Consultation length, process quality and diagnosis quality of primary care in rural China: A cross-sectional standardized patient study

Contact time in GP Care: Descriptive patterns and a scoping review of the literature

BACKGROUND

Contact time in general practice (GP) refers to the duration a physician spends with a patient during an appointment. There are significant differences in contact times across OECD countries, raising questions about the influencing factors and potential consequences of these variations.

OBJECTIVE

To study the determinants and consequences of the length of consultations in GP care.

METHOD

We descriptively investigate differences in average appointment durations in GP care across OECD countries. We then conduct a scoping review of the literature encompassing 150 studies in seven topical clusters.

RESULTS

We identify considerable differences in contact times across countries and find evidence for substitution effects between the length of consultations and the number of consultations per year. There is also an association between reimbursement schemes and visit lengths. The review reveals consistent evidence for a few determinants, such as patient characteristics and physician experience, but mixed evidence on the effects of contact time on shared decision-making and health outcomes. The literature is dominated by correlational studies.

CONCLUSION

Descriptive comparisons show shorter contact times are substituted with more frequent visits, and fee-for-service payment systems result in longer contact times compared to capitation systems. For future health policy discussions, it is crucial to clarify which service delivery form is socially desired and economically sustainable.

"The doctor will see you now… but not for long": Linking physicians' racial attitudes and patients' discrimination experiences to racial disparities in the duration of medical consultations

OBJECTIVE

To investigate the relationship between non-Black physicians' racial attitudes, Black patients' discrimination experiences, and consultation duration in diverse clinical settings.

METHODS

Secondary analyses were conducted on data from three prior studies involving non-Black primary care physicians (Study 1: n = 14, Study 2: n = 5) and their Black patients (Study 1: n = 118, Study 2: n = 31), as well as 15 non-Black oncologists and their 72 Black patients (Study 3). Data included physician and patient surveys, along with video-recorded consultations.

RESULTS

Study 1 revealed that, relative to other physicians, physicians whose racial attitudes fit an aversive racist profile (i.e., low explicit racial bias, high implicit bias) had longer consultations with Black patients who reported more (vs. fewer) discrimination experiences. Study 2 and 3 found that physicians' implicit racial bias is negatively associated with consultation duration. Finally, a meta-analysis supported the effects of aversive racism and patients' discrimination experiences on consultation duration.

DISCUSSION

These findings demonstrate how physicians' racial attitudes and patients' discrimination experiences can affect medical consultation duration-an important aspect of patient-provider communication quality.

PRACTICAL VALUE

These results provide initial evidence for the importance of helping physicians manage the negative consequences of their implicit bias within the current structural constraints of limited medical consultation time and empowering Black patients to advocate for their healthcare needs.

Efficiency analysis of primary health care resources: DEA and Tobit regression evidence from village clinics in Jiangsu Province

Background

Village clinics are essential for delivering primary health care in rural China, yet their resource allocation efficiency remains a concern. Many clinics face challenges such as low technical efficiency, imbalanced resource distribution, and insufficient technological progress, which may hinder the delivery of quality healthcare services.

Methods

This study evaluates the resource allocation efficiency of village clinics across 13 cities in Jiangsu Province, China, using Data Envelopment Analysis. The Malmquist Productivity Index was applied to assess efficiency changes over time, and Tobit regression was employed to identify influencing factors.

Results

The overall efficiency of village clinic resource allocation in Jiangsu Province is suboptimal. In 2022, the average technical efficiency was 0.869, with seven cities classified as inefficient. Among them, three exhibited decreasing returns to scale, while four demonstrated increasing returns to scale. Reducing the number of village clinics and health technicians while increasing medical revenue could improve efficiency. From 2015 to 2022, the average Malmquist Productivity Index was 0.96, with a significant decline of 11.6% in 2021-2022, primarily due to a 6.8% decrease in technological change. Random-effects Tobit regression revealed that population density positively correlates with technical efficiency (coefficient = 0.0014, p < 0.05), whereas per capita disposable income, healthcare fiscal expenditure, and urbanization rate showed no statistically significant effects.

Conclusion

The resource allocation efficiency of village clinics in Jiangsu Province is insufficient, with technological change being a key driver of efficiency fluctuations. Population density plays a significant role in efficiency variation. To enhance efficiency, optimizing resource allocation strategies and promoting technological advancements are essential for strengthening rural primary health care.

US Real-World Effectiveness, Tolerability, and Healthcare Resource Utilization After Addition of Fremanezumab for Preventive Treatment in Patients Using Gepants for Acute Treatment of Migraine: Results From a Retrospective Chart Review

INTRODUCTION

Fremanezumab, a monoclonal antibody (mAb) targeting the calcitonin gene-related peptide (CGRP) pathway, and gepants, small molecule CGRP receptor antagonists, are both approved for the treatment of migraine or its symptoms. This study assessed effectiveness, tolerability, and migraine-related healthcare resource utilization (HCRU) after the addition of fremanezumab for preventive migraine treatment in patients using gepants for acute treatment.

METHODS

Data were extracted during a retrospective chart review from electronic medical records from the Dent Neurologic Institute. Eligible patients were ≥ 18 years old, using gepants (rimegepant or ubrogepant), who initiated fremanezumab between January 1, 2020, and May 1, 2021 (index date: date of fremanezumab initiation) and continued concomitant use of gepants and fremanezumab for ≥ 1 month (post-index; between 7-9 months of follow-up). Outcomes included monthly migraine days (MMD), adverse events (AEs), reasons for discontinuation, and migraine-related HCRU.

RESULTS

A total of 55 patients [female, 93%; mean (SD) age, 43.5 (13.5) years] met the inclusion criteria. All patients were diagnosed with chronic migraine. Patients had an average (SD) MMD of 15.8 (7.4) at the index date. Average (SE) change in MMD from index date to post-index was - 6.5 (1.0) days (p < 0.0001). Five patients (9.1%) experienced AEs post-index; no serious AEs (SAEs) were reported. The number of migraine-related medications used decreased from the index date to post-index by a mean of 0.6 for preventive medications (p = 0.070), and 0.8 for acute medications (p = 0.050). The number of outpatient office-based visits also decreased [mean (SD): 6 months pre-index, 5.8 (4.4) vs. 6 months post-index, 4.1 (4.0); p < 0.0001].

CONCLUSION

The addition of fremanezumab preventively to gepants for acute migraine treatment was effective, resulted in fewer outpatient office visits, and yielded no SAEs or AEs that were novel to these migraine medication classes.

How general practitioners in France are coping with increased healthcare demand and physician shortages. A panel data survey and hierarchical clustering

BACKGROUND

General practitioners (GPs) face quantitative and qualitative changes in patient demand and doctor shortages.

OBJECTIVES

To investigate how GPs cope with doctor shortage issues.

MATERIALS AND METHODS

Two cross-sectional surveys of a representative panel of 1530 GPs in 2019 and 2022 about their perceptions of physician shortages, working hours worked (WHW), and adaptive behaviors. Hierarchical clustering enabled identification of profiles with different adaptation patterns. Multiple Poisson or logistic regression models studied associations between GPs' profiles and professional characteristics.

RESULTS

87.4 % of GPs applied at least one adaptation to control patients' healthcare demand. 24 % adopted task-shifting while their average WHW decreased by 3.6 h between 2019 and 2022. Four GP profiles were identified. "Low adapters/low workload" and "Low adapters/high workload" (25 % of the sample each) reported 2.4 adaptive measures: 75.5 % refused to be new patients' preferred doctor in the former group (vs 5.1 %). "High adapters/unchanged consultations" (30.7 %) and "High adapters/shortened consultations" (18.9 %) reported 4.8 and 6.1 adaptations, respectively. They were more likely to practice in medically underserved areas.

CONCLUSION

These results call into question GPs' gatekeeper role in the French healthcare system. Moreover, the marked reduction in WHW in underserved areas is likely to exacerbate their uneven distribution nationwide. Encouraging vertical integration between HCPs while enhancing cooperation and task-shifting is probably a pathway toward improving the relative GP shortage.

Investigating the Relationship Between Patient-Centered Communication and Quality of E-Consult in China: A Cross-Sectional Standardized Patient Study

Patient-centered communication is widely acknowledged as an essential element of high-quality healthcare. Our study attempted to explore the weaknesses in the actual doctor-patient communication process and the most critical elements in patient-centered communication to improve the service quality of e-consult. We recruited ten standardized patients presenting fixed cases (urticaria and childhood diarrhea) for 321 valid interactions to measure patient-centered communication and e-consult service quality. The scores of patient-centered communication included exploring the patient's disease experience, understanding the patient's social situation, and reaching a consensus between doctors and patients. We measured the quality of e-consult services by the total words of doctor's responses, accurate diagnosis, appropriate prescription, lifestyle modification advice, patient satisfaction, continuance intention, and cost. Ordinary least-squares and logistic regression were performed to investigate the association between patient-centered communication and e-consult service quality. The total mean score of patient-centered communication was 17.67. The mean words of responses and cost were 178.55 words and 39.46 yuan, respectively. 82.87% of doctors diagnosed accurately, with 21.81% prescribing appropriate prescriptions and 81.93% providing lifestyle modification advice. 254 interactions obtained high satisfaction, and 218 had continuance intention after the interactions. Doctors with higher patient-centered communication levels would provide more words of responses. They were more likely to provide accurate diagnoses, appropriate prescriptions, and lifestyle modification advice, resulting in better patient satisfaction, continuance intention, and higher costs. Therefore, it is necessary to standardize and improve the doctor-patient communication process of e-consult and develop training for different doctors.

Primary care quality and provider disparities in China: a standardized-patient-based study

Background

Primary health care is the foundation of high-performing health systems. Achieving an improved primary care system requires a thorough understanding of the current quality of care among various providers within the system. As the world's largest developing country, China has made significant investments in primary care over the past decade. This study evaluates the quality of primary care across different provider types in China, offering in-sights for enhancing China's primary care system.

Methods

We merged data from four standardized patient (SP) research projects to compare the quality of five major primary care providers in China: rural clinics, county hospitals, migrant clinics, urban community health cen-ters (CHCs), and online platforms. We evaluated quality of care across process quality (e.g., checklist completion), diagnosis quality (e.g., diagnostic accuracy), and case management (e.g., correct medication), employing multiple regression analyses to explore quality differences by provider type, and their associations with physician characteristics.

Findings

We document a poor quality of primary care in China, with no-table disparities across different providers. CHCs emerge as relatively reliable primary care providers in terms of process quality, diagnostic accuracy, and cor-rect medication prescriptions. Online platforms outpace rural clinics, county hospitals, and migrant clinics in many areas, showcasing their potential to en-hance access to quality healthcare resources in under-resourced rural regions. We observe a positive association between the qualifications of physicians and the quality of primary care, underscoring the necessity for a greater presence of more highly qualified practitioners.

Interpretation

Primary care quality in China varies greatly among providers, reflecting inequalities in healthcare access. While online platforms indicate po-tential for improving care in under-resourced areas, their high referral rates suggest they cannot completely substitute traditional care. The findings em-phasize the need for more qualified practitioners and stringent regulation to enhance care quality and reduce unnecessary treatments.

Funding

No founders had a role in the study design, data collection, data analysis, data interpretation, or writing of the report. We have acknowledged this in the revised manuscript.

The Significance of Physician-Patient Communication on Telemedicine Patients' Health Outcomes: Evidence from Indonesia

The importance of physician-patient communication on patient health outcomes has been globally known. Poor communication in clinical settings, including in telemedicine visits, has been identified as a key barrier to successful medical consultation. This barrier is even more prevalent among people from linguistically and culturally diverse communities. This study investigated the influence of physician-patient communication on telemedicine patient health outcomes in Indonesia, a developing country with great linguistic and cultural diversity. This study utilized secondary data from a telemedicine utilization survey conducted during the coronavirus disease 2019 (COVID-19) pandemic. Socioeconomic factors and communication features were included as predictors of patients' health improvement. Logistic regressions were utilized to examine the significance of the communication features on patients' health. The analysis results indicated that five communication features including the adequacy of consultation length, a timely physician response, the provision of an explanation of the medication and possible side effects, the patient's ability to utter their physical condition and opinion regarding medication goals, and the patient's ability to comprehend physician explanations and instructions were significantly associated with the patient's health outcomes. Physicians and healthcare providers should focus on the provision of communication features revealed in this study to elevate the likelihood of improved health conditions in telemedicine patients.

Social disparities in access and quality of consultation in outpatient care in Germany

BACKGROUND

Overall, research on social determinants of access and quality of outpatient care in Germany is scarce. Therefore, social disparities (according to sex, age, income, migration background, and health insurance) in perceived access and quality of consultation in outpatient care (primary care physicians and specialists) in Germany were explored in this study.

METHODS

Analyses made use of a cross-sectional online survey. An adult population sample was randomly drawn from a panel which was recruited offline (N = 2,201). Perceived access was assessed by waiting time for an appointment (in days) and travel time to the practice (in minutes), while quality of consultation was measured by consultation time (in minutes) and quality of communication (scale of four items, Cronbach's Alpha 0.89).

RESULTS

In terms of primary care, perceived access and quality of consultation was worse among women compared to men. Estimated consultation time was shorter among people with statutory health insurance compared to privately insured respondents. Regarding specialist care, people aged 60 years and older reported shorter waiting times and better quality of communication. Lower income groups reported lower quality of communication, while perceived access and quality of consultation was worse among respondents with a statutory health insurance. Variances explained by the social characteristics ranged between 1% and 4% for perceived access and between 3% and 7% for quality of consultation.

CONCLUSION

We found social disparities in perceived access and quality of consultation in outpatient care in Germany. Such disparities in access may indicate structural discrimination, while disparities in quality of consultation may point to interpersonal discrimination in health care.

Process quality, diagnosis quality, and patient satisfaction of primary care in Rural Western China: A study using standardized patients

OBJECTIVES

Patient satisfaction is an essential indicator of the doctor-patient relationship. This study aimed to investigate the relationship between primary care quality and patient satisfaction for non-communicable diseases (NCDs) in rural western China.

METHODS

The study utilized the standardized patients (SPs) approach to present typical symptoms of unstable angina and diabetes to rural healthcare providers. After the consultations, the SPs completed a satisfaction survey. Ordinary least squares and quantile regression were used to examine the association between quality of primary care and patient satisfaction.

RESULTS

We examined 178 anonymous SPs visits. The results showed that higher process quality for angina SPs was correlated with stronger satisfaction for provider ability at a low quantile of ability satisfaction. For diabetes SPs, higher process quality increased overall satisfaction at a low quantile of overall satisfaction, whereas a correct diagnosis significantly contributed to communication satisfaction at a high quantile of communication satisfaction.

CONCLUSIONS

The study found positive associations between process and diagnosis quality and SPs satisfaction. Notably, the influence of process quality was most significant among patients with lower satisfaction levels.

PRACTICE IMPLICATIONS

Provider's process quality could be a key area of improving the satisfaction levels, especially for patients with lower levels of satisfaction.

Physician Communication Behaviors on Patient Satisfaction in Primary Care Medical Settings in Bangladesh

OBJECTIVES

This study aims at exploring the effects of physicians' communication behaviors on patients' satisfaction in primary care medical consultations in Chattogram, Bangladesh. The study used a quantitative research approach designed with a cross-sectional survey.

METHODS

Data were collected using post-consultation and facilitator administered questionnaire from the patients who visited the physician for medical consultation in different hospitals and clinics in Chattogram city. Seven hundred patients were included as the study participants. A hierarchical linear regression analysis was performed to examine the factors contributing to the outcome variables.

RESULTS

A statistically significant difference (P < .001) appeared regarding patients' perception of adequate consultation, physicians' nonverbal behavior, inhibiting behavior and patients' participating behavior in private and public settings. However, R2 value shows that physicians' patient-centered behaviors appeared as the stronger predictors of patient satisfaction toward medical interviews, followed by socioeconomic variables of patients and physicians and patients' participation during the consultation. Presence of a third person with patients during consultation (β = -.05, P = .040), physicians' private setting of consultation (β = .16, P < .001), physicians' seniority (β = .05, P = .042), patients' participating behavior during consultation (β = .20, P < .001), physicians' nonverbal behavior (β = .10, P < .001), physicians' inhibiting behavior (β = -.39, P < .001), and physicians' facilitating behavior with patients (β = .32, P < .001) were reported as the influencing factors of patients' satisfaction with medical consultation.

CONCLUSION

This study suggests the profound impact of physicians' patient-centered communication behaviors on patient satisfaction in primary care settings, overshadowing even socioeconomic factors and patient participation.

It's About Time: A Study of Rheumatology Patient Consultation Times

OBJECTIVE

A study was conducted evaluating the process of a rheumatology consultation.

METHODS

Data on consultation times was obtained from 100 patient processes over three months. Prior to data collection, unstructured interviews were conducted with the entire staff of the rheumatology clinic in Shalamar Hospital, to understand the consultation process. Based on this, consultation was divided into distinct segments (vitals, history and examination, specialist registrar consultation, specialist consultation, documentation and exercise/prescription handing over) and data was collected for the time taken for the patient to complete each segment. Designation of the personnel conducting the process, diagnosis, current visit number and general notes were also recorded.

RESULTS

Patients with rheumatoid arthritis (RA) consulted for an average time of 33.4 and 27.4 minutes for new and established patients respectively in our observations. Patients with systemic lupus erythematosus (SLE) on the other hand spent 34.5 and 37 minutes for new and established patients respectively. The greatest time spent during any segment of the consultation was during documentation, which averaged 10 minutes per patient.

CONCLUSION

Our study found that consultation times at Shalamar Hospital's rheumatology clinic align with international guidelines. Implementing a triaging method could optimize resource allocation, while entrusting specialist nurses with stable patient follow-ups could enhance patient flow and provision of health education.

Structural Determinants of Child Health in Rural China: The Challenge of Creating Health Equity

Over the past two decades, the literature has shown a clear gradient between child health and wealth. The same health-wealth gradient is also observed among children in China, with a large gap in health between rural and urban children. However, there are still unanswered questions about the main causes of China's rural-urban child health inequality. This paper aims to review the major factors that have led to the relatively poor levels of health among China's rural children. In addition to the direct income effect on children's health, children in rural areas face disadvantages compared with their urban counterparts from the beginning of life: Prenatal care and infant health outcomes are worse in rural areas; rural caregivers have poor health outcomes and lack knowledge and support to provide adequate nurturing care to young children; there are large disparities in access to quality health care between rural and urban areas; and rural families are more likely to lack access to clean water and sanitation. In order to inform policies that improve health outcomes for the poor, there is a critical need for research that identifies the causal drivers of health outcomes among children. Strengthening the pediatric training and workforce in rural areas is essential to delivering quality health care for rural children. Other potential interventions include addressing the health needs of mothers and grandparent caregivers, improving parenting knowledge and nurturing care, improving access to clean water and sanitation for remote families, and most importantly, targeting poverty itself.

Investigating the relationship between consultation length and quality of tele-dermatology E-consults in China: a cross-sectional standardized patient study

Background

Consultation length, the time a health provider spend with the patient during a consultation, is a crucial aspect of patient-physician interaction. Prior studies that assessed the relationship between consultation length and quality of care were mainly based on offline visits. Research was lacking in E-consults settings, an emerging modality for primary health care. This study aims to examine the association between consultation length and the quality of E-consults services.

Methods

We defined as standardized patient script to present classic urticaria symptoms in asynchronous E-consults at tertiary public hospitals in Beijing and Hangzhou, China. We appraised consultation length using six indicators, time waiting for first response, time waiting for each response, time for consultation, total times of provider’s responses, total words of provider’s all responses, and average words of provider’s each response. We appraised E-consults services quality using five indicators building on China’s clinical guidelines (adherence to checklist; accurate diagnosis; appropriate prescription; providing lifestyle modification advice; and patient satisfaction). We performed ordinary least squares (OLS) regressions and logistic regressions to investigate the association between each indictor of consultation length and E-consults services quality.

Results

Providers who responded more quickly were more likely to provide lifestyle modification advice and achieve better patient satisfaction, without compromising process, diagnosis, and prescribing quality; Providers who spent more time with patients were likely to adhere to clinical checklists; Providers with more times and words of responses were significantly more likely to adhere to the clinical checklist, provide an accurate diagnosis, appropriate prescription, and lifestyle modification advice, which achieved better satisfaction rate from the patient as well.

Conclusions

The times and words that health providers provide in E-consult can serve as a proxy measure for quality of care. It is essential and urgent to establish rules to regulate the consultation length for Direct-to-consumer telemedicine to ensure adequate patient-provider interaction and improve service quality to promote digital health better.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08566-2.

Patient Activeness During Online Medical Consultation in China: Multilevel Analysis

Background

Online medical consultation is an important complementary approach to offline health care services. It not only increases patients’ accessibility to medical care, but also encourages patients to actively participate in consultation, which can result in higher shared decision making, patient satisfaction, and treatment adherence.

Objective

This study aims to explore multilevel factors that influence patient activeness in online medical consultations.

Methods

A data set comprising 40,505 patients from 300 physicians in 10 specialties was included for multilevel analysis. Patient activeness score (PAS) was calculated based on the frequency and the proportion of patient discourses to the total frequency of doctor-patient interactions. Intraclass correlation coefficients were calculated to identify between-group variations, and the final multilevel regression model included patient- and physician-level factors.

Results

Patients were not equally active in online medical consultations, with PASs varying from 0 to 125.73. Patient characteristics, consultation behavioral attributes, and physician professional characteristics constitute 3 dimensions that are associated with patient activeness. Specifically, young and female patients participated more actively. Patients’ waiting times online (β=–.17; P<.001) for physician responses were negatively correlated with activeness, whereas patients’ initiation of conversation (β=.83; P<.001) and patient consultation cost (β=.52; P<.001) in online medical consultation were positively correlated. Physicians’ online consultation volumes (β=–.10; P=.01) were negatively associated with patient activeness, whereas physician online consultation fee (β=.03; P=.01) was positively associated. The interaction effects between patient- and physician-level factors were also identified.

Conclusions

Patient activeness in online medical consultation requires more scholarly attention. Patient activeness is likely to be enhanced by reducing patients’ waiting times and encouraging patients’ initiation of conversation in online medical consultation. The findings have practical implications for patient-centered care and the improvement of online medical consultation services.