Commentaries on health services research

Skin cancer control in the primary care setting: are we making any progress?

Exploring the Potential Causes of the Emergence of Hospitalists: Chicken vs. Egg

Family Physicians Sue to Shine Light on RUC Deliberations, Claim Specialists Skew Reimbursement Against Primary Care

Health care reform should be driven by the goals of better patient experience, improved population health, lower per capita costs, and improved provider satisfaction. Electronic consultation (eConsult) services have been adopted by several jurisdictions in the United States, Canada, and Europe to improve access to specialists by primary care providers (PCPs) and are being heralded as a key component for delivery of coordinated care. The primary intent of an eConsult service is to provide PCPs with efficient, timely, direct access to specialist expertise to help guide the management of their patients, reduce the need for unnecessary face-to-face specialty consultations, and improve the quality of the initial face-to-face consultation when needed, through the preconsultative communication.In addition to improving access to care, eConsult services have been praised by PCPs and specialists for their educational value, in particular their ability to enrich practice-based learning. Less recognized, but equally important from the educational perspective, include the abilities of eConsult programs to promote reflection by PCPs and specialists, improve collegiality and professionalism between primary and specialist care, inform continuing professional development activities and maintenance of certification, and enhance training programs' teaching of effective communication and care coordination.As eConsult services become increasingly available, the medical community must leverage the educational opportunities inherent in eConsult programs to further improve the delivery of coordinated specialty care. The educational role of eConsults should be considered as a priority outcome in their evaluation and must be highlighted and optimized in next iterations of eConsult systems design.

BackgroundIn the current context of increasingly fragmented healthcare systems where patients are seen by multiple doctors in different settings, patients’ relational continuity with one doctor is regaining relevance; however little is known about relational continuity with specialists. The aim of this study is to explore perceptions of relational continuity with primary care and secondary care doctors, its influencing factors and consequences from the viewpoint of users of the Catalan national health system (Spain).MethodsWe conducted a descriptive-interpretative qualitative study using a two-stage theoretical sample; (i) contexts: three healthcare areas in the Catalan national health system with differing characteristics; (ii) informants: users 18 years or older attended to at both care levels. Sample size (n = 49) was reached by saturation. Data were collected by individual semi-structured interviews, which were audio recorded and transcribed. A thematic content analysis was carried out segmenting data by study area, and leaving room for new categories to emerge from the data.ResultsPatients across the areas studied generally experienced consistency of primary care doctors (PCD), alongside some inconsistency of specialists. Consistency of specialists did not seem to be relevant to some patients when their clinical information was shared and used. Patients who experienced consistency and frequent visits with the same PCD or specialist described and valued having established an ongoing relationship characterised by personal trust and mutual accumulated knowledge. Identified consequences were diverse and included, for example, facilitated diagnosis or improved patient-doctor communication. The ascription to a PCD, a health system-related factor, facilitated relational continuity with the PCD, whereas organizational factors (for instance, the size of the primary care centre) favoured consistency of PCD and specialists. Doctor-related factors (for example, high technical competence or commitment to patient care) particulary fostered the development of an ongoing relationship.ConclusionsConsistency of doctors differs depending on the care level as does the relevance attributed to it. Most influencing factors can be applied to both care levels and might be addressed by healthcare managers to foster relational continuity. More research is needed to fully understand the relevance patients assign to relational continuity with specialists.

Medical Malpractice in Gastroenterology

Emotions and medicine. What do patients expect from their physicians?

Perceptions of primary health care physicians about the prescription of antibiotics in Saudi Arabia: Based on the model of Theory of planned behaviour

IntroductionIn Switzerland, primary care physicians (PCP) often disregard guideline recommendations and prescribe antibiotics to treat self-limiting infections,1–3 but when PCPs who participated in quality circles (QC) were informed by the...

Hospitalists and primary care.

The contributions of primary care to improvements in many aspects of population and individual health are well documented (Starfield, Shi, and Macinko 2005). In addition to the health benefits, there are reductions in health system costs and reductions in disparities in health across population subgroups. The findings are robust over time and across areas and health systems. International comparisons show that countries with health systems based on strong primary care have better health at lower costs. Studies within countries, including both industrialized as well as middle income and developing countries, are consistent in showing greater improvements in health consequent to legislative and administrative policy initiatives directed at strengthening primary care, including increases in the supply and use of primary care practitioners and clinical improvements in primary care practice. The special and critical features of primary care are well known and include first contact access and use of primary care facilities and practitioners; person-focused (not disease-focused) care over time; comprehensiveness of services available and provided within primary care; and coordination of services when they are needed elsewhere (Starfield, Shi, and Macinko 2005).

Objective The aim of this study was to identify perceived barriers to appropriate antibiotic prescribing across different healthcare settings. Methods A cross-sectional survey of clinicians in Australian hospitals and primary care was undertaken between June and October 2019. The perceived barriers to appropriate antibiotic prescribing were considered as dependent variables, whereas age, sex, clinical experience, healthcare setting and the use of guidelines were considered independent variables. We used multivariate logistic regression to identify factors predictive of inappropriate antibiotic prescribing. Content analysis of free-text responses provided additional insights into the impediments to appropriate prescribing. Results In all, 180 clinicians completed the survey. Overall, diagnostic uncertainty and limited access to guidelines and prescribing information were significant barriers to appropriate antibiotic prescribing. Factors associated with these barriers were clinical experience, care setting (hospitals vs primary care) and the use of guidelines. Experienced clinicians (>11 years) were less likely to consider that limited access to information negatively affected prescribing practices (experience 11-20 years, odds ratio (OR) 0.66, 95% confidence interval (CI) 0.31-0.84; experience >20 years, OR 0.51, 95% CI 0.24-0.91). Conversely, general practitioners considered diagnostic uncertainty (OR 1.31, 95% CI 1.09-1.63) and patient expectations (OR 1.41, 95% CI 1.12-1.84) were more likely to be perceived barriers to appropriate prescribing. The use of guidelines and clinical experience may counteract this. Conclusion Years of experience, use of guidelines and type of setting were predictors of clinicians' perceptions regarding antibiotic prescribing. Our data highlight the importance of individual and setting characteristics in understanding variations in prescribing practices and designing targeted interventions for appropriate antibiotic prescribing. What is known about the topic? Inappropriate antibiotic prescribing is a significant health issue in Australia. Drivers of inappropriate prescribing are known, but how individual and setting characteristics contribute to variations in prescribing behaviour has not been fully understood. What does this paper add? Diagnostic uncertainty and limited access to prescribing information, including guidelines, formulary restrictions and antibiotic resistance patterns, can limit appropriate antibiotic prescribing. Clinicians' years of experience, the healthcare settings and clinician use of guidelines are important predictors of antibiotic prescribing behaviour. What are the implications for practitioners? The findings of this study can inform the design of tailored interventions to promote rational antibiotic prescribing practices in general practice and hospital settings.

The American Academy of Pediatrics (AAP) policy statement entitled “The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care”1 from the Committee on Psychosocial Aspects of Child and Family Health is found in this month's issue of Pediatrics . Few experienced pediatric practitioners would disagree with this description of our life's work. Most embrace this “renewed commitment” to relevant and comprehensive care for our children and families. It is not hard to look past the examination room and appreciate the struggles, tensions, and morbidities that this complex world presents our patients as they grow and develop. But what about the complex world of our practices? We are well-intended, but are we well-trained, and are we able to follow through on our “commitment”? “ Mental health needs of children and adolescents are increasing while access to behavioral health, mental health, and substance abuse service is decreasing .”2 The rate of psychosocial problems identified by primary care physicians in the children they care for has increased from 7% to 18% in the past 20 years. Information accumulated by the Pediatric Research in Office Settings (PROS) group3 confirmed what practicing pediatricians already know: the children we see for earaches bring with them symptoms of their behavioral health. These children may have attentional difficulties, conduct issues, or significant problems of mood. They may suffer acute adjustment difficulties or evidence posttraumatic stress from physical, emotional, or sexual abuse, and may experience family poverty, family divorce, or a host of other intrinsic or situational problems that impact on their health and the ability of their family and caregivers to provide for their health. We are seeing more problems and, lacking referral sources, often have to provide more care. Skills needed to address the new morbidities are part of our …

This paper deals with the some of the important variable factors relating to health care in Saudi Arabia, with special emphasis on primary health. Other aspects considered are the financial influen...

Antibiotic overuse in China: call for consolidated efforts to develop antibiotic stewardship programmes