To study people's views on the accessibility and continuity of primary medical care provided by different providers: a public primary healthcare centre (PPHC), occupational healthcare (OHC), and a private practice (PP).
A nationwide population-based questionnaire study.
A total of 6437 (from a sample of 10,000) Finns aged 15-74 years.
Period of time (in days) to get an appointment with any physician was assessed via a single structured question. Accessibility and continuity were evaluated with a five-category Likert scale. Values 4-5 were regarded as good.
Altogether 72% had found that they could obtain an appointment with a physician within three days, while 6% had to wait more than two weeks. Older subjects and subjects with chronic diseases perceived waiting times as longer more often than younger subjects and those without chronic diseases. The proportion of subjects who perceived access to care to be good was 35% in a PPHC, 68% in OHC, and 78% in a PP. The proportion of subjects who were able to get successive appointments with the same doctor was 45% in a PPHC, 68% in OHC, and 81% in a PP. A personal doctor system was related to good continuity and access in a PPHC.
Access to and continuity of care in Finland are suboptimal for people suffering from chronic diseases. The core features of good primary healthcare are still not available within the medical care provided by public health centres.
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A survey of adolescents with a chronic disease attending six specialty clinics was conducted to determine the sources of their primary health care and to estimate the extent of unmet health needs. Sixty-one patients completed a self-administered questionnaire. Forty percent had no source of primary care other than the subspecialty clinic treating their chronic condition. Seventy-eight percent regarded the subspecialist as their "personal" physician, although only 27% actually spoke to this physician about their general health needs. For 44% general health needs were not being met. These findings suggest that these adolescents expect the subspecialty clinic to provide primary care; yet they receive, at best, fragmented health care. This situation could be improved by a decision on the part of the subspecialty to restrict its role to providing only specific specialty care or to coordinate overall care.
Two urban community health centres in Vancouver and Prince George, BC.
Two hundred sixty-nine HIV-positive patients (18 years of age or older) who received primary care at either of the study sites.
Systematic implementation of the CCM during an 18-month period.
Documented pneumococcal vaccination, documented syphilis screening, documented tuberculosis screening, antiretroviral treatment (ART) status, ART status with undetectable viral load, CD4 cell count of less than 200 cells/mL, and CD4 cell count of less than 200 cells/mL while not taking ART compared during a 36-month period.
Overall, 35% of participants were women and 59% were aboriginal persons. The mean age was 45 years and most participants had a history of injection drug use that was the presumed route of HIV transmission. During the study follow-up period, 39 people died, and 11 transferred to alternate care providers. Compared with their baseline clinical status, study participants showed statistically significant (P
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The World Health Organization calls for more work evaluating the effect of health care reforms on gender equity in developed countries. We performed this evaluation in Ontario, Canada where primary care models resulting from reforms co-exist.
This cross sectional study of primary care practices uses data collected in 2005-2006. Healthcare service models included in the study consist of fee for service (FFS) based, salaried, and capitation based. We compared the quality of care delivered to women and men in practices of each model. We performed multi-level, multivariate regressions adjusting for patient socio-demographic and economic factors to evaluate vertical equity, and adjusting for these and health factors in evaluating horizontal equity. We measured seven dimensions of health service delivery (e.g. accessibility and continuity) and three dimensions of quality of care using patient surveys (n = 5,361) and chart abstractions (n = 4,108).
Health service delivery measures were comparable in women and men, with differences
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Helmholtz Zentrum Muenchen - German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, PO Box 1129, 85758 Neuherberg, Germany. email@example.com
BACKGROUND: Studies on the association between access to health care and household income have rarely included an assessment of 'forgone care', but this indicator could add to our understanding of the inverse care law. We hypothesize that reporting forgone care is more prevalent in low income groups. METHODS: The study is based on the 'Survey of Health, Ageing and Retirement in Europe (SHARE)', focusing on the non-institutionalized population aged 50 years or older. Data are included from France, Germany, Greece, Italy and Sweden. The dependent variable is assessed by the following question: During the last twelve months, did you forgo any types of care because of the costs you would have to pay, or because this care was not available or not easily accessible? The main independent variable is household income, adjusted for household size and split into quintiles, calculating the quintile limits for each country separately. Information on age, sex, self assessed health and chronic disease is included as well. Logistic regression models were used for the multivariate analyses. RESULTS: The overall level of forgone care differs considerably between the five countries (e.g. about 10 percent in Greece and 6 percent in Sweden). Low income groups report forgone care more often than high income groups. This association can also be found in analyses restricted to the subsample of persons with chronic disease. Associations between forgone care and income are particularly strong in Germany and Greece. Taking the example of Germany, forgone care in the lowest income quintile is 1.98 times (95% CI: 1.08-3.63) as high as in the highest income quintile. CONCLUSION: Forgone care should be reduced even if it is not justified by an 'objective' need for health care, as it could be an independent stressor in its own right, and as patient satisfaction is a strong predictor of compliance. These efforts should focus on population groups with particularly high prevalence of forgone care, for example on patients with poor self assessed health, on women, and on low income groups. The inter-country differences point to the need to specify different policy recommendations for different countries.
Adults with chronic medical conditions are more likely to report unmet health care needs. Whether unmet health care needs are associated with an increased risk of adverse health outcomes is unclear.
Adults with at least one self-reported chronic condition (arthritis, chronic obstructive pulmonary disease, diabetes mellitus, heart disease, hypertension, mood disorder, stroke) from the 2001 and 2003 cycles of the Canadian Community Health Survey were linked to national hospitalization data. Participants were followed from the date of their survey until March 31, 2005, for the primary outcomes of all-cause and cause-specific admission to hospital. Secondary outcomes included length of stay, 30-day and 1-year all-cause readmission to hospital, and in-hospital death. Negative binomial regression models were used to estimate the association between unmet health care needs, admission to hospital, and length of stay, with adjustment for socio-demographic variables, health behaviours, and health status. Logistic regression was used to estimate the association between unmet needs, readmission, and in-hospital death. Further analyses were conducted by type of unmet need.
Of the 51 932 adults with self-reported chronic disease, 15.5% reported an unmet health care need. Participants with unmet health care needs had a risk of all-cause admission to hospital similar to that of patients with no unmet needs (adjusted rate ratio [RR] 1.04, 95% confidence interval [CI] 0.94-1.15). When stratified by type of need, participants who reported issues of limited resource availability had a slightly higher risk of hospital admission (RR 1.18, 95% CI 1.09-1.28). There was no association between unmet needs and length of stay, readmission, or in-hospital death.
Overall, unmet health care needs were not associated with an increased risk of admission to hospital among those with chronic conditions. However, certain types of unmet needs may be associated with higher or lower risk. Whether unmet needs are associated with other measures of resource use remains to be determined.
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Communication between healthcare settings at patient transfers between primary and secondary care, 'handover', is a critical and risky process for patients. Patients' views on their roles in these processes are often lacking despite the knowledge that patient participation contributes to enhanced safety and wellbeing.
This study aims to improve the knowledge and understanding of patients' perspectives about their participation in handover.
Twenty-three Swedish patients with chronic diseases were individually interviewed about their experiences with handovers between three clinical microsystems: emergency room, emergency ward and primary healthcare centres. Data were analysed using inductive qualitative content analysis.
Patients participated within the microsystems by exchanging information, and between microsystems by making contact with and conveying information to their next healthcare provider. Enablers for participation included positive encounters with providers, patient empowerment and beliefs about organisational factors. Patients' trust in their providers, and providers' attitudes were important factors in patients' willingness to communicate. Patients who thought medical records access was shared across microsystems volunteered less information to their providers. Patients with experiences of non-effective handovers took more responsibility in the handover to ensure continuity of care.
Patients participate actively in handovers when they feel a need for involvement to ensure continuity of care, and are less active when they perceive that their contribution is unnecessary or not valued. In acute care settings with short hospital stays and less time to establish a trusting relationship between patients and their providers, discharge encounters may be important enablers for patient engagement in handovers. The advantages of a redundant handover process need to be considered.
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Capital Health in Edmonton, Alberta, implemented a system-wide chronic disease management model to support people with chronic disease and their primary care physicians. Groups of family physicians, in partnership with the health region, developed primary care networks to provide services that are customized to meet the priorities of the local community. Management of chronic disease is a cornerstone service, and diabetes management is the most fully developed program. Key to its success are standardized protocols, consistent follow-up and patient education by trained primary care nurses. This model will be used as a template for the management of other chronic diseases.