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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.

SUBMITTER: Hansen H

PROVIDER: S-EPMC5445300 | biostudies-literature | 2017 May

REPOSITORIES: biostudies-literature

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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.

Hansen H H Pohontsch N J NJ Bole L L Schäfer I I Scherer M M

BMC family practice 20170525 1

<h4>Background</h4>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.<h4>Methods</h4>We conducted 27 focus groups with gene ...[more]

PMID: 28545402

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Project description:BACKGROUND:Among other factors, the patients' consultation reasons and GPs' spectrum of services determine the process and outcome of the medical treatment. So far, however, there has been little information on differences in reasons for consultation and GPs' services between urban and rural areas. Our study's goal was thus to investigate these factors in relation to the regional location of GPs' practices. METHODS:We conducted a cross-sectional observational study based on standardised GP interviews in a quota sampling design. All counties and independent cities within a radius of 120?km around Hamburg were divided into three regional categories (urban area, environs, rural area) and stratified proportionally to the population size. Differences in the number of reasons for consultation and services were analysed by multivariate linear regressions in mixed models adjusted for random effects on the levels of the German federal states and administrative districts. Differences in individual consultation reasons and services were identified by logistic regression via stepwise forward and backward selection. RESULTS:Primary care practices in 34 of the 37 selected administrative districts (91.9%) were represented in the dataset. In total, 211 GPs were personally interviewed. On average, GPs saw 344 patients per month with a slightly higher number of patients in rural areas. They reported 59.1?±?15.4 different reasons for consultation and 30.3 ± 3.9 different services. There was no statistically significant regional variation in the number of different consultation reasons, but there was a broader service spectrum by rural GPs (ß?=?-?1.42; 95% confidence interval?-?2.75/-?0.08; p =?0.038) which was statistically explained by a higher level of medical training. Additionally, there were differences in the frequency of individual consultation reasons and services between rural and urban areas. CONCLUSION:GPs in rural areas performed more frequently services usually provided by medical specialists in urban areas. This might be caused by a low availability of specialists in rural areas. The association between medical training and service spectrum might imply that GPs compensate the specific needs of their patients by completing advanced medical training before or after setting up a medical practice. TRIAL REGISTRATION:The study was registered in ClinicalTrials.gov (NCT02558322).

Project description:Discriminatory behaviors among inter-ethnic relations in schools have long been noted and studied, but there are several correlations between discriminatory behaviors and other constructs that need further investigation. As an example, the relation between perceived discrimination and contextual problems-which include family, school and peer problems-among children and adolescents in Latin America has received little attention from previous studies. Further, the mediating role of ethnic identification and collective self-esteem in this relation also needs to be considered as they could be proven as protective factors for discriminatory behavior and its outcomes. Therefore, this study aimed to, first, establish the relationship between perceived discrimination and contextual problems in inter-ethnic students aged 8-19 years living in Arica, Chile; and second, to identify the role that ethnic identification and collective self-esteem play within this relation. In order to investigate this matter, a cross-sectional study was carried out with 3700 students in 29 schools between the fourth year of primary education and the last year of secondary education, aged between 9-18 years, with 48.4% men and 51.6% women. The sample was divided into primary and secondary school groups. The scales utilized were the Everyday Discrimination Scale, Multi-Group Ethnic Identity Measure-Revised Scale, Collective Self-Esteem Scale and the dimensions of contextual family, school and peer problems, as well as the general index of contextual problems of the Child and Adolescent Assessment System. For data analysis, we tested a path analytic model at both the within and between levels to account for the relations between variables. In each group the models obtained an optimal fit. We found that perceived discrimination and ethnic identification were directly related to contextual problems (.23-.39), and collective self-esteem had only a mediating role. This study showed that strategized interventions focusing on ethnic identification and perceived discrimination should be utilized by schools to create a better developing environment.

Project description:BackgroundMedically unexplained symptoms (MUS) and somatoform disorders are common in general practices, but there is evidence that general practitioners (GPs) rarely use these codes. Assuming that correct classification and coding of symptoms and diseases are important for adequate management and treatment, insights into these processes could reveal problematic areas and possible solutions. Our study aims at exploring general practitioners' views on coding and reasons for not coding MUS/somatoform disorders.MethodsWe invited GPs to participate in six focus groups (N = 42). Patient vignettes and a semi-structured guideline were used by two moderators to facilitate the discussions. Recordings were transcribed verbatim. Two researchers analyzed the data using structuring content analysis with deductive and inductive category building.ResultsThree main categories turned out to be most relevant. For category a) "benefits of coding" GPs described that coding is seen as being done for reimbursement purposes and is not necessarily linked to the content of their reference files for a specific patient. Others reported to code specific diagnoses only if longer consultations to explore psychosomatic symptoms or psychotherapy are intended to be billed. Reasons for b) "restrained coding" were attempting to protect the patient from stigma through certain diagnoses and the preference for tentative diagnoses and functional coding. Some GPs admitted to c) "code inaccurately" attributing this to insufficient knowledge of ICD-10-criteria, time constraints or using "rules of thumb" for coding.ConclusionsThere seem to be challenges in the process of coding of MUS and somatoform disorders, but GPs appear not to contest the patients' suffering and accept uncertainty (about diagnoses) as an elementary part of their work. From GPs' points of view ICD-10-coding does not appear to be a necessary requirement for treating patients and coding might be avoided to protect the patients from stigma and other negative consequences. Our findings supply a possible explanation for the commonly seen difference between routine and epidemiological data. The recent developments in the DSM-5 and the upcoming ICD-11 will supposedly change acceptance and handling of these diagnoses for GPs and patients. Either way, consequences for GPs' diagnosing and coding behavior are not yet foreseeable.

Project description:BACKGROUND:In most countries, the general practitioner (GP) is the first point of contact in the healthcare system and coordinator of healthcare. However, in Germany it is possible to consult an outpatient specialist even without referral. Coordination by a GP might thus reduce health expenditures and inequalities in the healthcare system. The study describes the patients' willingness/commitment to use the GP as coordinator of healthcare and identifies regional and patient-related factors associated with the aforementioned commitment to the GP. METHODS:Cross-sectional observational study using a standardised telephone patient survey in northern Germany. All counties and independent cities within a radius of 120?km around Hamburg were divided into three regional categories (urban areas, environs, rural areas) and stratified proportionally to the population size. Patients who had consulted the GP within the previous three months, and had been patients of the practice for at least three years were randomly selected from medical records of primary care practices in these districts and recruited for the study. Multivariate linear regression models adjusted for random effects at the level of federal states, administrative districts and practices were used as statistical analysis methods. RESULTS:Eight hundred eleven patients (25.1%) from 186 practices and 34 administrative districts were interviewed. The patient commitment to a GP attained an average of 20 out of 24 possible points. Significant differences were found by sex (male vs. female: +?1.14 points, p <?0.001), morbidity (+?0.10 per disease, p =?0.043), education (high vs. low: -?1.74, p <?0.001), logarithmised household net adjusted disposable income (-?0.93 per step on the logarithmic scale, p =?0.004), regional category (urban areas: -?0.85, p =?0.022; environs: -?0.80, p =?0.045) and healthcare utilisation (each GP contact: +?0.30, p <?0.001; each contact to a medical specialist: -?0.75, p =?0.018). Professional situation and age were not significantly associated with the GP commitment. CONCLUSION:On average, the patients' commitment to their GP was relatively strong, but there were large differences between patient groups. An increase in the patient commitment to the GP could be achieved through better patient information and targeted interventions, e.g. to women or patients from regions of higher urban density. TRIAL REGISTRATION:The study was registered in ClinicalTrials.gov (NCT02558322).

Dataset Information

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.

Publications

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.

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