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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Further work needed
Do patients perceive the after-hours acute care providers to have complementary skills?
Can results be extrapolated to US model?
Where can this research lead?
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Marc Afilalo, Montreal, Canada Chief, Emergency dept, Jewish General hospital
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Various models of care have emerged as a possible solution to problems posed by the limitations of the current structures of care and increasing patient needs. Patient satisfaction is viewed as an important indicator of quality of care of the services provided to patients and their families. Satisfaction is also an indicator that policy makers, managers and administrators use in formulating action plans to improve quality of care. Michelle Howard et al, conducted a survey on satisfaction with health care services used for urgent health care problems in the previous 6 months among family practice patients. The question asked was how dissatisfied or satisfied patients were with how their most recent emergency was handled. Howard et al, found that those patients who reported an urgent heath problem and who visited or talked to their family doctor were more satisfied then those who visited an emergency department, a walk in clinic, or used a telephone advisory service. Based on these findings the authors suggest that there is support for increasing financial and human resources to enhance access to primary care services. However, more then half of the patients (55%) had their emergency handled by the emergency department compared to only 16% by their family doctor. At first glance the study’s findings are not surprising but are the patients’ conditions and circumstances really comparable? As the authors correctly point out there are many limitations with this study. A very important limitation is that we do not know what led the patients to choose the various services available for their urgent problem. Was it their condition, accessibility, referral, convenience, etc. Further work in this area is needed before specific evidence-based recommendations can be made regarding service satisfaction before increasing financial and human resources to enhance access to primary care services. Competing interests: None declared |
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Eric P Moll van Charante, Amsterdam, The Netherlands Family Physician, Dept. Family Practice, Academic Medical Centre, University of Amsterdam
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Howard et al. have produced an important survey on patient satisfaction with different after-hours acute care providers and I agree with JoAnn Elizabeth Leavey that it would be worthwhile to extend the survey towards both various urban and rural areas to find out if there are differences in determinants that are related to overall patient satisfaction. In the Netherlands, like Denmark and many parts of the UK, family physicians or general practitioners (GPs) have a strong role as gatekeepers to secondary care. Over the last decade, the after-hours primary health care has been reorganized from small scale rotas into large-scale (GP) cooperatives.[1] Currently there are more than 130 of such cooperatives in the Netherlands that cover over 90 percent of the Dutch population, generally with groups of 40 to 120 full-time participating GPs serving populations of 50,000 up to 500,000 people. We developed a postal questionnaire for a national survey on satisfaction with after-hours primary health care.[2;3] Similar to Howard et al. and studies from the UK[4] we reported that respondents who had only received nurse telephone advice showed lower satisfaction levels than respondents who had come into contact with a GP. Furthermore, expectation of care mode appeared most strongly related to overall satisfaction, which was previously described by McKinley et al.[5] Patients who expected, but did not receive a centre consultation or home visit, most negatively evaluated both the accessibility and the nurse telephone consultation.[6] Also, evaluation of accessibility was negatively associated with a higher distance and chronic illness, and positively associated with a rural population and high age (>65 years). Finally, in our survey the presence of a GP ('telephone doctor') within the call-centre of the telephone help-line seemed to be related to a better evaluation of the nurse telephone consultation. As is admitted by the authors, an important limitation of the study by Howard et al. might be that the nature and severity of the problems that the after-hours care providers are facing are in fact very different. Although the number of population-based studies are small, in Europe there is consistent evidence that the use of after-hours acute care is complementary in nature.[6-11] E.g. while AEDs are predominantly facing young adult males with injuries, GPs are generally consulted for symptoms that are related to infections (young children) or chronic illnesses (elderly patients). It is my impression, however, that compared to the rural and suburbanised areas, GPs working in large cities seem to have a less prominent position as gatekeepers to secondary care where there are more passers-by, more inhabitants who are not registered with a personal GP, more illegal residents, and relatively high numbers of patients from ethnic groups who find it more self-evident to visit the AED or have more difficulty in finding the GP cooperative.[12] Further support for variability in the GPs' gatekeeping role is provided by the association between the total annual AED contact rate and the percentage of self-referrals within this demand, which ranges from 25% (less than 10,000 contacts/yr) in rural areas to as high as 70% (more than 50,000 contacts/yr) in the large cities.[13] In the literature, factors that were found to contribute to a higher use of the AED are proximity[14] and social deprivation.[9;14;15] As a result, the severity of problems presented by AED self-referrals may vary regionally, perhaps showing higher levels of urgency in the more suburbanised and rural areas. In one of our recent studies (personal communication) we found that patients contacting the AED or GP generally rank their problems equally high in terms of perceived acuteness (both injury and non-injury), so that selecting self-reported 'urgent health problems' may not be a reliable measure of true severity. Furthermore, the majority of AED self-referrals indicated that their problems could not have been handled by a GP, therefore making it uncertain to what extent their own physicians could have substituted the care for these patients. Hence, Howard et al. may have compared satisfaction levels between various providers on different, complementary types of problems that may not always be eligible for the care by GPs. In the Netherlands, one study comparing satisfaction levels with small and large-scale after-hours primary health care did not find any significant difference.[16] Nevertheless, Dutch GPs are still debating on the optimal scale of their after-hours care, while in the UK there is renewed discussion on the precise role and position of the GP during after-hours.[17;18] Currently, many Dutch health policymakers propagate the integration of GP and A&E services into one after-hours health care centre using one triage system, as this would offer a chance to improve the effectiveness and quality of care at a lower cost. Patient organisations seem to favour these developments, arguing that many patients with an urgent after-hours problem feel indecisive about whom they should contact: the GP, the AED or the ambulance service. One study has shown that integration of GP and A&E services led to the deflection of a group of AED self-referrals to the GP,[19] but whether this organizational change is beneficial in terms of quality, patient satisfaction and costs has yet to be assessed. It would be interesting to repeat the study by Howard et al. in different geographical settings and for different models of acute after-hours care and complement the analysis with measures on the nature of the presenting problems (e.g. ICPC coding) their severity (e.g. triage instruments) and overall demand for all acute after-hours medical services present in the area. References (1) van Uden CJ, Giesen PH, Metsemakers JF, Grol RP. Development of
Out-of-Hours Primary Care by General Practitioners (GPs) in The
Netherlands: From Small-call Rotations to Large-scale GP Cooperatives. Fam
Med 2006; 38(8):565-569. Competing interests: None declared |
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Lee A. Resnick, MD, Cleveland, OH, USA President, Urgent Care Association of America
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It would be very difficult to extrapolate the results of this study to the US model of "urgent care" for a number of reasons. Most importantly, the Canadian model is a public health model. It's "walk-in clinics" are essentially public health clinics and cannot be compared to the predominantly private network of urgent care centers across the US. The first "private" urgent care center in all of Canada opened only in the last year, while there are an estimated 15,000 such centers throughout the US, and this number is growing by hundreds every year. The rapid growth of the urgent care industry has been driven largely by patient dissatisfaction with the access, quality and comfort of acute care services delivered by the nation's emergency departments and primary care network alike. It is not surprising, however, to learn that most patients would prefer to be cared for by the physician they have entrusted their primary care to. However, primary care has been unable to meet all the urgent care needs of their patients. The reasons for this are largely due to 2 things: 1.)Lack of considerable after-hours access, and 2.)Inabilty to treat a broad enough range of acute care services. While there are individual practices that have found a way to do both primary care and acute care well, the majority have not. I would argue that the "market" in the US has already communicated their satisfaction with urgent care centers as a provider of acute care services. Additional study is needed (and planned) to confirm this hypothesis. Competing interests: None declared |
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JoAnn Elizabeth Leavey, Vancouver, BC Clinical Research Scientist, Adjunct Professor, University of British Columbia
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This is a very important survey and worthwhile for others to replicate in different locations to have comparative sites. For efficacy, efficiency and quality/health indicator development reasons, it would be interesting to look at large and small urban areas, as well as rural and remote areas to get a sense of patient satisfaction and the different issues that exist in diverse geological settings. The Family Physician role continues to be extremely important in early detection and intervention in major physiological and mental disorders. Dr. Nicholas Kates in Hamilton Ontario has been a champion of shared mental health care for many years. At any given time there is somewhere between 50-80% of patients with mental disorders being managed by family physicians (for further inquiry see http://www.shared-care.ca/). This is likely the result of a trust relationship that is commonly built between patients and their family physicians. This underscores one example as to the importance of this study's findings. If the family physician is supported by specialists and proper funding in order to extend clinic hours to meet the access and availability issues, they can in turn reduce the burden of current levels of emergency room activity by managing patients in the community, and therefore relieving emergency room personnel to focus on critical and urgent problems. Further and likely more importantly, the patient community may in the longer term have better health outcomes as a result of continuity of care, reduced stress levels in terms of who will be treating them; and last, if family physicians have more of an opportunity to see their patients consistently, a preventative component is more probable. Future directions - where can this research lead? It would be extremely important to see this research replicated as mentioned above. In addition, considering other research variables such as: level of care expectations of patients in each service with their rationale; wait times and how that might influence patient satisfaction ratings; a list of actual diagnoses treated and the influence of satisfaction with service accessed and why; communication, physician attitude and outcome satisfaction from the physician perspective and matched with the patient surveyed to compare/validate the results. If differences exist, it provides another way in which to understand perceived events and how to improve results. Lastly, it would be interesting to see how this information could inform quality of care and health indicator development for Family Physicians and their community practices. Competing interests: None declared |
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