Frequencies of emergency department use and hospitalization comparing patients with different types of substance or polysubstance-related disorders

Background This study measured emergency department (ED) use and hospitalization for medical reasons among patients with substance-related disorders (SRD), comparing four subgroups: cannabis-related disorders, drug-related disorders other than cannabis, alcohol-related disorders and polysubstance-related disorders, controlling for various clinical, sociodemographic and service use variables. Methods Clinical administrative data for a cohort of 22,484 patients registered in Quebec (Canada) addiction treatment centers in 2012-13 were extracted for the years 2009-10 to 2015-16. Using negative binomial models, risks of frequent ED use and hospitalization were calculated for a 12-month period (2015-16). Results Patients with polysubstance-related disorders used ED more frequently than other groups with SRD. They were hospitalized more frequently than patients with cannabis or other drug-related disorders, but less frequently than those with alcohol-related disorders. Patients with alcohol-related disorders used ED more frequently than those with cannabis-related disorders and underwent more hospitalizations than both patients with cannabis-related and other drug-related disorders. Co-occurring SRD-mental disorders or SRD-chronic physical illnesses, more years with SRD, being women, living in rural territories, more frequent consultations with usual general practitioner or outpatient psychiatrist, and receiving more interventions in community healthcare centers increased frequency of ED use and hospitalization, whereas both adverse outcomes decreased with high continuity of physician care. Behavioral addiction, age less than 45 years, living in more materially deprived areas, and receiving 1-3 interventions in addiction treatment centers increased risk of frequent ED use, whereas living in semi-urban areas decreased ED use. Patients 25-44 years old receiving 4+ interventions in addiction treatment centers experienced less frequent hospitalization. Conclusion Findings showed higher risk of ED use among patients with polysubstance-related disorders, and higher hospitalization risk among patients with alcohol-related disorders, compared with patients affected by cannabis and other drug-related disorders. However, other variables contributed substantially more to the frequency of ED use and hospitalization, particularly clinical variables regarding complexity and severity of health conditions, followed by service use variables. Another important finding was that high continuity of physician care helped decrease the use of acute care services. Strategies like integrated care and outreach interventions may enhance SRD services.

Eliciting preferences of patients about the quality of hospital services in the west of Iran using discrete choice experiment analysis

Objectives Knowing about accurate customer expectations is the most important step in defining and delivering high-quality services. This study aimed to evaluate the preferences of patients referring to two hospitals in Kermanshah, Iran. Method Discrete choice experiment (DCE) method used to elicit preferences of 328 patients who were admitted in two hospitals of Kermanshah city in the west of Iran. Literature review and experts opinion were used to identify a candidate list of attributes related to the quality of cares in hospitals. The final study attributes were quality of physician care, quality of nursing care, waiting time for admission, cleaning of wards and toilets, and behavior of staff. Experimental design applied to extract choice sets of hospitals. The data was analyzed by a conditional logit regression. Results The regression results showed the most important predictors of hospital selection by respondents was the good quality of physician care (aOR: 3.18, 95% CI 2.61, 3.87), followed by friendly behavior of staffs (aOR: 2.03, 95% CI 1.81, 2.27), cleanness of wards and toilet (aOR: 1.61, 95% CI 1.40, 1.85), and finally quality of nursing cares (aOR: 1.13, 95% CI 0.89, 1.44). However, increasing waiting time made disutility in the study participants (aOR: 0.69, 95% CI 0.60, 0.80). Conclusions Our study finding emphasized some potential opportunity of quality augmentation in hospital sector by paying attention to different quality attributes including quality of physician, friendly behavior of staffs, cleanness of hospital environment and finally quality of nursing cares. Considering patients preferences in decision making process could lead to substantial satisfaction improvement.

Drivers of respiratory healthcare demand in Acre state, Brazilian Amazon: a cross-sectional study

1.1 BackgroundThe scant knowledge on drivers of demand for respiratory healthcare in Brazilian Amazon, where the gap of human and physical healthcare resources is wide, is expanded with two surveys conducted at the west of the region in Acre state. Potential drivers, informed by a review of twelve recent papers, were classified in seven categories comprising the individual, household, community and macroeconomic dimensions.1.2 MethodsOn-field quantitative structured surveys were conducted in 2017 and 2019 based in coupled conglomerate-quota-randomization sampling, with support of community health agents. Adults responded about their own or their children’s health. Whether physician care was sought to treat the latest episode of respiratory illnesses or of dry cough was analysed statistically with multiple non-linear regressions having as covariates the potential predictors informed by literature.1.3 ResultsThe propensity to seek healthcare and to purchase medication was larger when targeting children rather than adults. Influenza was the most frequent cause of latest episodes of respiratory illnesses and dry cough, what makes the below-40% healthcare seeking rate worrying as it may sustain a considerable local contagion rate. Illnesses’ severity, including the pain experienced, were the main predictors, revealing that subjective perception exerted stronger influence than objective individual’s and households’ characteristics. The insignificance of education indicated that it was not the sole determinant of health literacy, the latter a more important driver, according to literature. Income was insignificant due to respondents relying almost uniquely on free healthcare offered by the Brazilian Health System.1.4 ConclusionsResults suggest that subjective underestimation of respiratory illnesses’ consequences for oneself and for local society could motivate a refusal to seek treatment. This is in line with some previous studies but departs from those overemphasizing the role of objective factors. Social consequences, of, for instance, macroeconomic nature, needs highlighting, based on studies detecting a long-run relationship between healthcare demand, health and economic performance at national level. Microeconomic behavioural policy is needed to change subjective perceptions of symptoms and illnesses with nudges and educational interventions.

Reallocations in acne healthcare: exploring the possible roles and added value of non-physicians by a mixed-methods study design

Background A highly promoted opportunity for optimizing healthcare services is to expand the role of non-physician care providers by care reallocation. Reallocating care from physicians to non-physicians can play an important role in solving systemic healthcare problems such as care delays, hospital overcrowding, long waiting lists, high work pressure and expanding healthcare costs. Dermatological healthcare services, such as the acne care provision, are well suited for exploring the opportunities for care reallocation as many different types of care professionals are involved in the care process. In the Netherlands, acne care is mainly delivered by general practitioners and dermatologists. The Dutch healthcare system also recognizes non-physician care providers, among which dermal therapists and beauticians are the most common professions. However, the role and added value of non-physicians is still unclear. The present study aimed to explore the possibilities for reallocating care to non-physicians and identify drivers for and barriers to reallocation. Methods A mixed-method design was used collecting quantitative and qualitative data from representatives of the main 4 Dutch professions providing acne care: dermatologists, GP’s, Dermal therapists and beauticians. Results A total of 560 questionnaires were completed and 24 semi-structured interviews were conducted. A broad spectrum of non-physician tasks and responsibilities were delineated. Interviewed physicians considered acne as a low-complexity skin condition which made them willing to explore the possibilities for reallocating. A majority of all interviewees saw a key role for non-physicians in counselling and supporting patients during treatment, which they considered an important role for increasing patients’ adherence to proposed treatment regimes, contributing to successful clinical outcome. Also, the amount of time non-physicians spend on patients was experienced as driver for reallocation. Legislation and regulations, uncertainties about the extent of scientific evidence and proper protocols use within the non-physician clinical practice were experienced as barriers influencing the possibilities for reallocation. Conclusions Delineated roles and drivers demonstrate there is room and potential for reallocation between physicians and non-physicians within acne healthcare, when barriers are adequately addressed.

Measurement of Pharmacist-Physician Collaborative Care on Therapeutic Inertia in Patients With Type 2 Diabetes

Background Team-based care practice models have been shown to improve diabetes-related therapeutic inertia, yet the method and type of antidiabetic treatment intensification (TI) leading to improvements in glycemic control are not well understood. Objective To evaluate time to TI in a pharmacist-physician practice model (PPM) as compared with usual medical care (UMC), explore the method and type of antidiabetic TI, and evaluate achievement of hemoglobin A1C (A1C) goal among each cohort. Methods This was a retrospective cohort study conducted between January 1, 2017, and December 31, 2018. Median time to TI was calculated and compared between patients in the PPM and UMC groups using the log rank test. Descriptive statistics were used to evaluate the method and type of TI and A1C goal achievement. Results A total of 56 patients were included. The median (interquartile range) time to antidiabetic TI among the PPM cohort was 37.5 days (8, 216.5), as compared with 142 days (16, 465) in the UMC cohort ( P = 0.19). At 1 year post–index date, 25% of patients in the PPM cohort reached their A1C goal compared with 18.8% of patients in the UMC cohort. This effect was maintained in the subgroup (n = 49) of patients receiving TI (23.1% vs 17.8%). Conclusion and Relevance A shorter time to TI and improvement in A1C goal achievement was observed with pharmacist-physician care compared with UMC. These findings suggest that pharmacist-physician care may be one of several interventions necessary to overcome therapeutic inertia in diabetes care.

Characterising generalism in clinical practice: a systematic mixed studies review protocol

BackgroundGeneralist physician care is associated with improved patient outcomes. Despite initiatives to promote generalism in educational settings, recruitment to generalist disciplines remains less than required to serve societal needs. Increasingly this impacts not just general practice but generalist specialties such as internal medicine, surgery and paediatrics. One potential factor for this deficit is a lack of explicit attention to generalism as a praxis, including clarifying key aspects of generalist expertise.AimTo examine empirical clinical literature on generalism and characterise how generalism is described and delivered by physicians in primary and secondary care.Design & SettingSystematic mixed studies review including quantitative, qualitative, mixed-methods studies and systematic reviews of physician generalist practice.MethodMedline, Psycinfo, Socioindex, EMBASE, OVID Healthstar, Scopus, Web of Science will be searched for English language studies from 1999 to present, using a structured search. Given study heterogeneity we will not perform quality appraisal. Two reviewers will perform study selection for each study. Data extraction will focus on how generalism is defined and characterised, including the clinical care provided by generalists and patient experiences of generalist care. Quantitative and qualitative data will be summarised in tabular and narrative form. Convergent synthesis design will then be used to synthesise quantitative and qualitative data.ConclusionFindings will characterise generalism and generalist practice from a grass-roots clinical perspective. By identifying similarities and differences across generalist disciplines, this work will inform more focused educational initiatives on generalism at undergraduate and postgraduate level, including collaborations between generalist disciplines.