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PubMed2006

A qualitative study in rural and urban areas on whether--and how--to consult during routine and out of hours.

BACKGROUND: Patients vary widely when making decisions to consult primary care. Some present frequently with trivial illness: others delay with serious disease. Differences in health service provision may play a part in this. We aimed to explore whether and how patients' consulting intentions take account of their perceptions of health service provision. METHODS: Four focus groups and 51 semi-structured interviews with 78 participants (45 to 64 years) in eight urban and rural general practices in Northeast and Southwest Scotland. We used vignettes to stimulate discussion about what to do and why. Inductive analysis identified themes and explored the influence of their perceptions of health service provision on decision-making processes. RESULTS: Anticipated waiting times for appointments affected consulting intentions, especially when the severity of symptoms was uncertain. Strategies were used to deal with this, however: in cities, these included booking early just in case, being assertive, demanding visits, or calling out-of-hours; in rural areas, participants used relationships with primary care staff, and believed that being perceived as undemanding was advantageous. Out-of-hours, decisions to consult were influenced by opinions regarding out-of-hours services. Some preferred to attend nearby emergency departments or call 999. In rural areas, participants tended to delay until their own doctor was available, or might contact them even when not on call. CONCLUSION: Perceived barriers to health service access affect decisions to consult, but some patients develop strategies to get round them. Current changes in UK primary care are unlikely to reduce differences in consulting behaviour and may increase delays by some patients, especially in rural areas.

After-Hours Care↗
PubMed2006

Consultations in primary care for symptoms attributed to electromagnetic fields--a survey among general practitioners.

BACKGROUND: Five percent of the Swiss population attribute symptoms to electromagnetic fields (EMF). General practitioners (GPs) might play a key role in recognising an emerging health risk, since they are the first to observe and follow up persons who attribute symptoms to EMF. It is unclear to what extent EMFs have become an issue in general practice and which experiences GPs report from the consultations. METHODS: We conducted telephone interviews in a random sample of GPs in Switzerland in order to assess the frequency of consultations in primary care due to EMF and the GPs' experience with these patients. RESULTS: 342 general practitioners were interviewed, corresponding to a response rate of 28.2%. 69% of the GPs reported at least one consultation due to EMF, but GPs with a certificate in complementary medicine were much more likely to report EMF consultations. The median of EMF consultation numbers within one year was three. An overview of the most recent EMF-related consultation per GP yielded sleep disorders, headaches and fatigue as the most often reported symptoms and mobile phone base stations, power lines and the own use of mobile phones as the main EMF sources suspected to be associated to symptoms. GPs judged the association between EMF and the symptoms to be plausible in 54% of the cases. There was no combination of symptoms and EMF sources that was remarkably and consistently judged to be a plausible cause of the symptoms. CONCLUSION: In our survey, GPs often judged the association between the health problems and the suspected exposure to be plausible. This plausibility assessment seems to be based on grounds of preventive positions in a situation of scientific uncertainty. More research effort is needed to obtain more insight on a potential association between long term EMF exposure and unspecific symptoms.

Anxiety↗
PubMed2006

Improving the use of research evidence in guideline development: 3. Group composition and consultation process.

BACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the third of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVE: In this review we address the composition of guideline development groups and consultation processes during guideline development. METHODS: We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: What should be the composition of a WHO-panel that is set up to develop recommendations? The existing empirical evidence suggests that panel composition has an impact on the content of the recommendations that are made. There is limited research evidence to guide the exact composition of a panel. Based on logical arguments and the experience of other organisations we recommend the following: Groups that develop guidelines or recommendations should be broadly composed and include important stakeholders such as consumers, health professionals that work within the relevant area, and managers or policy makers. Groups should include or have access to individuals with the necessary technical skills, including information retrieval, systematic reviewing, health economics, group facilitation, project management, writing and editing. Groups should include or have access to content experts. To work well a group needs an effective leader, capable of guiding the group in terms of the task and process, and capable of facilitating collaboration and balanced contribution from all of the group members. Because many group members will not be familiar with the methods and processes that are used in developing recommendations, groups should be offered training and support to help ensure understanding and facilitate active participation.What groups should be consulted when a panel is being set up?We did not identify methodological research that addressed this question, but based on logical arguments and the experience of other organisations we recommend that as many relevant stakeholder groups as practical should be consulted to identify suitable candidates with an appropriate mix of perspectives, technical skills and expertise, as well as to obtain a balanced representation with respect to regions and gender. What methods should WHO use to ensure appropriate consultations? We did not find any references that addressed issues related to this question. Based on logical arguments and the experience of other organisations we believe that consultations may be desirable at several stages in the process of developing guidelines or recommendations, including: Identifying and setting priorities for guidelines and recommendations, commenting on the scope of the guidelines or recommendations, commenting on the evidence that is used to inform guidelines or recommendations, commenting on drafts of the guidelines or recommendations, commenting on plans for disseminating and supporting the adaptation and implementation of the guidelines or recommendations, key stakeholder organisations should be contacted directly whenever possible, consultation processes should be transparent and should encourage feedback from interested parties.

Journal Article↗
PubMed1995

[Trends of air pollution versus those of consultation rate and mortality rate for bronchial asthma in individuals aged 40 years and above in the Yokkaichi region].

We performed correlation analysis on the relationship between changes in air pollution and the consultation rate for bronchial asthma in the Yokkaichi region, taking effects of various socioeconomic factors into consideration. The effects of changes in air pollution on the mortality rate due to bronchial asthma were also evaluated. 1. Evaluation of annual changes in the simple correlation coefficient between the consultation rate and the concentration of each pollutant showed no significant correlation with a decrease in the air pollutant concentration in the age group less than 10 years old. However, in the middle-advanced male and female groups aged 40 years and above, the influence of past air pollution still remained. In addition, the partial correlation coefficients between the consultation rate for bronchial asthma and the degree of pollution, socioeconomic factors, and the rate of heavy smokers were calculated. A significant correlation was observed between the consultation rate for the females in each age group and the rate of patients receiving public assistance. 2. The mortality rate due to bronchial asthma in the polluted area increased rapidly with a time lag of several years after the peak of air pollution but decreased gradually thereafter. Presently, the mortality rate in the polluted area is similar to that in the non-polluted (control) area. 3. The mean age of death due to bronchial asthma was elevated because of a decrease in the deaths of those aged less than 60 years. As a result, the difference in the mean age of death due to bronchial asthma between the polluted area and the control area disappeared. With the recent remarkable alleviation of air pollution, the consultation rate and mortality rate due to bronchial asthma have decreased considerably. However, differences are still observed compared with the control area in some age levels so that continuation of monitoring of air pollution as well as consultation and mortality rates is considered necessary.

Adult↗
PubMed2004

Health beliefs and communication in the travel clinic consultation as predictors of adherence to malaria chemoprophylaxis.

OBJECTIVES: The objectives were, first, to determine whether adherence to malaria prophylaxis could be predicted by (i) health beliefs specified by the Health Belief Model and the Theory of Planned Behaviour, and (ii) communication during the consultation in a travel clinic; and secondly, to examine the impact of the consultation in changing travellers' health beliefs. DESIGN: A prospective study using regression analysis. METHODS: The participants were 130 consecutive travellers attending a travel medicine clinic. Health beliefs were measured pre- and post-consultation. The consultations were coded from audiotape using the Roter Interaction Analysis System and a content analysis method recording discussion about malaria and prophylaxis. Adherence was assessed by a follow-up telephone interview. RESULTS: Perceived susceptibility to malaria, perceived benefits of medication and intentions to adhere increased significantly as a result of the consultation, and the perceived permanent nature of side effects reduced significantly. At follow-up (N = 107), 62% reported full adherence, 25% partial adherence and 12% poor/no adherence. A multinomial logistic regression analysis revealed that perceived benefits of medication, length of stay, health professional discussion about adherence and travellers' questions and statements independently predicted reported adherence. CONCLUSIONS: Health beliefs and communication significantly predicted adherence in this setting. The findings also suggested qualitative differences between travellers who adhered fully, partially or poorly. Although the clinic consultation had a positive impact, emphasizing benefits of medication and resolving potential barriers to adherence could improve adherence in the population.

Adolescent↗
PubMed2003

Using three-channel video to evaluate the impact of the use of the computer on the patient-centredness of the general practice consultation.

The aim of this study was to assess the feasibility of using three-channel video to explore the impact of the computer on general practitioner (GP) consultations. A previous study had highlighted the limitations of using single-channel video: firstly, there was a lack of information about exactly how the computer was being used, and secondly difficulty in interpreting the body language of the consulting clinician. More information was needed to understand the impact of the computer on the consultation, and in this pilot three-channel video was used to overcome these constraints. Four doctors consulted, with the patient's role played by an actor with a preset script and preloaded personal and family history record programmed into the computer. The output was analysed using the Roter Interaction Analysis System (RIAS) and observational methods were used to explore the effect of computers on aspects of verbal and non-verbal behaviour and the completeness of the computer data record. Three-channel video proved to be a feasible and valuable technique for the analysis of primary care GP consultations, with advantages over single-channel video. Interesting differences in non-verbal and verbal behaviour became apparent with different types of computer use during the consultation. Implications for the three-channel video technique for training, monitoring GP competence and providing feedback are discussed.

Attitude to Computers↗
PubMed2005

Ethical goals of community consultation in research.

In response to the traditional emphasis on the rights, interests, and well-being of individual research subjects, there has been growing attention focused on the importance of involving communities in research development and approval. Community consultation is a particularly common method of involving communities. However, the fundamental ethical goals of community consultation have not been delineated, which makes it difficult for investigators, sponsors, and institutional review boards to design and evaluate consultation efforts. Community consultation must be tailored to the communities in which it is conducted, but the purposes of consultation-the ethical goals it is designed to achieve-should be universal. We propose 4 ethical goals that give investigators, sponsors, institutional review boards, and communities a framework for evaluating community consultation processes.

Community Participation↗
PubMed1999

Patients' attitude toward consultations by a physician without a white coat in Japan.

OBJECT: To know how Japanese patients perceive their physicians without a white coat during consultations. SUBJECTS AND METHODS: The patients who visited a university clinic were divided into two groups: those seen by a physician in a white coat (the white-coat group) and those seen by a physician in private clothes (the private-clothes group). Questionnaires were distributed to the patients, which asked the tension and satisfaction of consultations as well as their preference for physician's attire. The answers of the white-coat group were compared with those of the private-clothes group. RESULTS: The percentage of new patients who felt tense during consultations was greater in the white-coat group (42%) than in the private-clothes group (33%). Seventy-one percent of the patients in the white-coat group preferred physicians in a white coat whereas only 39% preferred so in the private-clothes group (p<0.0001). However, the degree of patients' satisfaction for the consultation showed no statistical difference between the groups. Sixty-nine percent of the patients older than or equal to 70 years preferred a white coat while 52 percent of the patients younger than 70 years preferred so (p=0.002). CONCLUSION: Physician's white coats did not influence the satisfaction with the consultations for most Japanese patients in a university clinic, although elderly patients as well as those seen by a physician in a white coat tended to prefer the white coat to the private clothes. Furthermore, practice without a white coat might reduce patients' tension during their first consultation.

Adolescent↗
PubMed1989

Isolating the impact of psychiatric consultations in the general hospital: psychiatric comorbidities and nursing intensity.

The amount of nursing services represents a substantial portion of the total cost of hospital treatment of medical/surgical patients. Patients receiving psychiatric consultations were compared to matched patients (DRG and LOS) who did not receive psychiatric services on the intensity of their nursing service needs. These two groups were then compared on the measure of nursing intensity before and after the timing of the consultation. Those who received a consultation had significantly lower intensity scores prior to seeing the psychiatrist. Although patients receiving psychiatric consultations did not show a significantly greater reduction in nursing acuity relative to their baseline levels than did the matched control patients, the amount of time the psychiatrist spent with consultation patients was positively related with the change in nursing intensity post-consultation.

Costs and Cost Analysis↗
PubMed2003

A randomised controlled trial to assess the impact of a package comprising a patient-orientated, evidence-based self-help guidebook and patient-centred consultations on disease management and satisfaction in inflammatory bowel disease.

OBJECTIVES: To determine if a whole systems approach to self-management improves clinical outcomes and leads to cost-effective use of NHS services. DESIGN: Nineteen hospitals were randomised to 10 control sites and nine intervention sites. Consultants from intervention sites received training in patient-centred care before recruitment and introduced the intervention to eligible patients. Patients at the control sites were recruited and went on to have an ordinary consultation. Qualitative interviews were undertaken to obtain an in-depth understanding of patients' and consultants' experience of the intervention. SETTING: Follow-up outpatient clinics at 19 hospitals in the north-west of England. PARTICIPANTS: Seven hundred patients (297 at intervention sites and 403 at control sites) with established ulcerative colitis or Crohn's disease, aged 16 years and over, and able to write in English. INTERVENTIONS: Consultants were trained to provide a patient-centred approach to care. Guidebooks on ulcerative colitis and Crohn's disease were developed with patients prior to the study. Patients prepared a written self-management plan and self-referred to services based on a self-evaluation of their need for advice. MAIN OUTCOME MEASURES: Rates of hospital outpatient consultation, quality of life (QoL) and acceptability to patients. Health service resource use and assessed cost effectiveness using the EQ-5D. RESULTS: After 1 year, the intervention resulted in fewer hospital visits, without change in the number of primary care visits. Patients felt more able to cope with their condition. The intervention produced no reduction in QoL and did not raise anxiety. The intervention group reported fewer symptom relapses; 74% of patients in the intervention group indicated a preference to continue the system. Qualitative results showed the guidebook was effective but organisational limitations constrained patient-centred aspects of the intervention for some. Cost-effectiveness analyses favoured self-management over standard care. CONCLUSIONS: Further use of this method in chronic disease management seems likely to improve overall patient satisfaction and reduce health expenditure without evidence of adverse effect on disease control. Further attention needs to be given to self-referral and access arrangements and a re-distribution of control to patients through increased adherence to patient-centred norms on the part of consultants. Future research is recommended to evaluate the operating systems within secondary and primary care that would allow self-managers to self-refer and to keep them informed of new treatments, also to explore models for training health professionals in self-care methods, to study long-term effects of self-management in chronic disease and to transfer this approach to other chronic conditions.

Adolescent↗
PubMed2004

Acute clinical ethics consultation: the practicalities.

In Australia there has been only limited experience with ethics consultation, and there are no reports of practical details. In 1999, the Institutional Clinical Ethics Committee at John Hunter Hospital, Newcastle, initiated an Acute Clinical Ethics Service (ACES) to formalise a perceived need within the hospital for ethics consultation. This need had previously been met by ad-hoc councils of "wise men". The ACES approach uses a team of people with different perspectives to provide an ethics consultation in a timely manner. Our initial experience of ACES has shown that a formal process of ethics consultation may be preferable to informal approaches in many circumstances; even when genuine consensus is not possible, an ethics consultation nevertheless provides an opportunity to share different points of view and helps to avoid practices that may be unacceptable. The specific implications of acute ethics consultations are not yet fully elucidated.

Abortion, Induced↗
PubMed1999

Someone to talk to? The role of loneliness as a factor in the frequency of GP consultations.

BACKGROUND: There are many reasons why people frequently consult their general practitioner (GP). Although loneliness is increasingly recognized as a problem affecting well-being for elderly people, it has rarely been addressed as a predictor of frequency of consultation. AIM: To examine whether loneliness is associated with rates of GP consultations (home and surgery visits). METHOD: Analysis of data collected in face-to-face interviews at the second wave of a longitudinal health survey of two adult age cohorts living in four socially contrasting urban localities in Glasgow City. There were a total of 691 subjects: 142 males and 176 females aged 40 years at interview; and 167 males and 206 females aged 60 years at interview. Frequency of reported GP consultations in the past 12 months at home or in the surgery was examined. RESULTS: After controlling for sociodemographic and socioeconomic variables and health, loneliness was significantly associated with frequency of consultation at the surgery but not with the frequency of home visits. CONCLUSION: Loneliness may still be underestimated as a factor related independently to frequency of consultations with a GP at the surgery.

Adult↗
PubMed1999

Consultation of medical narratives in the electronic medical record.

This article presents an overview of a research project concerning the consultation of medical narratives in the electronic medical record (EMR). It describes an analysis of user needs, the design and implementation of a prototype EMR system, and the evaluation of the ease of consultation of medical narratives when using this system. In a questionnaire survey, 85 hospital physicians judged the quality of their paper-based medical record with respect to data entry, information retrieval and some other aspects. Participants were more positive about the paper medical record than the literature suggests. They wished to maintain the flexibility of data entry but indicated the need to improve the retrieval of information. A prototype EMR system was developed to facilitate the consultation of medical narratives. These parts were divided into labeled segments that could be arranged source-oriented and problem-oriented. This system was used to evaluate the ease of information retrieval of 24 internists and 12 residents at a teaching hospital when using free-text medical narratives divided at different levels of detail. They solved, without time pressure, some predefined problems concerning three voluminous, inpatient case records. The participants were randomly allocated to a sequence that was balanced by patient case and learning effect. The division of medical narratives affected speed, but not completeness of information retrieval. Progress notes divided into problem-related segments could be consulted 22% faster than when undivided. Medical history and physical examination divided into segments at organ-system level could be consulted 13% faster than when divided into separate questions and observations. These differences were statistically significant. The fastest divisions were also appreciated as the best combination of easy searching and best insight in the patient case. The results of our evaluation study suggest a trade-off between searching and reading: too much detailed segments will delay the consultation of medical narratives. Validation of the results in daily practice is recommended.

Attitude of Health Personnel↗
PubMed1999

What do patients want from doctors? Content analysis of written patient agendas for the consultation.

BACKGROUND: Although much has been written about what patients want when they contact their general practitioner (GP), there are no published data from large cohort studies of what patients expect. AIM: To describe the expectations of a large group of patients who consulted with their GPs. METHOD: A GP and a social sciences graduate carried out a content analysis of written agenda forms completed by 819 patients who consulted 46 randomly selected GPs. Inter- and intra-rater reliabilities were confirmed. RESULTS: A total of 756 (92%) agenda forms were returned. Inter-rater reliability was satisfactory (kappa > 0.6 for all but two main themes). Almost all patients had requests they wished to make of their doctor, 60% had their own ideas about what was wrong, and 38% had considered explanations about why they were unwell. Forty-two per cent and 24% of patients had consulted because they had reached the limit of their anxiety or tolerance respectively. Seven per cent, 4%, and 2% had comments, which were usually negative, to make about previous management, communication with doctors, or time in the consultation. CONCLUSION: These data demonstrate that most patients come to the consultation with a particular agenda. Failure to address this agenda is likely to adversely affect the outcome of many consultations.

Family Practice↗
PubMed2002

[The first consultation].

The first time patient consultation with a psychiatrics nurse is the first step in a patient's therapeutic procedure when he/she consults a mental health center. Obviously, its importance is based on three aspects: 1. the reception and initial aid provided to a patient, 2. determining the degree of the patient's needs and recording pertinent information in a clinical file which will allow for better planning of successive treatment, 3. in a diagnosis of a patient's problems and selecting the most opportune nursing care plan. We wish to place special stress on those problems and treatments which we refer to as "intra-consultation" and which enable better communication and patient confidence with respect to successive ongoing treatment and "extra-consultation" care; these features are those precise ones which make first time patient consultation a nurse's activity. This study refers to 500 consultations which occurred during 1996-97 under the auspices of a general study of basic nursing care plans.

Humans↗
PubMed1992

Why do patients consult the general practitioner? Determinants of their decision.

In order to obtain more information about the reasons why patients consult their general practitioner 1000 patients completed a questionnaire in the waiting rooms of eight general practices. After the consultation the patients received a second questionnaire. The aim of the study was to determine why people decide to consult their general practitioner about one complaint but not about a second complaint. Both questionnaires were based on the health belief model, augmented by three other factors: the perceptions patients have of their own abilities to cope with their condition (efficacy of self care), their knowledge about the complaint and their need for information. The results showed that two of the additional factors (efficacy of self care and need for information) as well as most of the factors of the health belief model (efficacy of general practitioner care, perceived severity of complaint and cues to consult) were important determinants of consulting the general practitioner. The results suggest that patients sometimes expect information from their general practitioner rather than medical treatment. Furthermore, as the perceived efficacy of general practitioner care is also an important determinant, unnecessary consultation or unnecessary delay in treatment could be prevented by offering patients information about the potential effectiveness of medical care or self care for specific conditions. Implications for general practitioners' daily practice and future research are discussed.

Attitude to Health↗
PubMed2004

An international consultation: the development of family medicine in Vietnam.

An effective international consultation on health system reform can be approached using the five-step process of establishing goals, conducting a needs assessment, defining objectives, developing methods, and designing evaluation strategies. This structure provided guidance to a consultation we provided to the Ministry of Health, Socialist Republic of Vietnam (SRV) to review its current health care delivery system. The consultation examined all levels of health care delivery and medical education. The SRV has an extensive, but poorly staffed, "commune health center" system. There is a widespread perception that the quality of medical care is low in these health centers. People leave their communities to obtain health care elsewhere at more-specialized levels and more-expensive sites. Our consultation included an analysis of the potential effect of creating a primary health care delivery system based on the model of family medicine. In addition to consulting, part of the time spent in Vietnam was used to advocate for changes in the system to allow for movement toward a primary health care delivery system. The consultation culminated in the creation of the specialty of family medicine and in the establishment of the medical education system to train family physicians.

Community Health Services↗
PubMed2005

Comparison of GP and nurse practitioner consultations: an observational study.

BACKGROUND: Studies show that satisfaction with nurse practitioner care is high when compared with GPs. Clinical outcomes are similar. Nurse practitioners spend significantly longer on consultations. AIM: We aimed to discover what nurse practitioners do with the extra time, and how their consultations differ from those of GPs. DESIGN OF STUDY: Comparative content analysis of audiotape transcriptions of 18 matched pairs of nurse practitioner and GP consultations. SETTING: Nine general practices in south Wales and south west England. METHOD: Consultations were taped and clinicians' utterances coded into categories developed inductively from the data, and deductively from the literature review. RESULTS: Nurse practitioners spent twice as long with their patients and both patients and clinicians spoke more in nurse consultations. Nurses talked significantly more than GPs about treatments and, within this, talked significantly more about how to apply or carry out treatments. Weaker evidence was found for differences in the direction of nurses being more likely to: discuss social and emotional aspects of patients' lives; discuss the likely course of the patient's condition and side effects of treatments; and to use humour. Some of the extra time was also spent in getting doctors to approve treatment plans and sign prescriptions. CONCLUSIONS: The provision of more information in the longer nurse consultations may explain differences in patient satisfaction found in other studies. Clinicians need to consider how much information it is appropriate to provide to particular patients.

England↗