How do general practitioners experience providing care to refugees with mental health problems? A qualitative study from Denmark

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Minor surgery in general practice and effects on referrals to hospital care: Observational study

<p>Abstract</p> <p>Background</p> <p>Strengthening primary care is the focus of many countries, as national healthcare systems with a strong primary care sector tend to have lower healthcare costs. However, it is unknown to what extent general practitioners (GPs) that perform more services generate fewer hospital referrals. The objective of this study was to examine the association between the number of surgical interventions and hospital referrals.</p> <p>Methods</p> <p>Data were derived from electronic medical records of 48 practices that participated in the Netherlands Information Network of General Practice (LINH) in 2006-2007. For each care-episode of benign neoplasm skin/nevus, sebaceous cyst or laceration/cut it was determined whether the patient was referred to a medical specialist and/or minor surgery was performed. Multilevel multinomial regression analyses were used to determine the relation between minor surgery and hospital referrals on the level of the GP-practice.</p> <p>Results</p> <p>Referral rates differed between diagnoses, with 1.0% of referrals for a laceration/cut, 8.2% for a sebaceous cyst and 10.2% for benign neoplasm skin/nevus. The GP practices performed minor surgery for a laceration/cut in 8.9% (SD:14.6) of the care-episodes, for a benign neoplasm skin/nevus in 27.4% (SD:14.4) of cases and for a sebaceous cyst in 26.4% (SD:13.8). GP practices that performed more minor surgery interventions had a lower referral rate for patients with a laceration/cut (-0.38; 95%CI:-0.60- -0.11) and those with a sebaceous cyst (-0.42; 95%CI:-0.63- -0.16), but not for people with benign neoplasm skin/nevus (-0.26; 95%CI:-0.51-0.03). However, the absolute difference in referral rate appeared to be relevant only for sebaceous cysts.</p> <p>Conclusions</p> <p>The effects of minor surgery vary between diagnoses. Minor surgery in general practice appears to be a substitute for specialist medical care only in relation to sebaceous cysts. Measures to stimulate minor surgery for sebaceous cysts may induce substitution.</p

A qualitative assessment of implementing a cross-cultural survey on cancer wards in Denmark - a description of barriers

<p>Abstract</p> <p>Background</p> <p>Research into migration and health is often confronted with methodological challenges related to the identification of migrants in various settings. Furthermore, it is often difficult to reach an acceptable level of participation among migrant groups in quantitative research. The aim of this study is to conduct a qualitative assessment of the barriers encountered during the implementation of a cross-cultural survey on cancer wards in Copenhagen, Denmark.</p> <p>Methods</p> <p>Participant observation at the involved wards was combined with qualitative interviews with selected nurses and informal talks with a wider group of nurses at the wards involved in the survey.</p> <p>Results</p> <p>One possible way to increase the participation of migrant patients in research is through the involvement of the hospital staff in contact with patients. Involvement of nurses on cancer wards in the delivery of questionnaires to patients was challenging, despite a general willingness to participate in psychosocial research. The main difficulties were found to be both external (policy changes, general strike among nurses) and internal on the wards (heavy workload, lack of time, focus on medical aspects of cancer rather than psychosocial aspects). These factors interacted and resulted in a lower priority being given to psychosocial research. Further, nurses expressed a feeling that researchers in general did not recognize their contribution in research, making it more difficult to engage fully in studies.</p> <p>Conclusions</p> <p>Involving hospital staff in research is feasible but not straightforward. Awareness of the influence of possible external and internal factors and efforts to deal with these factors are fundamental to the successful implementation of psychosocial cancer research in a hospital setting.</p

Does long-term care use within primary health care reduce hospital use among older people in Norway? A national five-year population-based observational study

<p>Abstract</p> <p>Background</p> <p>Population ageing may threaten the sustainability of future health care systems. Strengthening primary health care, including long-term care, is one of several measures being taken to handle future health care needs and budgets. There is limited and inconsistent evidence on the effect of long-term care on hospital use. We explored the relationship between the total use of long-term care within public primary health care in Norway and the use of hospital beds when adjusting for various effect modifiers and confounders.</p> <p>Methods</p> <p>This national population-based observational study consists of all Norwegians (59% women) older than 66 years (N = 605676) (13.2% of total population) in 2002-2006. The unit of analysis was defined by municipality, age and sex. The association between total number of recipients of long-term care per 1000 inhabitants (LTC-rate) and hospital days per 1000 inhabitants (HD-rate) was analysed in a linear regression model. Modifying and confounding effects of socioeconomic, demographic and geographic variables were included in the final model. We defined a difference in hospitalization rates of more than 1000 days per 1000 inhabitants as clinically important.</p> <p>Results</p> <p>Thirty-one percent of women and eighteen percent of men were long-term care users. Men had higher HD-rates than women. The crude association between LTC-rate and HD-rate was weakly negative. We identified two effect modifiers (age and sex) and two strong confounders (travel time to hospital and mortality). Age and sex stratification and adjustments for confounders revealed a positive statistically significant but not clinically important relationship between LTC-rates and hospitalization for women aged 67-79 years and all men. For women 80 years and over there was a weak but negative relationship which was neither statistically significant nor clinically important.</p> <p>Conclusions</p> <p>We found a weak positive adjusted association between LTC-rates and HD-rates. Opposite to common belief, we found that increased volume of LTC by itself did not reduce pressure on hospitals. There still is a need to study integrated care models for the elderly in the Norwegian setting and to explore further why municipalities far away from hospital achieve lower use of hospital beds.</p

Equity and health policy in Africa: Using concept mapping in Moore (Burkina Faso)

<p>Abstract</p> <p>Background</p> <p>This methodological article is based on a health policy research project conducted in Burkina Faso (West Africa). Concept mapping (CM) was used as a research method to understand the local views of equity among stakeholders, who were concerned by the health policy under consideration. While this technique has been used in North America and elsewhere, to our knowledge it has not yet been applied in Africa in any vernacular language. Its application raises many issues and certain methodological limitations. Our objective in this article is to present its use in this particular context, and to share a number of methodological observations on the subject.</p> <p>Methods</p> <p>Two CMs were done among two different groups of local stakeholders following four steps: generating ideas, structuring the ideas, computing maps using multidimensional scaling and cluster analysis methods, and interpreting maps. Fifteen nurses were invited to take part in the study, all of whom had undergone training on health policies. Of these, nine nurses (60%) ultimately attended the two-day meeting, conducted in French. Of 45 members of village health committees who attended training on health policies, only eight were literate in the local language (Moore). Seven of these (88%) came to the meeting.</p> <p>Results</p> <p>The local perception of equity seems close to the egalitarian model. The actors are not ready to compromise social stability and peace for the benefit of the worst-off. The discussion on the methodological limitations of CM raises the limitations of asking a single question in Moore and the challenge of translating a concept as complex as equity. While the translation of equity into Moore undoubtedly oriented the discussions toward social relations, we believe that, in the context of this study, the open-ended question concerning social justice has a threefold relevance. At the same time, those limitations were transformed into strengths. We understand that it was essential to resort to the focus group approach to explore deeply a complex subject such as equity, which became, after the two CMs, one of the important topics of the research.</p> <p>Conclusion</p> <p>Using this technique in a new context was not the easiest thing to do. Nevertheless, contrary to what local organizers thought when we explained to them this "crazy" idea of applying the technique in Moore with peasants, we believe we have shown that it was feasible, even with persons not literate in French.</p

Do list size and remuneration affect GPs' decisions about how they provide consultations?

Background: Doctors' professional behaviour is influenced by the way they are paid. When GPs are paid per item, i.e., on a fee-for-service basis (FFS), there is a clear relationship between workload and income: more work means more money. In the case of capitation based payment, workload is not directly linked to income since the fees per patient are fixed. In this study list size was considered as an indicator for workload and we investigated how list size and remuneration affect GP decisions about how they provide consultations. The main objectives of this study were to investigate a) how list size is related to consultation length, waiting time to get an appointment, and the likelihood that GPs conduct home visits and b) to what extent the relationships between list size and these three variables are affected by remuneration. Methods: List size was used because this is an important determinant of objective workload. List size was corrected for number of older patients and patients who lived in deprived areas. We focussed on three dependent variables that we expected to be related to remuneration and list size: consultation length; waiting time to get an appointment; and home visits. Data were derived from the second Dutch National Survey of General Practice (DNSGP-2), carried out between 2000 and 2002. The data were collected using electronic medical records, videotaped consultations and postal surveys. Multilevel regression analyses were performed to assess the hypothesized relationships. Results: Our results indicate that list size is negatively related to consultation length, especially among GPs with relatively large lists. A correlation between list size and waiting time to get an appointment, and a correlation between list size and the likelihood of a home visit were only found for GPs with small practices. These correlations are modified by the proportion of patients for whom GPs receive capitation fees. Waiting times to get an appointment tend to become shorter with increasing patient lists when there is a larger capitation percentage. The likelihood that GPs will conduct home visit rises with increasing patient lists when the capitation percentage is small. Conclusion: Remuneration appears to affect GPs' decisions about how they provide consultations, especially among GPs with relatively small patient lists. This role is, however, small compared to other factors such as patient characteristics.

Gender differences in the utilization of health-care services among the older adult population of Spain

BACKGROUND: Compared to men, women report greater morbidity and make greater use of health-care services. This study examines potential determinants of gender differences in the utilization of health-care services among the elderly. METHODS: Cross-sectional study covering 3030 subjects, representative of the non-institutionalized Spanish population aged 60 years and over. Potential determinants of gender differences in the utilization of health services were classified into predisposing factors (age and head-of-family status), need factors (lifestyles, chronic diseases, functional status, cognitive deficit and health-related quality of life (HRQL)) and enabling factors (educational level, marital status, head-of-family employment status and social network). Relative differences in the use of each service between women and men were summarized using odds ratios (OR), obtained from logistic regression. The contribution of the variables of interest to the gender differences in the use of such services was evaluated by comparing the OR before and after adjustment for such variables. RESULTS: As compared to men, a higher percentage of women visited a medical practitioner (OR: 1.24; 95% confidence limits (CL): 1.07–1.44), received home medical visits (OR: 1.67; 95% CL: 1.34–2.10) and took ≥3 medications (OR: 1.54; 95% CL: 1.34–1.79), but there were no gender differences in hospital admission or influenza vaccination. Adjustment for need or enabling factors led to a reduction in the OR of women compared to men for utilization of a number of services studied. On adjusting for the number of chronic diseases, the OR (95% CL) of women versus men for ingestion of ≥3 medications was 1.24 (1.06–1.45). After adjustment for HRQL, the OR was 1.03 (0.89–1.21) for visits to medical practitioners, 1.24 (0.98–1.58) for home medical visits, 0.71 (0.58–0.87) for hospitalization, and 1.14 (0.97–1.33) for intake of ≥3 medications. After adjustment for the number of chronic diseases and HRQL, the OR of hospitalization among women versus men was 0.68 (0.56–0.84). CONCLUSION: The factors that best explain the greater utilization of health-care services by elderly women versus men are the number of chronic diseases and HRQL. For equal need, certain inequality was observed in hospital admission, in that it proved less frequent among women

An evaluation of access to health care services along the rural-urban continuum in Canada

<p>Abstract</p> <p>Background</p> <p>Studies comparing the access to health care of rural and urban populations have been contradictory and inconclusive. These studies are complicated by the influence of other factor which have been shown to be related to access and utilization. This study assesses the equity of access to health care services across the rural-urban continuum in Canada before and after taking other determinants of access into account.</p> <p>Methods</p> <p>This is a cross-sectional study of the population of the 10 provinces of Canada using data from the Canadian Community Health Survey (CCHS 2.1). Five different measures of access and utilization are compared across the continuum of rural-urban. Known determinants of utilization are taken into account according to Andersen's Health Behaviour Model (HBM); location of residence at the levels of province, health region, and community is also controlled for.</p> <p>Results</p> <p>This study found that residents of small cities not adjacent to major centres, had the highest reported utilisation rates of influenza vaccines and family physician services, were most likely to have a regular medical doctor, and were most likely to report unmet need. Among the rural categories there was a gradient with the most rural being least likely to have had a flu shot, use specialist physicians services, or have a regular medical doctor. Residents of the most urban centres were more likely to report using specialist physician services. Many of these differences are diminished or eliminated once other factors are accounted for. After adjusting for other factors those living in the most urban areas were more likely to have seen a specialist physician. Those in rural communities had a lower odds of receiving a flu shot and having a regular medical doctor. People residing in the most urban and most rural communities were less likely to have a regular medical doctor. Those in any of the rural categories were less likely to report unmet need.</p> <p>Conclusion</p> <p>Inequities in access to care along the rural-urban continuum exist and can be masked when evaluation is done at a very large scale with gross indicators of rural-urban. Understanding the relationship between rural-urban and other determinants will help policy makers to target interventions appropriately: to specific demographic, provincial, community, or rural categories.</p