National primary care research & development centre




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NATIONAL PRIMARY CARE RESEARCH & DEVELOPMENT CENTRE


LIBRARY AND INFORMATION SERVICE




CURRENT AWARENESS BULLETIN



JULY-AUGUST 2008




ACCESS TO CARE 2

CHRONIC ILLNESS 5

The National Health Service in England has invested substantially in recent years to improve the quality of primary care services for patients with chronic diseases such as diabetes. A key aim of this investment is to reduce associated complication rates and decrease consequent hospital admission rates. The goal of the study was to examine associations between the quality of primary care services and hospital admission rates for diabetes mellitus in England. An ecological cross-sectional study design was used. Three hundred three primary care trusts in England participated in the public reporting and performance-linked reimbursement of quality measures, including measures relevant to diabetes care. A total of 1,760,898 persons with diabetes registered with 8441 family practices in England. Hospital admission rates (total admissions for diabetes, admissions for ketoacidosis) were compared with quality of care scores, diabetes prevalence and neighborhood socio-economic status. We found a 10-fold variation across the country in total admissions for diabetes despite uniformly high scores on quality measures over the first year of the new family practitioner contract. Significant but weak inverse associations were found between primary care quality scores and hospital admission rates in patients aged 60 years and older, with a correlation coefficient of -0.21 (P < .001) between glycemic control and total admissions. Neighborhood socioeconomic status was more strongly correlated with total hospital admission rates than quality scores in patients aged 25-59 years (r = 0.58; P < .001) and 60 years and older (r = 0.45; P < .001). Quality of care scores and prevalence data were available only at the practice level rather than at the patient level. Improving the quality of primary care services may lead to modest reductions in demand for hospital services among older patients with diabetes. However, low neighborhood socioeconomic status is more strongly associated with hospital admission rates for diabetes 7

COMPLEMENTARY MEDICINE 16

EMPOWERMENT 17

EVIDENCE BASED MEDICINE 18

HEALTH ECONOMICS 19

INFORMATION AND COMMUNICATION TECHNOLOGIES 22

MEDICINES MANAGEMENT 26

MENTAL HEALTH 28

NEED AND DEMAND FOR CARE 40

ORGANISATIONS 41

PATIENT AND PUBLIC INVOLVEMENT 42

PRIMARY/SECONDARY CARE INTERFACE 47

QUALITY OF CARE 48

RESEARCH AND DEVELOPMENT 58

SELF MANAGEMENT 64

SERVICE ORGANISATION AND DELIVERY 66

SOCIAL CAPITAL 67

WORKFORCE 68



As far as possible, a digital object identifier and PubMed identifier has been provided for each citation. Depending on subscription access rights, the doi should go straight to the article. Please inform the Library is these urls do not work, so the matter can be investigated. Thank you. These citations have been derived from PubMed.

ACCESS TO CARE



Giesen P, et al Rude or aggressive patient behaviour during out-of-hours GP care: Challenges in communication with patients. Patient Education and Counseling Online 10 July 2008;

http://dx.doi.org/10.1016/j.pec.2008.04.009

http://pmid.us/18547777

Objective GPs in out-of-hours care report that they feel at risk of rude or aggressive patient behaviour. We tried to get information about the incidence, types and patient characteristics of rude or aggressive behaviour.Methods Retrospective, observational study involving the analysis of medical records of all patients who contacted a Dutch GP cooperative between June 2001 and June 2002.Results Of the 36,259 patient records, 545 (1.5%) reported rude behaviour, 67 (0.2%) reported verbal aggression and physical aggression was not reported. Anxiety, sorrow, or pain was reported by patients in 49.7% of the cases with rude or aggressive behaviour. The conflict topic between patients and professional was mostly the request of a home visit (21.8%), or a centre consultation (17.3%). Patients with mental health problems (OR 2.3 CI 1.8-3.1) were more at risk for rude or aggressive behaviour.Conclusion Rude and aggressive behaviour on GP cooperatives occurs relative seldom and is associated with anxiety, sorrow, and pain. The wish to see a doctor instead getting a telephone advice is a frequent conflict topic between patient and professional.Practice implications The findings suggest that improved communication at the telephone, particularly exploring the expectation, needs and worries of patients, may reduce aggressive behaviour


Kay M, et al. Doctors as patients: a systematic review of doctors' health access and the barriers they experience. British Journal of General Practice 2008 58. (552) 501-508

http://dx.doi.org/10.3399/bjgp08X319486

http://pmid.us/18611318

Background The need to improve doctors' access to health care by reducing the barriers they experience has been regularly described in the literature, yet the barriers experienced are not well defined, despite the volume of expert opinion in this area. Aim To define what is known about doctors' access to health care from the data within the current literature. Design of study A systematic review of studies of doctors' health access. Method A systematic search of MEDLINE® and CINAHL, supplemented by citation searches and searches of the grey literature, identified both quantitative and qualitative studies. Two reviewers used specific criteria for inclusion of studies and quality assessment. The data were tabulated and analysed. Results Twenty-six articles met the inclusion criteria. The paucity of data and the overall poor quality of those data are highlighted. Despite this, many doctors appear to have a GP, but this does not ensure adequate health access. Systemic barriers to healthcare access (long hours and cultural issues) are more significant than individual barriers. Conclusion Expert opinion in this field is supported by poor-quality data. The current knowledge reveals important similarities between doctors and the general population in their healthcare access, especially with mental health issues. Understanding this may help the medical profession to respond to these issues of `doctors' health' more effectively.

Mehrotra A, Keehl-Markowitz L, Ayanian JZ. Implementing open-access scheduling of visits in primary care practices: a cautionary tale. Annals of Internal Medicine 2008 148 (12) 915-22.

http://pmid.us/18559842

Background: Open-access scheduling (also known as advanced access or same-day access) is a popular tool for improving patient access to primary care appointments. Objective: To assess the effect of open-access scheduling and describe the barriers to implementing the open-access scheduling model in primary care. Design: Case series. Setting: Boston, Massachusetts, metropolitan area. ParticipantS: 6 primary care practices studied from October 2003 through June 2006. Intervention: Implementation of open-access scheduling. Measurements: Time to third available appointments, no-show rates, and patient and staff satisfaction with appointment availability. Results: 5 of 6 practices were able to implement open-access scheduling. Within 4 months of implementation, these 5 practices substantially reduced their mean wait for third available appointments from 21 to 8 days for 15-minute visits and from 39 to 14 days for 30-minute visits. However, none of the 5 practices attained the goal of same-day access, and waits for third available appointments increased during 2 years of follow-up. No consistent changes in patient or staff satisfaction or patient no-show rates were found. Barriers to implementation included decreases in appointment supply from provider leaves of absence and departures and increases in appointment demand when practices reopened to new patients after initial implementation of open-access scheduling. Limitations: The study lacked control practices. The small number of practices and providers precluded formal statistical comparisons. Conclusion: In 5 of 6 primary care practices, implementation of open-access scheduling improved appointment access in some practices. However, none was able to achieve same-day access and patient and staff satisfaction and patient no-show rates were unchanged. Broader evaluation of open-access scheduling in primary care is needed


Rodriguez HP, et al Physician effects on racial and ethnic disparities in patients' experiences of primary care. Journal of General Intern Medicine 24th July 2008 .

http://dx.doi.org/10.1007/s11606-008-0732-8

http://pmid.us/18651194


Background: Few studies have clarified the mechanisms that contribute to racial and ethnic disparities in primary care quality among comparably-insured patients. Objective: To examine relative contribution of "between-" and "within-" physician effects on disparities in patients' experiences of primary care. Design: Regression models using physician fixed effects to account for patient clustering were specified to assess "between-" and "within-"physician effects on observed racial and ethnic disparities in patients' experiences of primary care. Participants: The Ambulatory Care Experiences Survey (ACES) was administered to patients visiting 1,588 primary care physicians (PCPs) from 27 California medical groups. The analytic sample included 49,861 patients (31.4 per PCP) who confirmed a PCP visit during the preceding 12 months. Main results: Most racial and ethnic minority groups were significantly clustered within physician practices (p < 0.001). "Between-physician" effects were mostly negative and larger than "within-physician" effects for Latinos, Blacks, and American Indian/Alaskan Natives, indicating that disparities are mainly attributable to patient clustering within physician practices with lower performance on patient experience measures. By contrast, "within-physician" effects accounted for most disparities for Asians and Pacific Islanders, indicating these groups report worse experiences relative to Whites in the same practices. Practices with greater concentration of Blacks, Latinos and Asians had lower performance on patient experience measures (p < 0.05). Conclusions: Targeting patient experience improvement efforts at low performing practices with high concentrations of racial and ethnic minorities might efficiently reduce disparities. Urgent study is needed to assess the contribution of "within-" and "between-" physician effects to racial and ethnic disparities in the technical quality of primary care


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Turnbull J, et al. Does distance matter: geographical variation in GP out-of-hours service use: an observational study. British Journal of General Practice 2008 58 (552) 471-7.

http://dx.doi.org/10.3399/bjgp08X319431

http://pmid.us/18611312

Background GP cooperatives are typically based in emergency primary care centres, and patients are frequently required to travel to be seen. Geography is a key determinant of access, but little is known about the extent of geographical variation in the use of out-of-hours services. Aim To examine the effects of distance and rurality on rates of out-of-hours service use. Design of study Geographical analysis based on routinely collected data on telephone calls in June (n = 14 482) and December (n = 19 747), and area-level data. Setting Out-of-hours provider in Devon, England serving nearly 1 million patients. Method Straight-line distance measured patients' proximity to the primary care centre. At area level, rurality was measured by Office for National Statistics Rural and Urban Classification (2004) for output areas, and deprivation by The Index of Multiple Deprivation (2004). Results Call rates decreased with increasing distance: 172 (95% confidence interval [CI] = 170 to 175) for the first (nearest) distance quintile, 162 (95% CI = 159 to 165) for the second, and 159 (95% CI = 156 to 162) per thousand patients/year for the third quintile. Distance and deprivation predicted call rate. Rates were highest for urban areas and lowest for sparse villages and hamlets. The greatest urban/rural variation was in patients aged 0-4 years. Rates were higher in deprived areas, but the effect of deprivation was more evident in urban than rural areas. Conclusion There is geographical variation in out-of-hours service use. Patients from rural areas have lower call rates, but deprivation appears to be a greater determinant in urban areas. Geographical barriers must be taken into account when planning and delivering services.


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