct and their perceived health outcome. The perceived reputation of the service also was a significant determinant of patient satisfaction and intention to return. Patient satisfaction and intention to return to the hospital were influenced also by non-physician factors such as nurses, clerks, and environmental comforts. Notably, patient intention to return was linked with patient perceived need of care and regularity of care. In multiple-regression results, patient satisfaction with the doctor and with the hospital had different determinants.     

Patient satisfaction with occupational health physicians, development of a questionnaire

Aims: To develop a questionnaire that measures specific aspects of patient satisfaction with occupational health physicians.

Methods: General patient satisfaction questionnaires, a literature survey, and interviews with patients were used. An initial questionnaire was distributed among sick listed patients (n = 432) of occupational physicians (n = 90) from different occupational health services. To reduce items and to develop scales exploratory factor analysis and reliability analysis was used. A linear regression model was used to predict satisfaction ratings from the scales of the questionnaire.

Results: Questions about independence of the occupational physician were difficult to ask unambiguously. The factor analysis revealed five relevant factors which were named "being taken seriously as a patient", "attitude towards occupational health services", "trust and confidentiality", "expectations", and "comfort and access". All scales could be reduced to a maximum of five items without reducing the scale reliability too much. In the regression analysis, 71% of the variance of satisfaction ratings was explained by the first four scales and most by the first scale. "Comfort and access" did not contribute significantly to the model.

Conclusions: A short questionnaire was developed to measure different aspects of patient satisfaction specific for occupational health. Whether the questionnaire can effectively lead to quality improvement in occupational health services should be investigated.

     

Patient satisfaction with care is associated with personal choice of physician

OBJECTIVE: To evaluate whether choosing one's own primary care doctor is associated with patient satisfaction with primary health care. To evaluate factors related to population's satisfaction with primary health care. POPULATION: A random sample of Estonian adult population (N=997). STUDY DESIGN: Cross-sectional study using a pre-categorized questionnaire which was compiled by the research group of the University of Tartu and the research provider EMOR. RESULTS: Altogether 68% of the respondents had been listed in their personal physician. Their overall satisfaction with the physician as well as satisfaction with several aspects of primary health care were significantly higher compared with those of unregistered respondents. Although some other factors (practice size, patient age, health status) also influenced patient satisfaction, presence of a personal physician appeared the most important predictor of high satisfaction with physician's punctuality and understanding, effectiveness of prescribed therapy, clarity of explanations given by the physician as well as with overall satisfaction with the physician. CONCLUSION: Personal doctor system is associated with patient satisfaction with different aspects of care.     

On Swallowing the Surgeon

ABSTRACT

Objective: To determine patient, hospital, and clinical characteristics associated with the length of stay (LOS), total hospital charges, and total hospital costs in cystic fibrosis (CF).

Methods: Hospital discharge records with primary and secondary diagnoses of CF were identified from the 2012 Kids’ Inpatient Database (KID) consisting of inpatient records of ages 0–20 years; and 2012 National Inpatient Sample (NIS) consisting of inpatient records of ages 21 and above. Both the databases are part of the Healthcare Cost and Utilization Project (HCUP). Patient demographics, hospital characteristics, clinical characteristics, and outcome measures from KID and NIS were utilized in the analyses. Univariate and multivariate statistical analyses were conducted using IBM SPSS Statistics 24.0.

Results: A total of 3142 and 10,258 CF-related hospital discharges were identified from 2012 KID and 2012 NIS databases, respectively. Among children, the mean (SD) LOS was 9.79 (10.51) days with a mean hospital costs of $26,249.23 (40,592.81). Adults had a mean LOS of 8.54 (8.42) days with a mean hospital costs of $21,600.91 (31,997.52). Number of procedures and total comorbidities were identified as the most important predictors of LOS, total hospital charges, and total hospital costs in both datasets.

Conclusions: Hospitalizations contribute significantly to the economic burden of CF. As inpatient costs in CF vary by patient, clinical, and hospital characteristics, healthcare decision makers need to utilize a targeted approach in different age groups to reduce hospital admission rates and the overall economic burden of CF.     

Clinical practice guidelines in dentistry: opinions of dental practitioners on their contribution to the quality of dental care

Objectives: To assess the opinions of general dental practitioners regarding the development and importance of clinical practice guidelines and their contribution to the quality of dental care.

Methods: A questionnaire was sent to a representative sample of 1656 dentists in the Netherlands. Factor analysis was conducted to identify scales of variables, and a reliability analysis was conducted to verify the reliability of the identified scales. The effect of the independent variables is expressed as odds ratio per scale part (standard deviation, SD). Regression analyses were conducted to study determinants of the opinions on clinical guidelines.

Results: The response rate was 73%; 54% of the respondents supported the development of clinical practice guidelines for dentists. Most respondents indicated that clinical practice guidelines could be used as a checklist, as a support in daily clinical decision making, and as a basis for continuing dental education. The factor analyses yielded four scale factors—contribution of guidelines to effectiveness of care (OR 1.95/SD), contribution of guidelines to professional autonomy (OR 1.70/SD), contribution of guidelines to quality of care (OR 2.52/SD), and contribution of guidelines to collaboration (OR 1.49/SD)—which complied with the criterion of Cronbach's alpha >0.60. Multiple regression analysis with the four scale factors as dependent variables yielded only extremely low correlations for practice and dentist characteristics (R²=0.01–0.04).

Conclusions: Only about 50% of dentists support the development and implementation of clinical guidelines. Guidelines are seen as helpful in the provision of continuing dental education and as a support in daily clinical decision making. The most important barrier to successful implementation of clinical practice guidelines is the fear of dental practitioners that guidelines will reduce their professional autonomy. Practice and dentist characteristics are unrelated to dentists' opinions on clinical practice guidelines.

     

Quality indicators for primary care mental health services

Objectives: To identify a generic set of face valid quality indicators for primary care mental health services which reflect a multi-stakeholder perspective and can be used for facilitating quality improvement.

Design: Modified two-round postal Delphi questionnaire.

Setting: Geographical spread across Great Britain.

Participants: One hundred and fifteen panellists representing 11 different stakeholder groups within primary care mental health services (clinical psychologist, health and social care commissioner, community psychiatric nurse, counsellor, general practitioner, practice nurse/district nurse/health visitor, psychiatrist, social worker, carer, patient and voluntary organisations).

Main outcome measures: Face validity (median rating of 8 or 9 on a nine point scale with agreement by all panels) for assessing quality of care.

Results: A maximum of 334 indicators were rated by panels in the second round; 26% were rated valid by all panels. These indicators were categorised into 21 aspects of care, 11 relating to general practices and 10 relating to health authorities or primary care groups/trusts. There was variation in the total number of indicators rated valid across the different panels. Overall, GPs rated the lowest number of indicators as valid (41%, n=138) and carers rated the highest number valid (91%, n=304).

Conclusions: The quality indicators represent consensus among key stakeholder groups in defining quality of care within primary care mental health services. These indicators could provide a guide for primary care organisations embarking on quality improvement initiatives in mental health care when addressing national targets and standards relating to primary care set out in the National Service Framework for Mental Health for England. Although many of the indicators relate to parochial issues in UK service delivery, the methodology used in the development of the indicators could be applied in other settings to produce locally relevant indicators.

     

Patient safety features of clinical computer systems: questionnaire survey of GP views

Aim: To investigate general practitioners' (GPs') stated knowledge, use and training needs related to the patient safety features of computerised clinical systems in England.

Design: Questionnaire survey.

Subjects and setting: GPs from six English primary care trusts.

Outcome measures: GPs' views on the importance of specified patient safety features on their computer system; their knowledge of the presence of specified safety features; previous training and perceived future training needs.

Results: Three hundred and eighty one GPs (64.0%) completed and returned the questionnaire. Although patient safety features were considered to be an important part of their computer system by the vast majority of GPs, many were unsure as to whether the system they were currently using possessed some of the specified features. Some respondents erroneously believed that their computers would warn them about potential contraindications or if an abnormal dose frequency had been prescribed. Only a minority had received formal training on the use of their system's patient safety features.

Conclusions: Patient safety was an issue high on the agenda of this GP sample. The importance of raising GPs' awareness of both the potential use and deficiencies of the patient safety features on their systems and ensuring that appropriate training is available should not be underestimated.

     

Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit*

Problem: Need for improved sedation strategy for adults receiving ventilator support.

Design: Observational study of effect of introduction of guidelines to improve the doctors' and nurses' performance. The project was a prospective improvement and was part of a national quality improvement collaborative.

Background and setting: A general mixed surgical intensive care unit in a university hospital; all doctors and nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than 24 hours.

Key measures for improvement: Reduction in patients' mean time on a ventilator and length of stay in intensive care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of consequences of changes.

Strategies for change: Multiple measures (protocol development, educational presentations, written guidelines, posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if beneficial.

Effects of change: Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from 7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (–0.9 to 2.9 days) from 9.3 days to 8.3 days. No accidental extubations or other incidents were identified.

Lessons learnt: Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement.

     

Patient satisfaction in Bangkok: the impact of hospital ownership and patient payment status.

INTRODUCTION: Patient satisfaction with care received is an important dimension of evaluation that is examined only rarely in developing countries. Evidence about how satisfaction differs according to type of provider or patient payment status is extremely limited. OBJECTIVE: To (i) compare patient perceptions of quality of inpatient and outpatient care in hospitals of different ownership and (ii) explore how patient payment status affected patient perception of quality. METHODS: Inpatient and outpatient satisfaction surveys were implemented in nine purposively selected hospitals: three public, three private for-profit and three private non-profit. RESULTS: Clear and significant differences emerged in patient satisfaction between groups of hospitals with different ownership. Non-profit hospitals were most highly rated for both inpatient and outpatient care. For inpatient care public hospitals had higher levels of satisfaction amongst clientele than private for-profit hospitals. For example 76% of inpatients at public hospitals said they would recommend the facility to others compared with 59% of inpatients at private for-profit hospitals. This pattern was reversed for outpatient care, where public hospitals received lower ratings than private for-profit ones. Patients under the Social Security Scheme, who are paid for on a capitation basis, consistently gave lower ratings to certain aspects of outpatient care than other patients. For inpatient care, patterns by payment status were inconsistent and insignificant. CONCLUSIONS: The survey confirms, to some extent, the stereotypes about quality of care in hospitals of different ownership. The results on payment status are intriguing but warrant further research.     

Sustaining better diabetes care in remote indigenous Australian communities*

Problem: Inhabitants of Torres Strait Islands have the highest prevalence of diabetes in Australia and many preventable complications. In 1999, a one year randomised cluster trial showed improved diabetes care processes and reduced admissions to hospital when local indigenous health workers used registers, recall and reminder systems, and basic diabetes care plans, supported by a specialist outreach service. This study looked at whether those improvements were sustained two years after the end of the trial.

Design: Three year follow up clinical audit of 21 primary healthcare centres, and review of admissions to hospital in the previous 12 months.

Background and Setting: Remote indigenous communities in far north east Australia, population about 9600, including 921 people with diabetes.

Key Measures for Improvement: Number of people on registers, care processes (regular measures of weight, blood pressure, haemoglobin A1c, urinary protein concentration, and concentrations of serum lipids and creatinine), appropriate clinical interventions (drug treatment and vaccinations), and intermediate patient outcome measures (weight, blood pressure, and glycaemic control). Admissions to hospital.

Strategies for Change: Audit and feedback to clinicians and managers; provision of clinical guidelines and a clear management structure; workshops and training.

Effects of Change: The number of people on registers increased from 555 in 1999 to 921 in 2002. Most care processes and clinical interventions improved. The proportion of people with good glycaemic control (haemoglobin A1c 7%) increased from 18% to 25% in line with increased use of insulin (from 7% to 16%). The proportion of those with well controlled hypertension (< 140/90) increased from 40% to 64%. The proportion admitted to hospital with a diabetes related condition fell from 25% to 20%. Mean weight increased from 87 kg to 91 kg.

Lessons Learnt: In remote settings, appropriate management structures and clinical support for people with diabetes can lead to improvements in care processes, control of blood pressure, and preventable complications that result in admission to hospital. Control of weight and glycaemia are more difficult and requires more active community engagement. Priorities now include increasing the availability and affordability of good food, achieving weight loss, and increasing appropriate use of hypoglycaemic agents, including insulin.