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Albrink K, Schröder D, Joos C, Müller F, Noack EM. Usability of an App for Medical History Taking in General Practice From the Patients' Perspective: Cross-Sectional Study. JMIR Hum Factors 2024; 11:e47755. [PMID: 38180798 PMCID: PMC10799287 DOI: 10.2196/47755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/10/2023] [Accepted: 11/20/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND A future shortage of physicians, especially in general practice, will result in an increasing workload for health care providers as a whole. Therefore, it is important to optimize patient-encounter processes to increase time efficiency related to visits. Utilizing digital tools to record patients' medical histories prior to a consultation offers great potential to achieve this goal. The collected information can be stored into the practice's electronic medical record, allowing for the general practitioner to review structured information of the patients' complaints and related medical history beforehand, thereby saving time during the encounter. However, the low usability of new digital developments in this setting often hinders implementation. OBJECTIVE The aim of this study was to evaluate the usability of an app designed for medical history taking in general practice to capture the patients' perspective. METHODS Between November 2021 and January 2022, we recruited 406 patients with acute complaints in one out-of-hour urgent care and seven general practice clinics. These study participants used the app during their waiting time and subsequently assessed its usability by completing the System Usability Scale (SUS), a robust and well-established 10-question survey measuring the perceived usability of products and technologies. Additionally, we collected general participant information, including age, sex, media usage, health literacy, and native language. Descriptive and inferential statistics were applied to identify patient characteristics associated with low or high SUS scores. RESULTS We analyzed data from 397 patients (56.7% female, 43.3% male). The mean total SUS score was 77.8 points; 54.4% (216/397) of participants had SUS scores of 80 points or higher, indicating high usability of the app. In a multiple linear regression predicting SUS score, male sex and higher age (65 years or older) were significantly negatively associated with the SUS score. Conversely, a higher health literacy score and German as the native language were significantly positively associated with the SUS score. CONCLUSIONS Usability testing based on the SUS anticipates successful implementation of the app. However, not all patients will easily adapt to utilizing the app, as exemplified by the participants of older age in this study who reported lower perceived usability. Further research should examine these groups of people, identify the exact problems in operating such an app, and provide targeted solutions. TRIAL REGISTRATION German Clinical Trials Register World Health Organization Trial Registration Data Set DRKS00026659; https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00026659.
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Affiliation(s)
- Klara Albrink
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
| | - Dominik Schröder
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
| | - Carla Joos
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
| | - Frank Müller
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
| | - Eva Maria Noack
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
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Lueckmann SL, Hoebel J, Roick J, Markert J, Spallek J, von dem Knesebeck O, Richter M. Socioeconomic inequalities in primary-care and specialist physician visits: a systematic review. Int J Equity Health 2021; 20:58. [PMID: 33568126 PMCID: PMC7874661 DOI: 10.1186/s12939-020-01375-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/28/2020] [Indexed: 12/05/2022] Open
Abstract
Background Utilization of primary-care and specialist physicians seems to be associated differently with socioeconomic status (SES). This review aims to summarize and compare the evidence on socioeconomic inequalities in consulting primary-care or specialist physicians in the general adult population in high-income countries. Methods We carried out a systematic search across the most relevant databases (Web of Science, Medline) and included all studies, published since 2004, reporting associations between SES and utilization of primary-care and/or specialist physicians. In total, 57 studies fulfilled the eligibility criteria. Results Many studies found socioeconomic inequalities in physician utilization, but inequalities were more pronounced in visiting specialists than primary-care physicians. The results of the studies varied strongly according to the operationalization of utilization, namely whether a physician was visited (probability) or how often a physician was visited (frequency). For probabilities of visiting primary-care physicians predominantly no association with SES was found, but frequencies of visits were higher in the most disadvantaged. The most disadvantaged often had lower probabilities of visiting specialists, but in many studies no link was found between the number of visits and SES. Conclusion This systematic review emphasizes that inequalities to the detriment of the most deprived is primarily a problem in the probability of visiting specialist physicians. Healthcare policy should focus first off on effective access to specialist physicians in order to tackle inequalities in healthcare. PROSPERO registration number CRD42019123222. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-020-01375-1.
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Affiliation(s)
- Sara Lena Lueckmann
- Institute of Medical Sociology, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany. .,University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.
| | - Jens Hoebel
- Division of Social Determinants of Health, Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Julia Roick
- Institute of Medical Sociology, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany.,University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Jenny Markert
- Institute of Medical Sociology, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany.,University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Jacob Spallek
- Department of Public Health, Brandenburg University of Technology Cottbus-Senftenberg, Senftenberg, Germany
| | - Olaf von dem Knesebeck
- Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Richter
- Institute of Medical Sociology, Medical Faculty, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112, Halle (Saale), Germany.,University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
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Engels A, Reber KC, Magaard JL, Härter M, Hawighorst-Knapstein S, Chaudhuri A, Brettschneider C, König HH. How does the integration of collaborative care elements in a gatekeeping system affect the costs for mental health care in Germany? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:751-761. [PMID: 32185524 DOI: 10.1007/s10198-020-01170-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 02/21/2020] [Indexed: 06/10/2023]
Abstract
Mental disorders are widespread, debilitating and associated with high costs. In Germany, usual care (UC) for mental disorders is afflicted by poor coordination between providers and long waiting times. Recently, the primary alternative to UC-the gatekeeping-based general practitioners (GP) program-was extended by the collaborative Psychiatry-Neurology-Psychotherapy (PNP) program, which is a selective contract designed to improve mental health care and the allocation of resources. Here, we assess the effects of the GP program and the PNP program on costs for mental health care. We analyzed claims data from 2014 to 2016 of 55,472 adults with a disorder addressed by PNP to compare costs and sick leave days between PNP, the GP program and UC. The individuals were grouped and balanced via entropy balancing to adjust for potentially confounding covariates. We employed a negative binomial model to compare sick leave days and two-part models to compare sick pay, outpatient, inpatient and medication costs over a 12-month period. The PNP program significantly reduced sick pay by 164€, compared to UC, and by 177€, compared to the GP program. Consistently, sick leave days were lower in PNP. We found lower inpatient costs in PNP than in UC (-194€) and in the GP program (-177€), but no reduction in those shares of inpatient costs that accrued in psychiatric or neurological departments. Our results suggest that integrating collaborative care elements in a gatekeeping system can favourably impact costs. In contrast, we found no evidence that the widely implemented GP program reduces costs for mental health care.
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Affiliation(s)
- Alexander Engels
- Department of Health Economics and Health Services Research, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Katrin Christiane Reber
- Department of Health Economics and Health Services Research, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Julia Luise Magaard
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | | | - Ariane Chaudhuri
- AOK Baden-Württemberg, Presselstraße 19, 70176, Stuttgart, Germany
| | - Christian Brettschneider
- Department of Health Economics and Health Services Research, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Hansen H, Schäfer I, Porzelt S, Kazek A, Lühmann D, Scherer M. Regional and patient-related factors influencing the willingness to use general practitioners as coordinators of the treatment in northern Germany - results of a cross-sectional observational study. BMC FAMILY PRACTICE 2020; 21:110. [PMID: 32552721 PMCID: PMC7302141 DOI: 10.1186/s12875-020-01180-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/01/2020] [Indexed: 11/29/2022]
Abstract
Background In most countries, the general practitioner (GP) is the first point of contact in the healthcare system and coordinator of healthcare. However, in Germany it is possible to consult an outpatient specialist even without referral. Coordination by a GP might thus reduce health expenditures and inequalities in the healthcare system. The study describes the patients’ willingness/commitment to use the GP as coordinator of healthcare and identifies regional and patient-related factors associated with the aforementioned commitment to the GP. Methods Cross-sectional observational study using a standardised telephone patient survey in northern Germany. All counties and independent cities within a radius of 120 km around Hamburg were divided into three regional categories (urban areas, environs, rural areas) and stratified proportionally to the population size. Patients who had consulted the GP within the previous three months, and had been patients of the practice for at least three years were randomly selected from medical records of primary care practices in these districts and recruited for the study. Multivariate linear regression models adjusted for random effects at the level of federal states, administrative districts and practices were used as statistical analysis methods. Results Eight hundred eleven patients (25.1%) from 186 practices and 34 administrative districts were interviewed. The patient commitment to a GP attained an average of 20 out of 24 possible points. Significant differences were found by sex (male vs. female: + 1.14 points, p < 0.001), morbidity (+ 0.10 per disease, p = 0.043), education (high vs. low: − 1.74, p < 0.001), logarithmised household net adjusted disposable income (− 0.93 per step on the logarithmic scale, p = 0.004), regional category (urban areas: − 0.85, p = 0.022; environs: − 0.80, p = 0.045) and healthcare utilisation (each GP contact: + 0.30, p < 0.001; each contact to a medical specialist: − 0.75, p = 0.018). Professional situation and age were not significantly associated with the GP commitment. Conclusion On average, the patients’ commitment to their GP was relatively strong, but there were large differences between patient groups. An increase in the patient commitment to the GP could be achieved through better patient information and targeted interventions, e.g. to women or patients from regions of higher urban density. Trial registration The study was registered in ClinicalTrials.gov (NCT02558322).
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Affiliation(s)
- Heike Hansen
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistr, 52 20246, Hamburg, Germany.
| | - Ingmar Schäfer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistr, 52 20246, Hamburg, Germany
| | - Sarah Porzelt
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistr, 52 20246, Hamburg, Germany
| | - Agata Kazek
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistr, 52 20246, Hamburg, Germany
| | - Dagmar Lühmann
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistr, 52 20246, Hamburg, Germany
| | - Martin Scherer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Martinistr, 52 20246, Hamburg, Germany
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Soziodemografische und gesundheitsbezogene Merkmale der Inanspruchnahme und des Zugangs zu haus- und fachärztlicher Versorgung – Ergebnisse einer deutschlandweiten Bevölkerungsbefragung von 2006 bis 2016. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2017; 126:52-65. [DOI: 10.1016/j.zefq.2017.07.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 07/18/2017] [Accepted: 07/25/2017] [Indexed: 11/21/2022]
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Xu J, Mills A. Challenges for gatekeeping: a qualitative systems analysis of a pilot in rural China. Int J Equity Health 2017; 16:106. [PMID: 28666445 PMCID: PMC5493841 DOI: 10.1186/s12939-017-0593-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 05/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gatekeeping involves a generalist doctor who controls patients' access to specialist care, and has been discussed as an important policy option to rebalance the primary care and hospital sectors in low- and middle-income countries, despite thin evidence. A gatekeeping pilot in a Chinese rural setting launched in 2013 has offered an opportunity to study the functioning of gatekeeping under such conditions. METHODS In this qualitative study within a mixed-method evaluation of the gatekeeping pilot, we developed an innovative systems analysis method, combining the World Health Organisation categorisation of health system building blocks, the "Framework" approach of policy analysis and causal loop analysis. We conducted in-depth interviews with 20 stakeholders from 4 groups (patients, doctors, health facility managers and government administrators) in the pilot area over two years. Based on information extracted from the interviews, we drew a causal loop diagram which highlighted the feedback loops within the system that had self-reinforcing or self-balancing characteristics, and used the diagram to examine systematically the mechanisms of intended and actual functioning of gatekeeping and analyse the systems level challenges that affected the effectiveness of gatekeeping. RESULTS Had the gatekeeping pilot programme worked as intended, it would incentivize both providers and patients to increase service utilization at primary care level, as well as establish and enhance two reinforcing feedback loops to shift balance towards primary care. However, a performance-based salary policy undermined the motivation for clinical primary care. Furthermore, the primary care providers suffered from three reinforcing feedback loops (related to primary care capacity, human resource sustainability, patients' faith) that trapped primary care development in vicious cycles. At the interface between hospitals and primary care providers, there were also feedback loops exacerbating the existing hospital dominance. These feedback loops were intensified by the unintended consequences of concurrent policies (restrictions on technologies and medicines) and delayed reform in hospitals. Furthermore, the gatekeeping policy itself faced resistance to further development, due to the prevailing ineffective and ritualistic nature of gatekeeping, which formed a balancing loop. CONCLUSIONS The study shows that the intended benefits of gatekeeping were illusionary largely due to weak and worsening primary care conditions, and delay, ineffectiveness or unintended consequences of several other ongoing reforms. One particularly dangerous development of the system, which deserves urgent attention, is the harming of the professional prospects of primary care doctors. Our findings highlight the need for coordination and prioritization in designing policies related to primary care and managing changes with multiple on-going reforms. The approach used here facilitates comprehensive study of intended and actual mechanisms, and demonstrates the challenges of a complex health system intervention in a dynamic environment.
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Affiliation(s)
- Jin Xu
- China Center for Health Development Studies, Peking University, Beijing, 100191 China
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Anne Mills
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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Schneider A, Donnachie E, Tauscher M, Gerlach R, Maier W, Mielck A, Linde K, Mehring M. Costs of coordinated versus uncoordinated care in Germany: results of a routine data analysis in Bavaria. BMJ Open 2016; 6:e011621. [PMID: 27288386 PMCID: PMC4908874 DOI: 10.1136/bmjopen-2016-011621] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The efficiency of a gatekeeping system for a health system, as in Germany, remains unclear particularly as access to specialist ambulatory care is not restricted. The aim was to compare the costs of coordinated versus uncoordinated patients (UP) in ambulatory care; with additional subgroup analysis of patients with mental disorders. DESIGN Retrospective routine data analysis of patients with statutory health insurance, using claims data held by the Bavarian Association of Statutory Health Insurance Physicians. A patient was defined as uncoordinated if he or she visited at least 1 specialist without a referral from a general practitioner within a quarter. Outcomes were compared with propensity score matching analysis. PARTICIPANTS The study encompassed all statutorily insured patients in Bavaria contacting at least 1 ambulatory specialist in the first quarter of 2011 (n=3 616 510). PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was total costs of ambulatory care; secondary outcomes were financial claims of general physicians, specialists and for medication. RESULTS The average age was 55.3 years for coordinated patients (CP, n=1 629 302), 48.3 years for UP (n=1 825 840). CP more frequently had chronic diseases (85.4%) as compared with UP (67.5%). The total unadjusted financial claim per patient was higher for UP (€234.52) than for CP (€224.41); the total adjusted difference was -€9.65 (95% CI -11.64 to -7.67), indicating lower costs for CP. The cost differences increased with increasing age. Total adjusted difference per patient with mental diseases as documented with an International Classification of Diseases (ICD)-10 F-diagnosis, was -€20.31 (95% CI -26.43 to -14.46). CONCLUSIONS Coordination of care is associated with lower ambulatory healthcare expenditures and is of particular importance for patients who are more vulnerable to medical interventions, especially for elderly and patients with mental disorders. The role of general practitioners as coordinators should be strengthened to improve care for these patients as this could also help to frame a more efficient health system.
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Affiliation(s)
- Antonius Schneider
- Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Ewan Donnachie
- Association of Statutory Health Insurance Physicians of Bavaria, München, Germany
| | - Martin Tauscher
- Association of Statutory Health Insurance Physicians of Bavaria, München, Germany
| | - Roman Gerlach
- Association of Statutory Health Insurance Physicians of Bavaria, München, Germany
| | - Werner Maier
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München—German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | - Andreas Mielck
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München—German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | - Klaus Linde
- Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Michael Mehring
- Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, München, Germany
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