Rural/urban differences in accounts of patients' initial decisions to consult primary care

Healthcare utilization is increased in children living in urban areas, with ethnicity-related disparities: A big data analysis study

This study aimed to investigate differences in pediatric healthcare utilization in Israel over 10 years by examining differences across populations defined by living environment and ethnicity. Data was obtained from the Clalit Health Care data warehouse, covering over 250,000 children residing in Haifa and Western Galilee districts. The population groups were categorized based on ethnicity (Jewish vs Arab) and residential settings (urban vs rural). Healthcare utilization was consistently higher among Jewish than Arab children, irrespective of the specific dimension analyzed. Additionally, urban-dwelling children exhibited higher usage rates than those residing in rural areas in all investigated dimensions. However, Jewish children showed significantly about 18% lower hospitalization rates than Arab children across all years (P < 0.001). No significant differences in hospitalizations were observed between urban and rural children (RR 0.999, CI (0.987-1.011)). Notably, the study revealed reduced antibiotic consumption and hospitalizations over the years for all populations. Additionally, we found that Arab children and those living in rural areas had reduced access to healthcare, as evidenced by 10-40% fewer physician visits, laboratory tests, and imaging (P < 0.001).    Conclusion: This study highlights the substantial population-based disparities in healthcare utilization among children in Israel despite the equalizing effect of the national health insurance law. Rural and low socioeconomic populations seem to have reduced healthcare access, showing decreased healthcare utilization. Consequently, it is imperative to address these disparities and implement targeted interventions to enhance healthcare access for Arab children and rural communities. The decline in antibiotic usage and hospitalizations suggests positive trends in pediatric health care, necessitating ongoing efforts to ensure equitable access and quality of care for all populations. What is Known: • Healthcare systems worldwide vary in coverage and accessibility, including Israel, which stands out for its diverse population. • Existing research primarily focuses on healthcare utilization among adults, leaving a need for comprehensive data on children's healthcare patterns globally. What is New: • Investigating over 250,000 children, this study reveals higher healthcare utilization among Jewish and urban children across all dimensions. • Despite Israel's national health insurance law, the study underscores the significant population-based disparities in healthcare utilization.

The Use of Vignettes to Improve the Validity of Qualitative Interviews for Realist Evaluation

Although realist evaluation (RE) requires multiple data collection methods, qualitative interviews are considered most valuable and are most frequently used. The guiding principles of RE may limit the emergence of new Context-Mechanism-Outcome (CMO) configurations by evoking particular underlying mechanisms. This paper proposes a new method for conducting semi-structured interviews in the RE context by drawing on the literature and examining the ability of vignettes to explore perceptions about specific situations. Vignettes are developed based on researchers' knowledge of the setting and program theory and are updated through an iterative process throughout data collection. Interviews focus on situations illustrated in the vignette to capture variations in interviewees' perceptions. This method constrains interviewees to using retroduction to identify the hidden underlying mechanisms that link contextual elements to outcomes based on their experiences. This method allows researchers to focus on CMO configurations without evoking mechanisms, which contributes to the rigor of the method.

Patient-reported experiences and satisfaction with head and neck surgery outreach clinics in regional New South Wales, Australia: A cross-sectional survey

RATIONALE

Head and neck surgery services are increasingly being centralised in Australia. Outreach models can overcome burdens of travel that patients in regional and rural areas experience when attending routine appointments, by providing services closer to home.

AIM

To explore patient-reported experiences and satisfaction with regional outreach services for head and neck surgery in Australia.

METHODS

Patients who attended two regional outreach clinics in New South Wales (NSW), Australia, were surveyed over a 6-month period. Patients completed the Outpatient Cancer Clinics Survey (2020 version) that explored perceptions and experiences of the clinic. Patients with cancer were asked to complete the Edmonton Symptom Assessment System and the Communication and Attitudinal Self-Efficacy scale. Descriptive statistics and analysis of data was performed, and results were compared to the NSW statewide Outpatient Cancer Clinics Survey (2020). Content analysis of free text responses was performed.

RESULTS

Some 128 patients responded (56% response rate; mean age 67.2 years, 46.1% female). Compared to the 2020 NSW survey, a higher proportion of patients in our cohort responded positively to 14 of the 26 questions, with the greatest differences observed for questions regarding waiting area comfort (+12.1%, p = 0.008), being informed about different treatment options (+9.5%, p = 0.04), and issues relating to parking (+9.5%, p = 0.03). A lower proportion of our sample responded positively to the question about whether health professionals knew enough about their medical history (-19.3%, p < 0.001). Respondents appreciated having a local clinic that helped them avoid travel to major cities and associated expenses and highlighted benefits of expert consultation and timeliness of investigations. However, cost of appointments and level of reimbursements remain barriers for some patients.

CONCLUSIONS

Patients had a high level of satisfaction with regional outreach clinics for head and neck surgery across most domains, indicating patients highly value this service.

The impact of rurality on patient experience and diagnostic pathway intervals in Scotland's cancer patients: Further results from a national cancer diagnosis audit

BACKGROUND

In Scotland 17 % of the population reside rurally and previous research has demonstrated worse cancer outcomes in this group. The underlying reason for this is unclear. This study aims to determine whether patient presenting factors, GP consultation factors or the diagnostic pathways differ between urban and rural patients within Scotland.

METHODS

This study combined two Scottish National Cancer Diagnosis Audits. Participating GPs collected data on the diagnostic pathway from primary to secondary care for cancer patients diagnosed during the audit period. Using the Scottish Government Urban Rural Classification, patients were designated as rural or urban dwellers and compared in descriptive analyses. Key cancer intervals (primary, diagnostic, secondary and treatment interval) were compared between urban and rural dwellers with an additional adjusted analysis for the main cancer sites.

RESULTS

A total of 4309 cancer diagnoses were included in the study; 22 % were in patients from rural locations. Rural patients had significantly more consultations and investigations prior to referral than their urban counterparts. There was no difference in prolonged cancer pathways between the two groups except in lung cancer patients where rural patients had a significantly increased odds of a diagnostic interval of >90 days.

CONCLUSION

Our findings suggest differences in the interaction between patients and GPs prior to referral in urban and rural settings. However, this does not appear to lead to prolonged patient pathways, except in lung cancer. Further research is needed to determine whether this delay is clinically significant and contributing to poorer outcomes in Scottish rural dwellers with lung cancer.

Stakeholder-led understanding of the implementation of digital technologies within heart disease diagnosis: a qualitative study protocol

INTRODUCTION

Cardiovascular diseases are highly prevalent among the UK population, and the quality of care is being reduced due to accessibility and resource issues. Increased implementation of digital technologies into the cardiovascular care pathway has enormous potential to lighten the load on the National Health Service (NHS), however, it is not possible to adopt this shift without embedding the perspectives of service users and clinicians.

METHODS AND ANALYSIS

A series of qualitative studies will be carried out with the aim of developing a stakeholder-led perspective on the implementation of digital technologies to improve holistic diagnosis of heart disease. This will be a decentralised study with all data collection being carried out online with a nationwide cohort. Four focus groups, each with 5-6 participants, will be carried out with people with lived experience of heart disease, and 10 one-to-one interviews will be carried out with clinicians with experience of diagnosing heart diseases. The data will be analysed using an inductive thematic analysis approach.

ETHICS AND DISSEMINATION

This study received ethical approval from the Sciences and Technology Cross Research Council at the University of Sussex (reference ER/FM409/1). Participants will be required to provide informed consent via a Qualtrics survey before being accepted into the online interview or focus group. The findings will be disseminated through conference presentations, peer-reviewed publications and to the study participants.

Barriers to Early Presentation amongst Rural Residents Experiencing Symptoms of Colorectal Cancer: A Qualitative Interview Study

Rural cancer inequalities are evident internationally, with rural cancer patients 5% less likely to survive than their urban counterparts. There is evidence to suggest that diagnostic delays prior to entry into secondary care may be contributing to these poorer rural cancer outcomes. This study explores the symptom appraisal and help-seeking decision-making of people experiencing symptoms of colorectal cancer in rural areas of England. Patients were randomly invited from 4 rural practices, serving diverse communities. Semi-structured interviews were undertaken with 40 people who had experienced symptoms of colorectal cancer in the preceding 8 weeks. Four key themes were identified as influential in participants' willingness and timeliness of consultation: a desire to rule out cancer (facilitator of help-seeking); stoicism and self-reliance (barrier to help-seeking); time scarcity (barrier to help-seeking); and GP/patient relationship (barrier or facilitator, depending on perceived strength of the relationship). Self-employed, and "native" rural residents most commonly reported experiencing time scarcity and poor GP/patient relationships as a barrier to (re-)consultation. Targeted, active safety-netting approaches, and increased continuity of care, may be particularly beneficial to expedite timely diagnoses and minimise cancer inequalities for rural populations.

The Additional Medical Expenditure Caused by Depressive Symptoms among Middle-Aged and Elderly Patients with Chronic Lung Diseases in China

Depression is one of the most common comorbidities in patients with chronic lung diseases (CLDs). Depressive symptoms have an obvious influence on the health function, treatment, and management of CLD patients. In order to investigate the additional medical expenditure caused by depressive symptoms among middle-aged and elderly patients with CLDs in China, and to estimate urban–rural differences in additional medical expenditure, our study used data from the 2018 China Health and Retirement Longitudinal Study (CHARLS) investigation. A total of 1834 middle-aged and elderly CLD patients were included in this study. A generalized linear regression model was used to analyze the additional medical expenditure on depressive symptoms in CLD patients. The results show that depressive symptoms were associated with an increase in medical costs in patients with CLDs. Nevertheless, the incremental medical costs differed between urban and rural patients. In urban and rural patients with more severe comorbid CLD and depressive symptoms (co-MCDs), the total additional medical costs reached 4704.00 Chinese Yuan (CNY) (USD 711.60) and CNY 2140.20 (USD 323.80), respectively. Likewise, for patients with lower severity co-MCDs, the total additional medical costs of urban patients were higher than those of rural patients (CNY 4908.10 vs. CNY 1169.90) (USD 742.50 vs. USD 176.90). Depressive symptoms were associated with increased medical utilization and expenditure among CLD patients, which varies between urban and rural areas. This study highlights the importance of mental health care for patients with CLDs.

Policy Goals of Contract Arrangements in Primary Care in Jeopardy: A Cross-Sectional Consumer Satisfaction Survey of Community Residents in Hangzhou, China

Objective

China is attempting to establish a voluntary contracting system in primary care. This study aimed to determine the degree of consumer satisfaction with the entitlements of contract arrangements and its associated factors.

Methods

A stratified cluster sampling strategy was adopted to recruit study participants from three administrative districts of Hangzhou municipality, each containing six residential communities. In each community, 50 households were recruited. A questionnaire was administered through face-to-face interviews with members of the households who signed a contract with community health centers, to collect data regarding their sociodemographic characteristics, health conditions, and knowledge of and attitudes toward the contract entitlements. Consumer satisfaction was measured using six items rated on a five-point Likert scale ranging from “1=very dissatisfied” to “5=very satisfied” and a summed score was calculated. A mixed linear regression model was established to identify individual predictors of consumer satisfaction after adjustment of the random (intercept) effect of household clusters.

Results

Overall, the respondents reported low levels of awareness and understanding of the contract entitlements, with an average knowledge score of 8.21 (SD = 3.74) out of a maximum possible of 19. The respondents had relatively lower levels of satisfaction (satisfied or very satisfied) with their prioritized entitlements (51.5%) and hospitals at home and telemedicine services (31.3%), compared with the contract and insurance policies (85.5%) and medical services provided (87.0%). Female gender, older age, chronic conditions, and perceived better health were associated with higher levels of satisfaction, while poor awareness and knowledge were associated with lower levels of satisfaction.

Conclusion

The study participants perceived limited benefits from the contract arrangements in primary care, which may jeopardize the policy purpose of the arrangements to encourage patients to use primary care as the first contact point in accessing health care services. It is evident that consumer satisfaction with the contract entitlements varies by healthcare needs. Lower levels of satisfaction are associated with poor awareness and knowledge of the entitlements.

Variation in appropriate diabetes care and treatment targets in urban and rural areas in England: an observational study of the 'rule of halves'

OBJECTIVES

To estimate the 'rule of halves' for diabetes care for urban and rural areas in England using several data sources covering the period 2015-2017; and to examine the extent to which any differences in urban and rural settings are explained by population characteristics and the workforce supply of primary care providers (general practices).

DESIGN

A retrospective observational study.

SETTING

Populations resident in predominantly urban and rural areas in England (2015-2017).

PARTICIPANTS

N=33 336 respondents to the UK Household Longitudinal Survey in urban and rural settings in England; N=4913 general practices in England reporting to the National Diabetes Audit and providing workforce data to NHS Digital.

OUTCOMES

Diabetes prevalence; administrative records of diagnoses of diabetes; provision of (all eight) recommended diabetes care processes; diabetes treatment targets.

RESULTS

Diabetes prevalence was higher in urban areas in England (7.80% (95% CI 7.30% to 8.31%)) relative to rural areas (7.24% (95% CI 6.32% to 8.16%)). For practices in urban areas, relatively fewer cases of diabetes were recorded in administrative medical records (69.55% vs 71.86%), and a smaller percentage of those registered received the appropriate care (45.85% vs 49.32%). Among estimated prevalent cases of diabetes, urban areas have a 24.84% achieving these targets compared with 25.16% in rural areas. However, adjusted analyses showed that the performance of practices in urban areas in providing appropriate care quality was not significantly different from practices in rural areas.

CONCLUSIONS

The 'rule of halves' is not an accurate description of the actual pattern across the diabetes care pathway in England. More than half of the estimated urban and rural diabetes population are registered with clinical practices and have access to treatment. However, less than half of those registered for treatment have achieved treatment targets. Appropriate care quality was associated with a greater proportion of patients with diabetes achieving treatment targets.

A cross-sectional study to assess knowledge of women about cervical cancer: an urban and rural comparison

INTRODUCTION

Cervical cancer and its etiopathogenesis, the age of women in whom it is diagnosed, average life expectancy, and prognosis are information widely covered in scientific reports. However, there is no coherent information regarding which regions-urban or rural-it may occur more often. This is important because the literature on the subject reports that people living in rural areas have a worse prognosis when it comes to detection, treatment, and life expectancy than city dwellers.

MATERIAL AND METHODS

The subjects of the study were women and their knowledge about cervical cancer. The research was carried out using a survey directly distributed among respondents and via the Internet, portals, and discussion groups for women from Poland. Three hundred twenty-nine women took part in the study, including 164 from rural and 165 from urban areas. The collected data enabled the following: (1) an analysis of the studied groups, (2) assessment of the respondents' knowledge about cervical cancer, and (3) comparison of women's knowledge depending on where they live.

RESULTS

The average assessment of all respondents' knowledge was 3.59, with women living in rural areas scoring 3.18 and respondents from the city-4.01. Statistical significance (p < 0.001) between the level of knowledge and place of residence was determined. The results indicate that an increase in the level of education in the subjects significantly increases the chance of getting the correct answer. In the case of age analysis, the coefficients indicate a decrease in the chance of obtaining the correct answer in older subjects despite the fact that a statistically significant level was reached in individual questions.

CONCLUSIONS

Women living in rural areas have less knowledge of cervical cancer than female respondents from the city. There is a need for more awareness campaigns to provide comprehensive information about cervical cancer to women in rural areas. A holistic approach to the presented issue can solve existing difficulties and barriers to maintaining health regardless of the place of life and residence.

IMPLICATION FOR CANCER SURVIVORS

They need intensive care for women's groups most burdened with risk factors.

Outpatient care in acute and prehospital emergency medicine by emergency medical and patient transport service over a 10-year period: a retrospective study based on dispatch data from a German emergency medical dispatch centre (OFF-RESCUE)

BACKGROUND

The number of operations by the German emergency medical service almost doubled between 1994 and 2016. The associated expenses increased by 380% in a similar period. Operations with treatment on-site, which retrospectively proved to be misallocated (OFF-Missions), have a substantial proportion of the assignment of the emergency medical service (EMS). Besides OFF-Missions, operations with patient transport play a dominant role (named as ON-Missions). The aim of this study is to work out the medical and economic relevance of both operation types.

METHODS

This analysis examined N = 819,780 missions of the EMS and patient transport service (PTS) in the catchment area of the emergency medical dispatch centre (EMDC) Bad Kreuznach over the period from 01/01/2007 to 12/31/2016 in terms of triage and disposition, urban-rural distribution, duration of operations and economic relevance (p < .01).

RESULTS

53.4% of ON-Missions are triaged with the indication non-life-threatening patient transport; however, 63.7% are processed by the devices of the EMS. Within the OFF-Mission cohort, 78.2 and 85.8% are triaged or dispatched for the EMS. 74% of all ON-Missions are located in urban areas, 26% in rural areas; 81.3% of rural operations are performed by the EMS. 66% of OFF-Missions are in cities. 93.2% of the remaining 34% of operations in rural locations are also performed by the EMS. The odds for both ON- and OFF-Missions in rural areas are significantly higher than for PTS (ORON 3.6, 95% CI 3.21-3.30; OROFF 3.18, 95% CI 3.04-3.32). OFF-Missions last 47.2 min (SD 42.3; CI 46.9-47.4), while ON-Missions are processed after 79.7 min on average (SD 47.6; CI 79.6-79.9). ON-Missions generated a turnover of more than € 114 million, while OFF-Missions made a loss of almost € 13 million.

CONCLUSIONS

This study particularly highlights the increasing utilization of emergency devices; especially in OFF-Missions, the resources of the EMS have a higher number of operations than PTS. OFF-Missions cause immensely high costs due to misallocations from an economic point of view. Appropriate patient management appears necessary from both medical and economic perspective, which requires multiple solution approaches.

Patient enablement after a consultation with a general practitioner-Explaining variation between countries, practices and patients

BACKGROUND

Patient enablement is a concept developed to measure quality in primary health care. The comparative analysis of patient enablement in an international context is lacking.

OBJECTIVE

To explain variation in patient enablement between patients, general practitioners (GPs) and countries. To find independent variables associated with enablement.

DESIGN

We constructed multi-level logistic regression models encompassing variables from patient, GP and country levels. The proportions of explained variances at each level and odds ratios for independent variables were calculated.

SETTING AND PARTICIPANTS

A total of 7210 GPs and 58 930 patients in 31 countries were recruited through the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. In addition, data from the Primary Health Care Activity Monitor for Europe (PHAMEU) study and Hofstede's national cultural dimensions were combined with QUALICOPC data.

RESULTS

In the final model, 50.6% of the country variance and 18.4% of the practice variance could be explained. Cultural dimensions explained a major part of the variation between countries. Several patient-level and only a few practice-level variables showed statistically significant associations with patient enablement. Structural elements of the relevant health-care system showed no associations. From the 20 study hypotheses, eight were supported and four were partly supported.

DISCUSSION AND CONCLUSIONS

There are large differences in patient enablement between GPs and countries. Patient characteristics and patients' perceptions of consultation seem to have the strongest associations with patient enablement. When comparing patient-reported measures as an indicator of health-care system performance, researchers should be aware of the influence of cultural elements.

Urban-rural disparity of preventive healthcare utilisation among children under the universal health insurance coverage in Taiwan: a national birth cohort analysis

OBJECTIVE

In the context of universal health insurance coverage, this study aimed to determine whether urban-rural inequality still exists in preventive health care (PHC) amongst children in Taiwan.

STUDY DESIGN

Prospective cohort study.

METHODS

A total of 184,117 mothers and their children born in 2009 were identified as the study cohort. The number of children born in urban, satellite and rural areas was 40,176, 57,565 and 86,805, respectively. All children were followed for 7 years, before which a total of seven times PHC were provided by Taiwan's National Health Insurance (NHI) programme. Ordinal logistic regression models were used to associate urbanisation level with the frequency of PHC utilisation. Stratified analyses were further performed in accordance with the children's birth weight and the mothers' birthplace.

RESULTS

Children from satellite areas had higher utilisation for the first four scheduled PHC visits. Children living in urban areas received more PHC for the fifth and sixth scheduled visits. Compared with those from rural areas, children in satellite areas exhibited a small but significant increase in odds in PHC utilisation, with a covariate-adjusted odds ratio (aOR) of 1.04 and 95% confidence interval (CI) of 1.02-1.06. By contrast, no significant difference was observed between rural and urban areas (aOR = 1.01). Further stratified analyses suggest more evident urban-rural difference in PHC utilisation amongst children with low birth weight and foreign-born mothers.

CONCLUSIONS

Given a universal health insurance coverage and embedded mechanisms in increasing the availability of healthcare resources in Taiwan, a slight urban-rural difference is observed in PHC utilisation amongst children. Hence, sociodemographic inequality in utilisation of PHC still exists. This issue should be addressed through policy intervention.

Reconceptualising Rural Cancer Inequalities: Time for a New Research Agenda

Evidence has shown for over 20 years that patients residing in rural areas face poorer outcomes for cancer. The inequalities in survival that rural cancer patients face are observed throughout the developed world, yet this issue remains under-examined and unexplained. There is evidence to suggest that rural patients are more likely to be diagnosed as a result of an emergency presentation and that rural patients may take longer to seek help for symptoms. However, research to date has been predominantly epidemiological, providing us with an understanding of what is occurring in these populations, yet failing to explain why. In this paper we outline the problems inherent in current research approaches to rural cancer inequalities, namely how ‘cancer symptoms’ are conceived of and examined, and the propensity towards a reductionist approach to rural environments and populations, which fails to account for their heterogeneity. We advocate for a revised rural cancer inequalities research agenda, built upon in-depth, community-based examinations of rural patients’ experiences across the cancer pathway, which takes into account both the micro and macro factors which exert influence on these experiences, in order to develop meaningful interventions to improve cancer outcomes for rural populations.

Support for people with long-term neurological conditions in rural English communities

Almost one-fifth of the population in England lives in rural areas. Compared to urban populations, the rural population is older and faces greater difficulties in accessing medical services. At the same time, healthcare teams in rural areas face particular challenges in recruiting and retaining staff, travelling between patients and keeping specialised knowledge up-to-date. Drawing upon a recent health needs assessment for people living with long-term neurological conditions in a rural English county, as well as a broader review of the literature, this paper considers the challenges of rurality and discusses potential solutions. Technological and community-based responses have often been suggested as responses to challenges of rurality. However, there is likely to be a need for up-front investment of resources and careful consideration of individual and community needs before these solutions can be applied to rural neurological care.

Natural polyphenols for the prevention of irritable bowel syndrome: molecular mechanisms and targets; a comprehensive review

Irritable bowel syndrome (IBS) is a well diagnosed disease, thoroughly attributed to series of symptoms criteria that embrace a broad range of abdominal complainers. Such criteria help to diagnosis the disease and can guide controlled clinical trials to seek new therapeutic agents. Accordingly, a verity of mechanisms and pathophysiological conditions including inflammation, oxidative stress, lipid peroxidation and different life styles are involved in IBS. Predictably, diverse therapeutic approaches are available and prescribed by clinicians due to major manifestations (i.e., diarrhea-predominance, constipation-predominance, abdominal pain and visceral hypersensitivity), psychological disturbances, and patient preferences between herbal treatments versus pharmacological therapies, dietary or microbiological approaches. Herein, we gathered the latest scientific data between 1973 and 2019 from databases such as PubMed, Google Scholar, Scopus and Cochrane library on relevant studies concerning beneficial effects of herbal treatments for IBS, in particular polyphenols. This is concluded that polyphenols might be applicable for preventing IBS and improving the IBS symptoms, mainly through suppressing the inflammatory signaling pathways, which nowadays are known as novel platform for the IBS management. Graphical abstract.

Factors influencing residents' decision to sign with family doctors under the new health care reform in China

BACKGROUND

As an important means through which to promote Chinese health care reform, the family doctor policy has attracted attention from various fields. This study aimed to explore the factors influencing residents' decision to sign with family doctors, with a view to informing the changes necessary to encourage additional residents to do so, thereby enhancing the efficacy of primary health care system reform.

METHODS

The residents of five communities in Xianning, Hubei Province, were selected, by convenience sampling, to participate in the study. We developed and administered a questionnaire to collect data, from which we obtained 725 valid response sets. Socio-demographic characteristics were summarized using descriptive statistics; and Pearson chi-squared test and binary logistic regression were performed to identify the factors influencing residents' decision to sign with family doctors.

RESULTS

We found that the factors influencing residents' decision to sign include their education level, medical insurance, chronic diseases, medical treatment habits, awareness of the family doctor policy, perception of the medical skills of family doctors, and attitudes towards family doctors' signing services (P < .05).

CONCLUSION

To encourage more residents to sign with family doctors, we recommend the implementation of the following: increasing publicity for the family doctor policy, promoting the reasonable distribution of high-quality resources, augmenting the standard of general medical education, and improving the skills and competencies of family doctors.

Deciding whether to consult the GP or an emergency department: A qualitative study of patient reasoning in Switzerland

Background: Non-urgent care is an important factor responsible for rising healthcare costs and general practitioners (GPs) are known to be more cost-effective than emergency departments (EDs).

Objectives: To understand the reasons why patients confronted with a medical problem perceived as urgent choose to consult either a GP or an ED.

Methods: We conducted a qualitative study in Switzerland, using data collected between 2014 and 2015 through semi-structured interviews of adults with non-vital medical problems. Half were recruited after an ambulatory consultation in an ED, and half were patients who consulted their GP. The audio-recorded interviews were transcribed, coded, and analysed according to the constant comparative method.

Results: The main reason given by patients who consulted their GP first was the quality of the relationship. The more meaningful the relationship, the more likely patients were to seek advice from their GP. One marker of a privileged relationship was GPs supplying their mobile phone number to the patient. The perceived nature of the complaint, for example, symptoms considered as life-threatening or severe pain, together with the expected waiting time in an ED were additional factors influencing the patients’ choice.

Conclusion: Our study showed that when patients are confronted with what they perceive as a medical emergency, the quality of the relationship with the GP, in particular the continuity of care provided, seem to be the major reasons why they consult their GP rather than an ED.

Sense-making strategies and help-seeking behaviours associated with urgent care services: a mixed-methods study

Background

Policy has been focused on reducing unnecessary emergency department attendances by providing more responsive urgent care services and guiding patients to ‘the right place’. The variety of services has created a complex urgent care landscape for people to access and navigate.

Objectives

To describe how the public, providers and policy-makers define and make sense of urgent care; to explain how sense-making influences patients’ strategies and choices; to analyse patient ‘work’ in understanding, navigating and choosing urgent care; to explain urgent care utilisation; and to identify potentially modifiable factors in decision-making.

Design

Mixed-methods sequential design.

Setting

Four counties in southern England coterminous with a NHS 111 provider area.

Methods

A literature review of policy and research combined with citizens’ panels and serial qualitative interviews. Four citizens’ panels were conducted with the public, health-care professionals, commissioners and managers (n = 41). Three populations were sampled for interview: people aged ≥ 75 years, people aged 18–26 years and East European people. In total, 134 interviews were conducted. Analyses were integrated to develop a conceptual model of urgent care help-seeking.

Findings

The literature review identified some consensus between policy and provider perspectives regarding the physiological factors that feature in conceptualisations of urgent care. However, the terms ‘urgent’ and ‘emergency’ lack specificity or consistency in meaning. Boundaries between urgent and emergency care are ill-defined. We constructed a typology that distinguishes three types of work that take place at both the individual and social network levels in relation to urgent care sense-making and help-seeking.Illness workinvolves interpretation and decision-making about the meaning, severity and management of physical symptoms and psychological states, and the assessment and management of possible risks. Help-seeking was guided bymoral work: the legitimation and sanctioning done by service users.Navigation workconcerned choosing and accessing services and relied on prior knowledge of what was available, accessible and acceptable. From these empirical data, we developed a model of urgent care sense-making and help-seeking behaviour that emphasises that work informs the interaction between what we think and feel about illness and the need to seek care (sense-making) and action – the decisions we take and how we use urgent care (help-seeking).

Limitations

The sample population of our three groups may not have adequately reflected a diverse range of views and experiences. The study enabled us to capture people’s views and self-reported service use rather than their actual behaviour.

Conclusions

Much of the policy surrounding urgent and emergency care is predicated on the notion that ‘urgent’ sits neatly between emergency and routine; however, service users in particular struggle to distinguish urgent from emergency or routine care. Rather than focusing on individual sense-making, future work should attend to social and temporal contexts that have an impact on help-seeking (e.g. why people find it more difficult to manage pain at night), and how different social networks shape service use.

Future work

A whole-systems approach considering integration across a wider network of partners is key to understanding the complex relationships between demand for and access to urgent care.

Study registration

This study is registered as UKCRN 32207.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Use of pre-hospital emergency medical services in urban and rural municipalities over a 10 year period: an observational study based on routinely collected dispatch data

BACKGROUND

Pre-hospital emergency medical services (EMS) are an integral part of emergency medical care. EMS planning can be achieved by analyzing patterns of use. However, long-term time trends of EMS use have rarely been studied. The objective of this retrospective study was to investigate utilization patterns over a ten year period, and to compare utilization trends between urban and rural municipalities and between events with and without prehospital emergency physician (PEP) dispatch.

METHODS

Routine data collected by 26 dispatch centers in the federal state of Bavaria, Germany, from 2007 to 2016 was analyzed. Emergency locations were classified into five levels of rurality. Negative binomial mixed effects regression models were fitted to predict emergency rates and to investigate differences in rates and utilization trends. Graphical representation methods were used to compare distribution of transport rates and distribution across daytime and weekday.

RESULTS

Twelve million two hundred thousand one hundred fifty-five dispatches assigned to 7,725,636 single emergencies were included. The mean number of emergencies per year and 1000 population (emergency rate) was 42.8 (±16.0) in rural municipalities and 80.7 (±9.3) in large cities. Compared to rural municipalities, cities had higher emergency rates without (IRR = 3.0, CI 2.2-4.0) and with pre-hospital physicians (IRR = 1.5, CI 1.2-2.0). Between 2007 and 2016, the absolute number of emergencies increased by 49.1%. Estimated annual percent change of emergency rates without physician activation ranged from 5.7% (CI 4.3-7.1) in cities to 7.8% (CI 7.6-7.9) in rural areas. Changes in emergency rates with physician attendance were lower, with estimated increases between 1.3 and 2.4%. The average proportion of patients transported to a hospital was lower in cities and remained unchanged. There were no considerable differences or changes in the distribution across daytime and weekdays.

CONCLUSION

Differences between cities and other areas suggest that the planning of EMS should be targeted to regional characteristics. A substantial increase in emergency rates was observed across all areas of Bavaria, but did not impact transport rates or temporal distributions. Further research is needed to better understand the urgency of emergency events and reasons behind increasing EMS utilization.

Community orientation of general practitioners in 34 countries

General practitioners (GPs) are frontline health workers. They should be sensitive to the health needs of the community in addition to caring for patients that visit their practice. Due to changes in demography, epidemiology, ecology and healthcare policy, a community orientation becomes more important. Our research question is: to what extent does community orientation of GPs vary between countries and GPs and how can this variation be explained? We use cross-sectional survey data from the QUALICOPC study, conducted among over 7000 GPs in 34 countries. Community orientation was measured through a scale constructed from three survey questions on whether GPs would take action when confronted with: repeated accidents in an industrial setting, frequent respiratory problems in patients living near a certain industry, and repeated cases of food poisoning in the local community. Independent variables are at healthcare system level and GP or practice level. Data were analysed using linear multilevel regression analysis. Community orientation varies between GPs and countries. Community orientation is more frequent in healthcare systems with a list system, among self-employed GPs, those using medical records to make overviews, and those more active in prevention and multidisciplinary cooperation. GPs in rural areas and areas with more people from ethnic minorities are more community oriented. Based on the variation between countries and GPs, we would like to raise awareness and underline the importance of multidisciplinary cooperation.

Urban-rural disparities in health care utilization among Chinese adults from 1993 to 2011

BACKGROUND

Despite economic growth and improved health outcomes over the past few decades, China still experiences striking urban-rural health inequalities. Urban and rural residents distinguished by the hukou system may experience profound disparities because of institutional effect. The aim of this study is to estimate trends in urban-rural disparities in self-care, outpatient care, and inpatient care utilization from a perspective of the hukou system.

METHODS

Data were extracted from the seven latest waves of the China Health and Nutrition Survey (CHNS). We used the hukou system to distinguish between urban and rural residents. Chi-square tests were performed to examine urban-rural gaps in self-care, outpatient care, and inpatient care utilization. Multinomial logistic regression was employed to confirm these disparities and to explore whether the urban-rural gaps have narrowed or widened from 1993 to 2011 once known determinants of utilization are taken into account according to Andersen/Aday's Health Behaviour Model.

RESULTS

The urban-rural disparities were evident after controlling for confounding variables: urban adults were 3.24 (p < 0.05), 2.23 (p < 0.1), and 4.77 (p < 0.01) times more likely to choose self-care vs. no care, outpatient care vs. no care, and inpatient care vs. no care than their rural counterparts, respectively. The results showed upward trends in self-care, outpatient care, and inpatient care utilization from 2004 to 2011. The urban-rural gaps in health care utilization gradually narrowed during the period of 1993-2011. The hukou distinctions of self-care, outpatient care, and inpatient care in 2011 were only 33.3%, 35.5%, and 9.6% of that in 1993, respectively.

CONCLUSIONS

Although rural residents were underutilizing health care when compared to their urban counterparts, the significant decrements in urban-rural disparities reflect the positive effect of the on-going health system reform in China. To maintain an equitable distribution of health care utilization, policy makers need to be aware of challenges due to aging problems and health expenditure increment.

Developing and Using Vignettes to Explore the Relationship Between Risk Management Practice and Recovery-Oriented Care in Mental Health Services

There is a lack of literature evaluating the development and use of vignettes to explore contested constructs in qualitative health care research where a conventional interview schedule might impose assumptions on the data collected. We describe the development and validation of vignettes in a study exploring mental health worker and service user understandings of risk and recovery in U.K. mental health services. Focus groups with mental health workers and service users explored study questions from experiential perspectives. Themes identified in the groups were combined with existing empirical literature to develop a set of vignettes. Feedback focus groups were conducted to validate and amend the vignettes. Following use in research interviews, results suggested that the vignettes had successfully elicited data on issues of risk and recovery in mental health services. Further research using creative, comparative methods is needed to fully understand how vignettes can best be used in qualitative health care research.

Seeking ambulance treatment for 'primary care' problems: a qualitative systematic review of patient, carer and professional perspectives

OBJECTIVES

To understand the reasons behind, and experience of, seeking and receiving emergency ambulance treatment for a 'primary care sensitive' condition.

DESIGN

A comprehensive, qualitative systematic review. Medline, Embase, PsychInfo, Cumulative Index of Nursing and Allied Health, Health Management Information Systems, Healthcare Management Information Consortium, OpenSigle, EThOS and Digital Archive of Research Theses databases were systematically searched for studies exploring patient, carer or healthcare professional interactions with ambulance services for 'primary care sensitive' problems. Studies using wholly qualitative approaches or mixed-methods studies with substantial use of qualitative techniques in both the methods and analysis sections were included. An analytical thematic synthesis was undertaken, using a line-by-line qualitative coding method and a hierarchical inductive approach.

RESULTS

Of 1458 initial results, 33 studies met the first level (relevance) inclusion criteria, and six studies met the second level (methodology and quality) criteria. The analysis suggests that patients define situations worthy of 'emergency' ambulance use according to complex socioemotional factors, as well as experienced physical symptoms. There can be a mismatch between how patients and professionals define 'emergency' situations. Deciding to call an ambulance is a process shaped by practical considerations and a strong emotional component, which can be influenced by the views of caregivers. Sometimes the value of a contact with the ambulance service is principally in managing this emotional component. Patients often wish to hand over responsibility for decisions when experiencing a perceived emergency. Feeling empowered to take control of a situation is a highly valued aspect of ambulance care.

CONCLUSIONS

When responding to a request for 'emergency' help for a low-acuity condition, urgent-care services need to be sensitive to how the patient's emotional and practical perception of the situation may have shaped their decision-making and the influence that carers may have had on the process. There may be novel ways to deliver some of the valued aspects of urgent care, more geared to the resource-limited environment.

Impact of travel time and rurality on presentation and outcomes of symptomatic colorectal cancer: a cross-sectional cohort study in primary care

BACKGROUND

Several studies have reported a survival disadvantage for rural dwellers who develop colorectal cancer, but the underlying mechanisms remain obscure. Delayed presentation to GPs may be a contributory factor, but evidence is lacking.

AIM

To examine the association between rurality and travel time on diagnosis and survival of colorectal cancer in a cohort from northeast Scotland.

DESIGN AND SETTING

The authors used a database linking GP records to routine data for patients diagnosed between 1997 and 1998, and followed up to 2011.

METHOD

Primary outcomes were alarm symptoms, emergency admissions, stage, and survival. Travel time in minutes from patients to GP was estimated. Logistic and Cox regression were used to model outcomes. Interaction terms were used to determine if travelling time impacted differently on urban versus rural patients.

RESULTS

Rural patients and patients travelling farther to the GP had better 3-year survival. When the travel outcome associations were explored using interaction terms, the associations differed between rural and urban areas. Longer travel in urban areas significantly reduced the odds of emergency admissions (odds ratio [OR] 0.62, P<0.05), and increased survival (hazard ratio 0.75, P<0.05). Longer travel also increased the odds of presenting with alarm symptoms in urban areas; this was nearly significant (OR 1.34, P = 0.06). Presence of alarm symptoms reduced the likelihood of emergency admissions (OR 0.36, P<0.01).

CONCLUSION

Living in a rural area, and travelling farther to a GP in urban areas, may reduce the likelihood of emergency admissions and poor survival. This may be related to how patients present with alarm symptoms.

How rural and urban patients in Australia with colorectal or breast cancer experience choice of treatment provider: A qualitative study

Modern healthcare systems promote patient choice of cancer treatment provider, but little is known about how place of residence influences decision-making. This research explored how rural and urban patients with breast or colorectal cancer experience choice of cancer treatment provider in Victoria, Australia. Realist thematic analysis of 43 semi-structured telephone interviews identified little active participation in decision-making regardless of area of residence or cancer diagnosis. Perceptions of choice were impacted by urgency for treatment, insurance status and access to providers, a key issue for rural patients. All patients wanted high quality care, but needed to trust health professional's recommendations. Rural patients experienced more complex decision-making, balancing a range of social factors with perceptions about quality of accessible care. Further research into variation in quality of care and complex cancer pathways for rural and urban cancer patients is warranted to inform choices and enhance patient-centred care.

Differences in Human Papillomavirus Vaccination Among Adolescent Girls in Metropolitan Versus Non-metropolitan Areas: Considering the Moderating Roles of Maternal Socioeconomic Status and Health Care Access

OBJECTIVES

This study is among the first to examine metropolitan status differences in human papillomavirus (HPV) vaccine initiation and completion among United States adolescent girls and is unique in its focus on how maternal socioeconomic status and health care access moderate metropolitan status differences in HPV vaccination.

METHODS

Using cross-sectional data from 3573 girls aged 12-17 in the U.S. from the 2008-2010 Behavioral Risk Factor Surveillance System, we estimate main and interaction effects from binary logistic regression models to identify subgroups of girls for which there are metropolitan versus non-metropolitan differences in HPV vaccination.

RESULTS

Overall 34 % of girls initiated vaccination, and 19 % completed all three shots. On average, there were no metropolitan status differences in vaccination odds. However, there were important subgroup differences. Among low-income girls and girls whose mothers did not complete high school, those in non-metropolitan areas had significantly higher probability of vaccine initiation than those in metropolitan areas. Among high-income girls and girls whose mothers completed college, those in metropolitan areas had significantly higher odds of vaccine initiation than those in non-metropolitan areas. Moreover, among girls whose mothers experienced a medical cost barrier, non-metropolitan girls were less likely to initiate vaccination compared to metropolitan girls.

CONCLUSIONS

Mothers remain essential targets for public health efforts to increase HPV vaccination and combat cervical cancer. Public health experts who study barriers to HPV vaccination and physicians who come into contact with mothers should be aware of group-specific barriers to vaccination and employ more tailored efforts to increase vaccination.

Validation of a new measure of availability and accommodation of health care that is valid for rural and urban contexts

Context

Patients are the most valid source for evaluating the accessibility of services, but a previous study observed differential psychometric performance of instruments in rural and urban respondents.

Objective

To validate a measure of organizational accessibility free of differential rural–urban performance that predicts consequences of difficult access for patient‐initiated care.

Design

Sequential qualitative–quantitative study. Qualitative findings used to adapt or develop evaluative and reporting items. Quantitative validation study.

Setting

Primary data by telephone from 750 urban, rural and remote respondents in Quebec, Canada; follow‐up mailed questionnaire to a subset of 316.

Main measures and analyses

Items were developed for barriers along the care trajectory. We used common factor and confirmatory factor analysis to identify constructs and compare models. We used item response theory analysis to test for differential rural–urban performance; examine individual item performance; adjust response options; and exclude redundant or non‐discriminatory items. We used logistic regression to examine predictive validity of the subscale on access difficulty (outcome).

Results

Initial factor resolution suggested geographic and organizational dimensions, plus consequences of access difficulty. After second administration, organizational accommodation and geographic indicators were integrated into a 6‐item subscale of Effective Availability and Accommodation, which demonstrates good variability and internal consistency (α = 0.84) and no differential functioning by geographic area. Each unit increase predicts decreased likelihood of consequences of access difficulties (unmet need and problem aggravation).

Conclusion

The new subscale is a practical, valid and reliable measure for patients to evaluate first‐contact health services accessibility, yielding valid comparisons between urban and rural contexts.

A systematic review of health service interventions to reduce use of unplanned health care in rural areas

RATIONALE, AIMS AND OBJECTIVES

Use of unplanned health care has long been increasing, and not enough is known about which interventions may reduce use. We aimed to review the effectiveness of interventions to reduce the use of unplanned health care by rural populations.

METHODS

The method used was systematic review. Scientific databases (Medline, Embase and Central), grey literature and selected references were searched. Study quality and bias was assessed using Cochrane Risk of Bias and modified Newcastle Ottawa Scales. Results were summarized narratively.

RESULTS

A total of 2708 scientific articles, reports and other documents were found. After screening, 33 studies met the eligibility criteria, of which eight were randomized controlled trials, 13 were observational studies of unplanned care use before and after new practices were implemented and 12 compared intervention patients with non-randomized control patients. Eight of the 33 studies reported modest statistically significant reductions in unplanned emergency care use while two reported statistically significant increases in unplanned care. Reductions were associated with preventative medicine, telemedicine and targeting chronic illnesses. Cost savings were also reported for some interventions.

CONCLUSION

Relatively few studies report on unscheduled medical care by specifically rural populations, and interventions were associated with modest reductions in unplanned care use. Future research should evaluate interventions more robustly and more clearly report the results.

Mothers' decision-making during times of stress as a lone parent: a qualitative study

INTRODUCTION

Little empirical evidence exists to identify the impact that a partner's absence or presence has on the mother's decision-making and her consequential help-seeking behaviour when her child is unwell.

METHODS

This study used a qualitative design in three phases using focus groups and interviews to explore Army mothers' help-seeking behaviour as a lone parent when their child was unwell during the out-of-hours period. Thirty-one parents from a British Army garrison were interviewed.

RESULTS

The findings demonstrated that Army life created a combination of stressors for Army mothers, which altered their help-seeking behaviour when their child was unwell. When their partner was available, mothers contacted health services as a last resort, once all other avenues had been exhausted. However, in contrast, in their partners' absence, they were contacted as a first resort.

CONCLUSION

An algorithm was generated from the findings, which illustrates the importance of ascertaining whether the mother is alone at the time of the consultation. Increased emotional vulnerability intensified the need for reassurance and affected a mother's decision-making ability. Primary healthcare staff should ascertain whether mothers are currently lone parents at an early stage of their assessment, as this may influence the entire consultation.

Strategies for reducing visual impairment and blindness in rural and remote areas of Africa

The prevalence of visual impairment (VI) and blindness in Africa is one of the highest in the world; a large proportion of the causes are preventable. The prevalence is particularly high in rural and remote areas, where many of the continent’s inhabitants live. This is of great concern because of the low number and poor distribution of primary eye care practitioners, as well as poor eye care infrastructure services in those areas. Uncorrected refractive errors are a major cause of avoidable VI and blindness, and optometrists play a major role in refractive error correction on the continent. However, as with other healthcare providers in Africa, optometrists are few and tend to be mainly in major cities. This paper highlights possible strategies, in alignment with the Ottawa Charter for Health Promotion, that can reduce VI in rural and remote areas of the continent. The strategies include increasing the eye care workforce, attracting them to rural areas and retaining them there, improving the eye care infrastructure, service improvement such as equitable distribution of eye care practitioners, implementing preventive measures such as vision screening and affordable spectacles, and eye health education such as eye health promotions, school health programmes and eye care awareness campaigns. Such strategies could drastically reduce the prevalence of VI and blindness in rural and remote areas of Africa.

Small rural emergency services still manage acutely unwell patients: a cross-sectional study

OBJECTIVE

Examine the range of clinical situations encountered at small rural emergency care services. We hypothesised that over a 12 month period, small rural emergency services would encounter almost the entire range of clinical situations described at designated EDs.

METHODS

We undertook a cross-sectional prospective study observing five small rural emergency care services in South West Victoria. Patients were included if they presented between 1 February 2011 and 31 January 2012, and their type of visit was recorded as an emergency presentation. Main outcome measures are reports that describe clinical activity using the Victorian Emergency Minimum Dataset data collected at the five facilities.

RESULTS

There were 14 318 emergency presentations to the five emergency care services over 1 year. Almost 6% of patients (5.94%, 851/14 318, 95% CI 5.6-6.3%) were in the two most urgent categories. With a wide spectrum of problems presented, the level 1 facility saw 18 of the possible 27 diagnostic categories, and the level 2 and 3 facilities both saw 25 out of 27 diagnostic categories. There were 26 586 procedures recorded. Of the 62 possible medical procedures, only seven were not performed at least once. Critical care procedures were performed in levels 2 and 3 facilities.

CONCLUSION

The five small rural emergency facilities encountered most of the clinical problems seen in full EDs. They saw almost all categories of emergency presentation, saw almost all diagnostic categories, treated critically ill and injured patients, and performed most procedures.

Factors associated with the utilization of primary care emergency centers in a Spanish region with high population dispersion: a mixed-methods study

BACKGROUND

Adequate access to primary care emergency centers is particularly important in rural areas isolated from urban centers. However, variability in utilization of emergency services located in primary care centers among inhabitants of nearby geographical areas is understudied. The objectives of this study are twofold: 1) to analyze the association between the availability of municipal emergency care centers and utilization of primary care emergency centers (PCEC), in a Spanish region with high population dispersion; and 2) to determine healthcare providers' perceptions regarding PCEC utilization.

METHODS

A mixed-methods study was conducted. Quantitative phase: multilevel logistic regression modeling using merged data from the 2003 Regional Health Survey of Castile and Leon and the 2001 census data (Spain). Qualitative phase:14 in-depth- interviews of rural-based PCEC providers.

RESULTS

Having PCEC as the only emergency center in the municipality was directly associated with its utilization (p < 0.001). Healthcare providers perceived that distance to hospital increased PCEC utilization, and distance to PCEC decrease its use. PCEC users were considered to be predominantly workers and students with scheduling conflicts with rural primary care opening hours.

CONCLUSIONS

The location of emergency care centers is associated with PCEC utilization. Increasing access to primary care by extending hours may be an important step toward optimal PCEC utilization. Further research would determine whether lower PCEC use by certain groups is associated with disparities in access to care.

Risk of several cancers is higher in urban areas after adjusting for socioeconomic status. Results from a two-country population-based study of 18 common cancers

Some studies suggest that there are urban-rural variations in cancer incidence but whether these simply reflect urban-rural socioeconomic variation is unclear. We investigated whether there were urban-rural variations in the incidence of 18 cancers, after adjusting for socioeconomic status. Cancers diagnosed between 1995 and 2007 were extracted from the population-based National Cancer Registry Ireland and Northern Ireland Cancer Registry and categorised by urban-rural status, based on population density of area of residence at diagnosis (rural <1 person per hectare, intermediate 1-15 people per hectare, urban >15 people per hectare). Relative risks (RR) were calculated by negative binomial regression, adjusting for age, country and three area-based markers of socioeconomic status. Risks were significantly higher in both sexes in urban than rural residents with head and neck (males RR urban vs. rural = 1.53, 95 % CI 1.42-1.64; females RR = 1.29, 95 % CI 1.15-1.45), esophageal (males 1.21, 1.11-1.31; females 1.21, 1.08-1.35), stomach (males 1.36, 1.27-1.46; females 1.19, 1.08-1.30), colorectal (males 1.14, 1.09-1.18; females 1.04, 1.00-1.09), lung (males 1.54, 1.47-1.61; females 1.74, 1.65-1.84), non-melanoma skin (males 1.13, 1.10-1.17; females 1.23, 1.19-1.27) and bladder (males 1.30, 1.21-1.39; females 1.31, 1.17-1.46) cancers. Risks of breast, cervical, kidney and brain cancer were significantly higher in females in urban areas. Prostate cancer risk was higher in rural areas (0.94, 0.90-0.97). Other cancers showed no significant urban-rural differences. After adjusting for socioeconomic variation, urban-rural differences were evident for 12 of 18 cancers. Variations in healthcare utilization and known risk factors likely explain some of the observed associations. Explanations for others are unclear and, in the interests of equity, warrant further investigation.

The epidemiology of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional condition of the bowel that is diagnosed using clinical criteria. This paper discusses the nature of the diagnostic process for IBS and how this impacts epidemiological measurements. Depending on the diagnostic criteria employed, IBS affects around 11% of the population globally. Around 30% of people who experience the symptoms of IBS will consult physicians for their IBS symptoms. These people do not have significantly different abdominal symptoms to those who do not consult, but they do have greater levels of anxiety and lower quality of life. Internationally, there is a female predominance in the prevalence of IBS. There is 25% less IBS diagnosed in those over 50 years and there is no association with socioeconomic status. IBS aggregates within families and the genetic and sociological factors potentially underlying this are reviewed. Patients diagnosed with IBS are highly likely to have other functional disease and have more surgery than the general population. There is no evidence that IBS is associated with an increased mortality risk. The epidemiological evidence surrounding these aspects of the natural history is discussed.

Measuring patients' help-seeking decisions: results of a pilot-scale survey using a newly developed tool

AIM

The aim of the study was to establish the scale and cost of ineffectively made consultations by self-referring patients across three North Wales primary care practices for 'day-to-day' conditions.

BACKGROUND

Little evidence exists of the scale of ineffectively made day-to-day help-seeking by self-referral patients. Examination of this issue is compromised by the use of traditional language to describe help-seeking, which is subjective and of limited use. There is little understanding about help-seeking for day-to-day conditions. Most research on help-seeking behaviour has considered help-seeking for specific services; specific cohorts; or specific conditions, rather than help-seeking for day-to-day conditions.

METHOD

A survey of all routine consultations made at four general practices in North Wales over a one-week period was conducted. Using objective definitional parameters classifying routine consultations as either effectively or ineffectively made, we measured the scale of ineffective help-seeking. General practitioners categorised consultations as either effective or ineffective. Ineffectively made consultations were categorised as follows: potentially avoidable; made with the wrong healthcare professional; or made at the wrong time.

FINDINGS

A total of 22 GPs made 1217 routine consultations for day-to-day symptoms, of which 24% were ineffectively made. Fifteen percent of consultations were potentially avoidable. Potentially avoidable consultations alone may be costing the NHS £87.85 million annually. The ineffective use of limited and scarce healthcare resources should be examined. Patient outcome may be potentially compromised directly by poor help-seeking decisions but also by ineffective use of resources.

Moral hazard and supplier-induced demand: empirical evidence in general practice

Changes in cost sharing and remuneration system in the Netherlands in 2006 led to clear changes in financial incentives faced by both consumers and general practitioner (GPs). For privately insured consumers, cost sharing was abolished, whereas those socially insured never faced cost sharing. The separate remuneration systems for socially insured consumers (capitation) and privately insured consumers (fee-for-service) changed to a combined system of capitation and fee-for-service for both groups. Our first hypothesis was that privately insured consumers had a higher increase in patient-initiated GP contact rates compared with socially insured consumers. Our second hypothesis was that socially insured consumers had a higher increase in physician-initiated contact rates. Data were used from electronic medical records from 32 GP-practices and 35336 consumers in 2005-2007. A difference-in-differences approach was applied to study the effect of changes in cost sharing and remuneration system on contact rates. Abolition of cost sharing led to a higher increase in patient-initiated utilisation for privately insured consumers in persons aged 65 and older. Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation indicate limited evidence for moral hazard.

Does patients' place of residence affect the type of physician performing primary excision of cutaneous melanoma in northern Scotland?

BACKGROUND

Rural residence may adversely affect cancer outcomes, perhaps because rural cancer patients are managed differently. Current UK guidelines recommend all patients with suspected melanoma be referred urgently for specialist excision biopsy; however, up to 20% of patients receive their biopsy in primary care. This project explored if rural dwellers with melanoma were more likely to have their primary biopsy in primary care.

METHODS

A clinical database of all primary cutaneous melanomas diagnosed in Northern Scotland between January 1991 and July 2007 was analyzed for patient demographics, clinical variables, and intermediate outcomes. Significant findings on univariate analysis were then included in a binary logistic regression model to adjust for confounders.

RESULTS

On univariate analysis patients living in rural areas were significantly more likely to have their melanomas excised in primary care compared with those living in the city (26.3% compared with 17.7%, P < .001). There were no significant differences between rural and urban dwellers in Breslow thickness or completeness of excision. Following adjustment for key confounders, those living in suburban areas and remote small towns were significantly more likely to be treated contrary to current UK melanoma guidelines compared to those in cities.

CONCLUSIONS

In Northern Scotland patients living in suburban areas and remote small towns are significantly more likely to have an initial melanoma excision in primary care, contrary to current UK guidelines. This geographical contrast signposts the way to further in-depth research into the interplay between place of residence and how the cancer journey is experienced.

Preferences for managing symptoms of differing severity: a discrete choice experiment

BACKGROUND

To design cost-effective health services it is important to understand why people adopt particular symptom management strategies.

AIM

To establish the relative importance of factors that influence decision making when managing symptoms of differing severity, to establish how people trade between these factors, and to estimate the monetary value placed on different management types.

DESIGN

Discrete choice experiment.

SETTING

UK online research panel.

METHOD

Successive members of an online panel were invited to participate until 480 discrete choice experiment questionnaires were completed. Relative preferences for managing three symptom scenarios of varying severity were measured. Symptom management was described by three characteristics (management type, availability, and cost). Preferences for ways of managing symptoms were measured by using conditional logit analysis.

RESULTS

A total of 98.5% of the completed questionnaires were valid (473 of 480 respondents). People preferred to manage minor symptoms by self-care or by visiting a pharmacy and were willing to pay £21.58 and £19.06, respectively, to do so. For managing moderately severe symptoms, people preferred to consult a general practitioner and were willing to pay £34.86 for this option. People preferred to manage potentially very severe symptoms by consulting a general practitioner and were willing to pay £73.08 to do so. Respondents were willing to trade between management types; options less preferred became more attractive when waiting time and cost were reduced.

CONCLUSION

People value self-care, supported self-care, and general practitioner consultation differently depending on the type of symptoms. Manipulating costs to users and waiting times for different services could allow policymakers to influence the services people choose when managing symptoms.

Troubling stoicism: Sociocultural influences and applications to health and illness behaviour

In light of the ambiguity of meanings attributed to the concept of stoicism we critically explore its use as a label to explain and describe health and illness behaviour, juxtaposing the often negative portrayals of contemporary stoicism against its classical and philosophical origins. By reflecting critically on the term ‘stoicism’, its application and dimensionality, we show how the term has evolved from classical to contemporary times in relation to changing context, and explore different understandings of the term across medical and health literature. We attend to sociocultural factors that are seen to influence the conceptualization of stoicism such as generational influences, gender and geographies. We make the assertion that by applying the label of ‘stoicism’ as it is known today, there is a danger of too readily accepting a term that masks particular health behaviours while missing an array of sociological factors that are important to how people deal with adversity arising from chronic health problems. We therefore encourage further questioning of this term.

Is travel-time to a specialist centre a risk factor for non-referral, non-attendance and loss to follow-up among patients with hepatitis C (HCV) infection?

Little is known about why many people diagnosed with hepatitis C virus (HCV) infection fail to reach and stay within specialist care services. We used a Geographic Information System and logit regression to investigate whether travel-time to a specialist centre was associated with an increased likelihood of non-referral, non-attendance and loss to follow-up among persons diagnosed with HCV between 1991 and 2003 in Tayside, Scotland (UK). Information was available on referral to, and utilisation of, the single HCV specialist centre in Tayside between 1991 and 2006. Longer travel-time to a specialist centre was associated with an increased likelihood of non-referral to a specialist centre following diagnosis (Odds Ratio: 1.25, 95% Confidence Interval: 1.09, 1.44). Patients living further from an HCV specialist centre were less likely to be referred to it for treatment that could cure their HCV infection. Neither a history of intravenous drug use (IDU), nor area deprivation predicted non-referral. Subsequent to referral, travel-time to a specialist centre was not associated with either non-attendance (0.83 (0.56, 1.21)) or loss to follow-up (0.98 (0.78, 1.22)), although a history of IDU was a strong predictor of both non-attendance and loss to follow-up. Non-attendance was less likely among older patients, while loss to follow-up was more common among those living in deprived areas. Once referred, patients appear able to cope with stress and financial cost of long and frequent journeys to hospital. However, as rates of referral improve from more geographically remote areas, long travel-times to an HCV specialist centre may become an important factor determining future utilisation.

Urbanization and the utilization of outpatient services under National Health Insurance in Taiwan

OBJECTIVES

This study aims to investigate the relationship between the level of urbanization and the utilization of outpatient services under the National Health Insurance (NHI) program in Taiwan.

METHODS

We adopted a two-part model using data from the 2001 National Health Interview Survey (NHIS) and the 2001 National Health Insurance Research Database (NHIRD) in Taiwan. Data for a total of 20,640 individuals were obtained for subsequent analysis in this study.

RESULTS

The results of the first part, the contact analysis, indicate that individuals residing in areas with lower urbanization levels are less likely to use outpatient services compared to those residing in areas with the highest urbanization levels. The second part of the frequency analysis revealed that, for those individuals that had previously utilized outpatient services, those residing in areas with lower urbanization levels tended to utilize outpatient services less than individuals residing in areas with higher levels of urbanization.

CONCLUSIONS

Our empirical results show that differences between urbanization levels are a major contributory factor associated with the probability and frequency of outpatient utilization in Taiwan.

Evidence summary: what do we know from qualitative research about people's care-seeking about oral health?

Since August 2009, members of the Primary Care Dentistry Research Forum (http://www.dentistryresearch.org) have taken part in an online vote to identify questions in day-to-day practice that they felt most needed to be answered with conclusive research. The question which receives the most votes each month forms the subject of a critical appraisal of the relevant literature. Each month a new round of voting takes place to decide which further questions will be reviewed. Dental practitioners and dental care professionals are encouraged to take part in the voting and submit their own questions to be included in the vote by joining the website. The paper below details a summary of the findings of the ninth critical appraisal. In conclusion, the critical appraisal showed a wide range of factors that influence care-seeking about oral health. These included both barriers and triggers to care-seeking. Only five papers were found that provided relevant data, and their data collection settings varied widely. Further research into care-seeking about oral health would be useful for both policy makers and practitioners in understanding patients' needs.