Regional variations of perceived problems in ambulatory care from the perspective of general practitioners and their patients - an exploratory focus group study in urban and rural regions of northern Germany.
ABSTRACT: BACKGROUND:Patients from rural and urban regions should have equitable access to health care. In Germany, the physician-patient-ratio and the supply of medical services vary greatly between urban and rural areas. The aim of our study was to explore the regional variations of the perceived health care problems in ambulatory care from the perspective of affected professionals and laypersons i.e. general practitioners and their patients. METHODS:We conducted 27 focus groups with general practitioners (n?=?65) and patients (n?=?145) from urban areas, environs and rural areas in northern Germany. Discussions were facilitated by two researchers using a semi-structured guideline. The transcripts were content analyzed using deductive and inductive categories. RESULTS:General practitioners and patients reported problems due to demographic change and patient behaviour, through structural inequalities and the ambulatory reimbursement system as well as with specialist care and inpatient care. A high physician density, associated with high competition between general practitioners, a high fluctuation of patients and a low status of general practitioners were the main problems reported in urban areas. In contrast, participants from rural areas reported an insufficient physician density, a lack of young recruits in primary care and a resulting increased workload as problematic. All regions are concerned with subjectively inadequate general practitioners' budgets, insufficiently compensated consultations and problems in the cooperation with specialists and inpatient care institutions. Most problems were mentioned by GPs and patients alike, but some (e.g. high competition rates in urban regions and problems with inpatient care) were only mentioned by GPs. CONCLUSIONS:While many problems arise in urban regions as well as in rural regions, our results support the notion that there is an urgent need for action in rural areas. Possible measures include the support of telemedicine, delegation of medical services and reoccupation of vacant practices. The attractiveness of working in rural areas for general practitioners, specialists and clinicians must be increased by consolidating and expanding rural infrastructure (e.g. child care and cultural life). The above mentioned results also indicate that the ambulatory reimbursement system should be examined regarding the reported inequalities. Measures to further enhance the cooperation between general practitioners, specialists and inpatient care should be taken to solve supra-regionally reported problems. Problems showing regional variations indicate the need for measures to balance these variations between the regions. This is the first German study to analyze subjective views of the stakeholders concerned on regionally variating problems in ambulatory care. Further studies are needed to quantify the extent of the identified problems and differences. A corresponding survey is currently under way.
Project description:Alzheimer's patients living in rural communities may face significant barriers to effective outpatient medical care.We sought to examine rural-urban differences in risk for ambulatory care sensitive hospitalizations (ACSH), an indicator of access to outpatient care, in community-dwelling veterans with dementia.Medicare and Veteran Affairs inpatient claims for 1,186 US veterans with dementia were linked to survey data from the 1998 National Longitudinal Caregiver Survey. ACSH were identified in inpatient claims over a 1-year period following collection of independent variables. Urban Influence Codes were used to classify care recipients into 4 categories of increasing county-level rurality: large metropolitan; small metropolitan; micropolitan; and noncore rural counties. We used the Andersen Behavioral Model of Health Services to identify veteran, caregiver, and community factors that may explain urban-rural differences in ACSH.Thirteen percent of care recipients had at least 1 ACSH. The likelihood of an ACSH was greater for patients in noncore rural counties versus large metropolitan areas (22.6% vs 12.8%, unadjusted odds ratio [OR]= 1.99; P < .01). The addition of other Andersen behavioral model variables did not eliminate the disparity (adjusted OR = 1.97; P < .05).We found that dementia patients living in the most rural counties were more likely to have an ACSH; this disparity was not explained by differences in caregiver, care recipient, or community factors. Furthermore, the annual rate of ACSH was higher in community-dwelling dementia patients compared to previous reports on the general older adult population. Dementia patients in rural areas may face particular challenges in receiving timely, effective ambulatory care.
Project description:Rural areas have problems in attracting and retaining primary care workforce. This might have consequences for the existing workforce. We studied whether general practitioners (GPs) in rural practices differ by age, sex, practice population and workload from those in less rural locations and whether their practices differ in resources and service profiles. We used data from 2 studies: QUALICOPC study collected data from 34 countries, including 7183 GPs in 2011, and Profiles of General Practice in Europe study collected data from 32 countries among 7895 GPs in 1993. Data were analyzed using multilevel analysis. Results show that the share of female GPs has increased in rural areas but is still lower than in urban areas. In rural areas, GPs work more hours and provide more medical procedures to their patients. Apart from these differences between locations, overall ageing of the GP population is evident. Higher workload in rural areas may be related to increased demand for care. Rural practices seem to cope by offering a broad range of services, such as medical procedures. Dedicated human resource policies for rural areas are required with a view to an ageing GP population, to the individual preferences and needs of the GPs, and to decreasing attractiveness of rural areas.
Project description:OBJECTIVES:A considerable proportion of regional variation in healthcare use and health expenditures is to date still unexplained. The aim was to investigate regional differences in the gatekeeping role of general practitioners and to identify relevant explanatory variables at patient and district level in Bavaria, Germany. DESIGN:Retrospective routine data analysis using claims data held by the Bavarian Association of Statutory Health Insurance Physicians. PARTICIPANTS:All patients who consulted a specialist in ambulatory practice within the first quarter of 2011 (n=3 616 510). OUTCOMES MEASURES:Of primary interest is the effect of district-level measures of rurality, physician density and multiple deprivation on (1) the proportion of patients with general practitioner (GP) coordination of specialist care and (2) the mean amount in Euros claimed by specialist physicians. RESULTS:The proportion of patients whose use of specialist services was coordinated by a GP was significantly higher in rural areas and in highly deprived regions, as compared with urban and less deprived regions. The hierarchical models revealed that increasing age and the presence of chronic diseases are the strongest predictive factors for coordination by a GP. In contrast, the presence of mental illness, an increasing number of medical condition categories and living in a city are predictors for specialist use without GP coordination. The amount claimed per patient was €10 to €20 higher in urban districts and in regions with lower deprivation. Hierarchical models indicate that this amount is on average higher for patients living in towns and lower for patients in regions with high deprivation. CONCLUSION:The present study shows that regional deprivation is closely associated with the way in which patients access primary and specialist care. This has clear consequences, both with respect to the role of the general practitioner and the financial costs of care.
Project description:BACKGROUND: The utilization of medical care for gastrointestinal diseases increased over the past decade worldwide. The aim of the study was to investigate the difference between rural and urban patients in seeking medical service for gastrointestinal diseases at ambulatory sector in Taiwan. METHODS: From the one-million-people cohort datasets of the National Health Insurance Research Database, the utilization of ambulatory visits for gastrointestinal diseases in 2009 was analyzed. Rural patients were compared with urban and suburban patients as to diagnosis, locality of visits and choice of specialists. RESULTS: Among 295,056 patients who had ambulatory visits for gastrointestinal diseases in 2009, rural patients sought medical care for gastrointestinal diseases more frequently than urban and suburban patients (1.60?±?3.90 vs. 1.17?±?3.02 and 1.39?±?3.47). 83.4% of rural patients with gastrointestinal diseases were treated by non-gastroenterologists in rural areas. Rural people had lower accessibility of specialist care, especially for hepatitis, esophageal disorders and gastroduodenal ulcer. CONCLUSION: The rural-urban disparity of medical care for gastrointestinal diseases in Taiwan highlighted the importance of the well communication between rural physicians and gastroenterologists. Besides the establishment of the referral system, the medical teleconsultation system and the arrangement of specialist outreach clinics in rural areas might be helpful.
Project description:OBJECTIVES:Data on patient safety problems (PSPs) in ambulatory care are scarce. The aim of the study was to record the frequency, type, severity and point of origin of PSPs in ambulatory care in Germany. DESIGN:Retrospective cross-sectional study. SETTING:Computer-assisted telephone interviews with randomly recruited citizens aged ?40 years in Germany who were asked about their experiences with PSPs in ambulatory care. PARTICIPANTS:10 037 citizens ?40 years. MEASURES:A new questionnaire was developed to record patient experiences with PSPs in ambulatory care. The study reported here targets patient experiences in the last 12 months. The questionnaire focuses on PSPs in seven areas of medical treatment: anamnesis/diagnostic procedures; medication; vaccination, injection, infusion; aftercare; outpatient surgery; office administration; other areas. For each PSP reported, detailed questions were asked about the specialist group concerned, and, on the most serious harm, the severity of the harm and its consequences. The target parameters are presented as proportions with 95% CIs. RESULTS:1422 of the respondents (14%) reported 2589 PSPs. The areas most frequently affected by PSPs were anamnesis/diagnostic procedures (61%) and medication (15%). General practitioners accounted for 44% of PSPs, orthopaedists for 15% and internists for 10%. 75% of PSPs were associated with harm, especially unnecessarily prolonged pain or deterioration of health; 35% of PSPs led to permanent harm. 804 PSPs (32%) prompted patients to see another doctor for additional treatment; 255 PSPs (10%) required inpatient treatment. CONCLUSION:PSPs experienced by patients are widespread in ambulatory care in Germany. The study reveals in which areas of medical treatment efforts to prevent PSPs could make the greatest contribution to improving patient safety. It also demonstrates the valuable contribution of patient reports to the analysis of PSPs.
Project description:PURPOSE:Several studies have identified differences in end-of-life (EOL) care between urban and rural areas, yet little is known about potential differences in care processes or family evaluations of care. The purpose of this study was to examine the relationship between rurality of residence and quality of EOL care within the Veterans Affairs health care system. METHODS:This study was a retrospective, cross-sectional analysis of 126,475 veterans who died from October 2009 through September 2016 in inpatient settings across 151 facilities. Using unadjusted and adjusted logistic regression, we compared quality of EOL care between urban and rural veterans using family evaluations of care and 4 quality of care indicators for receipt of (1) palliative care consult, (2) a chaplain visit, (3) death in an inpatient hospice unit, and (4) bereavement support. FINDINGS:Veterans from rural areas had lower odds of dying in an inpatient hospice unit compared to veterans from urban areas, before and after adjustment (large rural OR 0.73, 95% CI: 0.70-0.77; P < .001, small rural OR 0.81, 95% CI: 0.77-0.86; P < .001, isolated rural OR 0.87, 95% CI: 0.81-0.93; P < .001). Differences in comparisons of other quality of care indicators were small and of mixed significance. No significant differences were found in family ratings of care in fully adjusted models. CONCLUSION:Receipt of some EOL quality indicators differed with urban-rural residence for some comparisons. However, family ratings of care did not. Our findings call for further investigation into unmeasured individual characteristics and facility processes related to rurality.
Project description:BACKGROUND:The melanoma incidence and mortality rates in rural and remote communities are exponentially higher than in urban areas. Digital health could be used to close the urban/rural gap for melanoma and improve access to posttreatment and support care services. OBJECTIVE:The aim of this review was to understand how digital health is currently used for melanoma posttreatment care and determine the benefits for Australian rural and remote areas. METHODS:A systematic search of PubMed, Medline, PsycINFO, and Scopus was conducted in March 2018. Findings were clustered per type of intervention and related direct outcomes. RESULTS:Five studies met the inclusion criteria, but none investigated the benefits of digital health for melanoma posttreatment care in rural and remote areas of Australia. Some empirical studies demonstrated consumers' acceptance of digital intervention for posttreatment care. The findings did not take into consideration individual, psychological, and socioeconomic factors, even though studies show their significant impacts on melanoma quality of aftercare. CONCLUSIONS:Digital interventions may be used as an adjunct service by clinicians during melanoma posttreatment care, especially in regions that are less-resourced by practitioners and health infrastructure, such as rural and remote Australia. Technology could be used to reduce the disparity in melanoma incidence, mortality rates, and accessibility to posttreatment care management between urban and rural/remote populations.
Project description:CONTEXT: General practitioners should be competent to be accountable for patients' needs, but they do not acquire core competencies during education in medical schools. AIMS: This study was aimed at determine the most usual obstetric and gynecological as well as pediatric diseases in rural and urban care centers in Isfahan province. SETTINGS AND DESIGN: This is a cross-sectional descriptive study which was done in Isfahan province in 2011. Sixty-four physicians (general practitioners) in rural and urban health care centers in Isfahan province participated in this study. SUBJECTS AND METHODS: Participants completed valid and reliable questionnaires for gynecological/obstetric and pediatric diseases. These questionnaires included some demographic data and diseases of each category (according to general medicine curriculum). Scales 1-5 for each disease referral times was determined respectively as: Rare, sometimes, weekly to monthly, daily to weekly and daily. STATISTICAL ANALYSIS USED: The data were descriptively analyzed by SPSS 11.5(SPSS Inc. in Chicago). RESULTS: Nearly 43.7% of participants were male. The mean age of participants was 39.0 ± 7.0 and their mean working experience was 11.3 ± 5.9 years. The highest referral times' score in rural and urban care centers in gynecological and obstetric group was vaginal discharge; in pediatrics, it was the common cold. CONCLUSIONS: In this study, the extent to which general practitioners encountered different gynecological/obstetric and pediatric diseases in rural and urban care centers in Isfahan province was determined. Although, these data are useful for decision makers to establish medical core curriculum, other factors such as seasonal load of diseases should also be observed to determine the differences between rural and urban care centers in most usual diseases of women and children.
Project description:The disparity of rural and urban hospital utilization has aroused much concern. With the improvement of their living standards, patients in rural areas have an emerging need for traveling across borders for better medical treatment in China. This paper reveals the medical tourism of rural residents towards urban hospitals driven by hospital needs and points out that such disparities may be caused by medical tourism. The ratio of people aged 65 and above in total rural populations was used to identify the potential target customers for medical tourism. Based on rural and urban datasets ranging from 2007-2017 on the provincial level, this paper presents a mobile treatment model and market concentration model with an ecological foundation. The feasible generalized least squared approach was used in the estimation of the fixed-effect regressions. The study found that there was a positive and significant relationship between rural old-age ratios and urban inpatient visits from different income groups. On average, a one percent rise in rural old-age ratio would increase the inpatient visits of urban hospitals by 138 thousand persons. There was also a positive and significant relationship between the rural old-age ratio and the market concentration of urban inpatient visits. It was found that the rural old-age ratio significantly influenced the market concentration of urban inpatient visits in the middle-high income regions. The research showed that each income group from the rural aged population had participated in medical tourism, traveled to urbanized regions and made inpatient visits to urbanized medical facilities. It was also indicated that the rural aged population, especially from the middle-high income groups had a positive and significant influence on the market concentration of urban inpatient visits in the province.
Project description:This study explores the impact of lifestyle and environment on gene expression through whole transcriptome profiling of peripheral blood samples in Fijian population (native Melanesians and Indians) living in the rural and urban areas. 41 individuals (14 urban Melanesians, 10 rural Melanesians and 17 urban Indians) of both gender were sampled under informed consents. Only healthy individuals aged between 18 and 65 were sampled. RNA from each sample was hybridized to an Illumina array. No replicates were done in this study