In 2001, the Ontario Ministry of Health and Long-Term Care introduced the Ontario Stroke Strategy by designating regional stroke centres across the province. The primary role of these centres is to coordinate stroke care within the region and across the care continuum in keeping with best practices. Concurrently, Trillium Health Centre was identifying best practice projects to support its ongoing quest for excellence. With Trillium designated as a regional stroke centre, acute ischemic stroke care was an obvious choice for a best practice project. The aim of the project was to improve access to care and quality of care for stroke patients from emergency through acute care to in-patient rehabilitation. The team chose the rapid cycle change methodology. This approach to quality improvement advocates the testing of a series of small changes (i.e., process improvement ideas) in tandem with measurements to assess the impact of the change to drive further process improvements. The project was deemed a success, resulting in significant improvements in the timeliness and quality of care.
This study examined the effects of environmental changes, such as rearranging the seating area, playing soft music, and displaying scenes of nature, on aspects of patient satisfaction, ranging from satisfaction with the physical environment and wait times to continuity of care, confidentiality, and trust in providers. Patients receiving care in a new, innovative cancer center had significantly higher satisfaction scores on the physical environment and wait time subscales than the patients receiving care in an older, traditional center. However, the 2 centers did not differ on any of the other satisfaction subscales. Implications of these findings are discussed.
After a stay in the intensive care unit, patients risk experiencing delusional memories, memory loss, and symptoms of posttraumatic stress. Since the 1990s, diaries have been kept for intensive care unit patients to help fill in memory gaps, aid psychosocial recovery, and improve health-related quality of life. More insight is needed into the application of diaries. The aim of our study was to explore how patients and relatives use diaries in the context of the illness trajectory.
Qualitative multicentered design using in-depth semistructured interview technique.
A nine-bed general intensive care unit and a 13-bed thoracic surgical intensive care unit in Denmark.
A sample of 19 patients at 6-12 months postintensive care unit discharge and 13 relatives (n = 32).
Intensive care diaries and handover 1 or 3 months postintensive care unit discharge.
Grounded theory method was used to explore the use of diaries as a psychosocial process of recovery involving patients and relatives. Data were managed by NVivo software. The core category was "constructing the illness narrative," which was a process of narration embedded in our emerging theory of psychosocial recovery after critical illness. The main categories within the patient perspective were information acquisition and gaining insight, and the main categories within the relative perspective were supporting the patient, supporting oneself, and negotiating access.
Intensive care diaries are useful to patients as well as their relatives. Patients need to construct their illness narrative, and diaries are among the sources they use. The patients' project was to combine various sources of information in a process of information acquisition, narration, and evolving insight progressing toward recovery. The relatives supported the patients' project and also supported themselves by using the diary to uphold their own healing process. We recommend intensive care diaries as a low-technology, low-cost rehabilitative intervention for patients and relatives to help bridge the span from intensive care to recovery.
This study compares continuity of care between Germany - a social health insurance country, and Norway - a national health service country with gatekeeping and patient lists for COPD patients before and after initial hospitalization. We also investigate how subsequent readmissions are affected.
Continuity of Care Index (COCI), Usual Provider Index (UPC) and Sequential Continuity Index (SECON) were calculated using insurance claims and national register data (2009-14). These indices were used in negative binomial and logistic regressions to estimate incident rate ratios (IRR) and odds ratios (OR) for comparing readmissions.
All continuity indices were significantly lower in Norway. One year readmissions were significantly higher in Germany, whereas 30-day rates were not. All indices measured one year after discharge were negatively associated with one-year readmissions for both countries. Significant associations between indices measured before hospitalization and readmissions were only observed in Norway - all indices for one-year readmissions and SECON for 30-day readmissions.
Our findings indicate higher continuity is associated with reductions in readmissions following initial COPD admission. This is observed both before and after hospitalization in a system with gatekeeping and patient lists, yet only after for a system lacking such arrangements. These results emphasize the need for policy strategies to further investigate and promote care continuity in order to reduce hospital readmission burden for COPD patients.
OBJECTIVE--To examine the relation between general practitioners' knowledge about their patients and the use of resources in consultations. DESIGN--A cross sectional evaluation of consultations. SETTING AND SUBJECTS--A representative sample of 133 Norwegian general practitioners were each asked to record 30 consecutive consultations. 131 did so, and of 3990 possible registrations, 3918 (98%) were evaluated. MAIN OUTCOME MEASURES--The influence, as assessed by the doctor, of accumulated knowledge on the use of laboratory tests, expectant management, prescriptions, sickness certification, referrals, and time spent in the consultation. RESULTS--Accumulated knowledge was a substantial factor in saving time, especially in consultations with children, the elderly, patients with psychosocial problems, and those with chronic diseases. It also influenced the overall use of laboratory tests, expectant management, sickness certification, and referrals, and to a lesser degree the use of medication. CONCLUSION--The findings imply strong but complex associations between accumulated knowledge and the use of resources in the consultation.
OBJECTIVE--To evaluate the influence of continuity of care on patient satisfaction with consultations. DESIGN--Direct and episodic specific evaluation of patient satisfaction with recent consultation. SETTING AND SUBJECTS--A representative sample of 3918 Norwegian primary care patients were asked to evaluate their consultations by filling in a questionnaire. The response rate was 78%. MAIN OUTCOME MEASURES--The patient's overall satisfaction with the consultation was rated on a six point scale. Continuity of care was recorded as the duration and intensity of the present patient-doctor relationship and as patients' perception of the present doctor being their personal doctor or not. RESULTS--The multivariate analysis indicated that an overall personal patient-doctor relationship increased the odds of the patient being satisfied with the consultation sevenfold (95% confidence interval 4.9 to 9.9) as compared with consultations where no such relationships existed. The duration of the patient-doctor relationship had a weak but significant association with patient satisfaction, while the intensity of contacts showed no such association. CONCLUSION--Personal, continuous care is linked with patient satisfaction. If patient satisfaction is accepted as an integral part of quality health care, reinforcing personal care may be one way of increasing this quality.
To examine the opportunity for first-year family medicine residents to experience continuity of care during family medicine block time and half-day returns.
Retrospective analysis of patient encounter data during the 1987-1988 and 1991-1992 academic years to determine how much contact residents had with repeat patients.
Two family medicine teaching centres in Edmonton.
First-year family medicine residents: 24 residents during 1987-1988 and 24 during 1991-1992.
Number of patient-resident contacts and number of repeat contacts.
During the 4-month block time and half-day return, residents had repeat contact with 25.9% and 20.3% of the patients seen. These patients provided 48.3% and 37.7% of all visits at Centres A and B, respectively.
Increasing block time from 2 to 4 months resulted in only a slight increase in repeat contact with patients. Half-day returns did not appear to enhance the opportunity for continuity of care.
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: We determine the cost-effectiveness of a 2-stage emergency department intervention in addition to usual ED care compared with that of usual care alone.
The intervention comprises 2 steps: (1) identification of high-risk patients by using a screening tool and (2) a brief standardized nursing assessment to identify unresolved problems, followed by referral to an appropriate community provider. The patient population was composed of individuals aged 65 years and older to be released from the EDs of 4 Montreal hospitals. Patients were randomized by day of ED visit. The perspective of the study is societal, including patients, caregivers, and the formal health care (government-funded) system. Outcomes, measured from randomization to 4 months after randomization, included (1) functional decline, as measured by an activities of daily living instrument, or death, and (2) changes in depressive symptoms. Costs include post-ED care, including hospitalization, physician services, community care, outpatient drugs, and patient and caregiver costs. Cost items were measured with administrative databases and self-reported questionnaires. Unit costs for these items were either province-wide rates or else were estimated directly by using provider data. Cost-effectiveness is assessed in qualitative terms, such that outcomes and costs are compared separately.
The intervention was associated with a reduced rate of functional decline (including death) at 4 months. There was no effect of the intervention on change in the patient's depressive symptoms at 4 months relative to baseline. The estimated ratio of overall costs per patient in the intervention versus the control group, adjusted for covariates, was 0.94 (95% credible interval 0.75 to 1.17). Among patients who had visited the ED during the 30 days before the index visit, the ratio was 0.66 (95% credible interval 0.44 to 0.97).
In this study setting, the intervention is preferred over usual care because beneficial functional outcomes were observed, and overall societal costs were no higher than if usual care only was given.
Division of Community Engagement, Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-115 Edmonton Clinic Health Academy, Edmonton, AB T6G 2C9, Canada. firstname.lastname@example.org
Adv Health Sci Educ Theory Pract. 2012 Oct;17(4):585-96
Building on other models of longitudinal integrated clerkships (LIC), the University of Alberta developed its Integrated Community Clerkship with guiding principles of continuity of care, preceptor and learning environment. Professionalism is an important theme in medical education. Caring is important in professional identity formation and an ethic of caring is a moral framework for caring. This study explored the development of an ethic of caring in an LIC using empathy, compassion and taking responsibility as descriptors of caring. Through a hermeneutic phenomenological study, the authors focused on students' accounts of being with patients. Following an iterative process of successive analyses and explorations of the relevant literature, sensitizing concepts related to physician identity, and an ethic of caring were used to make sense of these accounts following the principles of constructivist grounded theory methodology. Continuity afforded by the LIC results in a safe environment in which students can meaningfully engage with patients and take responsibility for their care under the supervision of a physician teacher. Together these attributes foster an emerging physician identity born at the site of patient-student interaction and grounded in an ethic of caring. A medical student's evolving professional identity in the clerkship includes the emergence of an ethic of caring. Student accounts of being with patients demonstrate that the LIC at the University of Alberta affords opportunities for students be receptive to and responsible for their patients. This ethic of caring is part of an emerging physician identity for the study participants.
Comment In: Adv Health Sci Educ Theory Pract. 2013 Mar;18(1):139-4023114459
Comment In: Adv Health Sci Educ Theory Pract. 2013 Mar;18(1):135-823114458