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Working
Paper Series
Working
Papers:
- The DELPHI Project Working Paper Series: The Use of ICPC inthe DELPHI Project, 2005, G. Giles, V. Cherendra, A. Thind, S. Matten, J.N. Marshall, M. Stewart #05-1. Overview
- The Patient Peerception of Patient Centredness Questionnaire (PPPC), 2005, M. Stewart, L. Heredith, B. L. Ryan, J.B. Brown, #04-1. Executive Summary
- The Interface Between Primary Care and Psychiatry: Family Physicians and Their Dilemmas with Psychiatric Crises, 2002, V.R. Velamoor, J.D. Mendonca, B. Hennen, A. Grindrod, #02-1. Executive Summary
- The Woman Abuse Screening
Tool: A Ten-Year Program of Research, 2001, J.B. Brown, B.L. Ryan, #01-1. Executive Summary
-
Assessing Communication
Between Patients and Physicians: The Measure of Patient-Centered Communication,
2001, J.B. Brown, M. Stewart, B.L. Ryan, #95-2 (2nd edition). Executive Summary
-
Healing Partnerships Between
Patients And Family Doctors: An Aspect Of Quality Care, 1998, M. Stewart,
#98-1. Executive Summary
-
Guidelines For The Use Of The
Electronic Data Base In Ferns (Family Medicine Educational Research
Networks For Service), 1996, T. Freeman, #96-1. Executive Summary
-
Assessing Communication
Between Patients And Doctors: A Manual For Scoring Patient-Centred
Communication, 1995, J.B. Brown, M. Stewart, S. Tessier, #95-2. Executive Summary
-
Physician Services In The
Home: Planning For The Integrated Home Care Of Acute And Complex Illness, 1995,
I.R. McWhinney, #95-1. Executive Summary
-
Achieving The Transition From
Hospital To Home: How Older Patients And Their Caregivers Experience The
Discharge Process, 1993, C.L. McWilliam, #93-1. Executive Summary
-
Home Visits By Physicians:
Recent Trends And Future Needs, 1992, H. Kulatilaka, #92-1. Executive Summary
To order these working papers please contact Andrea Burt [ ajburt2@uwo.ca ]
Please note that there is no charge for these papers and they will be sent as PDF files to your email address.
THE DELPHI PROJECT WORKING PAPER SERIES: THE USE OF ICPC IN THE DELPHI PROJECT
G. Giles, V. Chevendra, A. Thind, S. Maaten, J.N. Marshall, M. Stewart
October 2005
OVERVIEW
This paper provides a brief review of the development and use of International Classification of Primary Care (ICPC) in primary care research as well as examines the use of the coding structure in the DELPHI Project. Challenges to the use of the ICPC in the DELPHI Project and subsequent lessons learned are also presented with the hope that those with similar interests might learn from our work.
THE PATIENT PERCEPTON OF PATIENT-CENTEREDNESS QUESTIONNAIRE (PPPC)
M. Stewart, L. Meredith, B.L. Ryan, J.B. Brown
April 2004
EXECUTIVE SUMMARY
Research has shown that the components of the patient-centered approach have positive relationships with a variety of worthy outcomes such as patient recovery, emotional health, physical function and physiologic outcomes. Other outcomes documented include: patient satisfaction, patient adherence, physician satisfaction, fewer malpractice complaints, and time. As well, programs that encouraged patients and physicians to communicate in a more patient-centered way have resulted in improved patient outcomes.
Based on the patient-centered clinical method, a method of scoring patient-physician encounters was developed called the Measure of Patient-centered Communication (MPCC). Information about this measure can be obtained from the working paper #95-2 second edition, Assessing Communication between Patients and Physicians: The Measure of Patient-centered Communication (MPCC).
Measures of the patient’s perception of patient-centered care have been developed which serve to
supplement and complement the MPCC. What more patient-centered research approach could one imagine than asking the patient to describe their experience of the visit with the doctor in a formal structured way? The measures, described in this working paper, have been used for research, but as well for education, by providing individual feedback to participating physicians on their patients’ perceptions.Patient perception measures are increasingly used to evaluate health care. Standard questionnaires to assess the patients’ view of themselves or to assess their satisfaction with care (which includes implicit comparisons by patients between their perceptions of care and their expectations of care) are not the topic of this working paper. Rather, this working paper covers patients’ reports of a recent experience of care. Other researchers have chosen such a focus to evaluate primary care generally. In general, such measures are: more sensitive to health care delivery changes than long-term health outcome measures; less expensive and more reliable than physician review methods; and focused on positive aspects of care (not mistakes), hence very suitable for quality improvement initiatives. These qualities make patient perception measures an important component of any healthcare research program.
Our own research has found that the patient perception of patient-centeredness questionnaire (PPPC) was directly related to patient outcomes, when the MPCC was not, again indicating the importance of patient reports of their care.
The current working paper presents the questionnaire measures of patients’ perception of the patient-centered clinical method.
THE INTERFACE BETWEEN PRIMARY
CARE AND PSYCHIATRY: FAMILY PHYSICIANS AND THEIR DILEMMAS WITH PSYCHIATRIC
CRISES
V.R. Velamoor, J.D. Mendonca, B. Hennen, A. Grindrod
January 2002
EXECUTIVE SUMMARY
This study investigated the services family physicians require to effectively handle psychiatric emergencies. We canvassed family physicians for their views on the crisis or emergency response available to them in 7 geographical regions of Southwestern Ontario: London and the counties of Middlesex, Elgin, Huron, Perth, Oxford and Kent.
A sample of 289 family physicians responded to a survey which comprehensively covered the following areas: gaps in the availability and effectiveness of services, collaborative service models, communication and educational needs of family physicians. We used focus groups and key informant interviews to highlight areas chosen for study by the survey including:
§ Existing Resources and Crisis Caseload
§ Services for Emergency Assessment
§ Services for “Less Urgent” Psychiatric Crises
§ Accessibility for Different Age Groups and Diagnoses
§ Communication Between Physicians and Specialized Services
§ Openness to Shared-Care Options
§ Continuing Education that Would Improve Skills in Handling Psychiatric Emergencies
§ Models of Crisis Response
THE WOMAN ABUSE SCREENING
TOOL: A TEN-YEAR PROGRAM OF RESEARCH
J.B. Brown, B.L. Ryan
November 2001
EXECUTIVE
SUMMARY
Frequently, research emanating
from clinical practice in the discipline of family medicine comes from a simple
question. The question initiating this
ten-year exploration of family physicians’ identification and treatment of
woman abuse epitomizes such an occurrence.
The overwhelming evidence of the serious physical, emotional and social
costs of woman abuse prompted one of the investigators, a family physician to
ask, “In my practice, I am not identifying these women - What am I doing
wrong?” In order to answer this
question a program of research on woman abuse was launched. Spanning a 10-year period from 1990 to 2000,
it has involved researchers from Ontario and Quebec in Canada, and New York
State in the U.S.
This Working Paper: (1) describes
how a program of research evolves; (2) summarizes the main studies including
the multiple methods used and the key findings; (3) illustrates the education
and dissemination process; and (4) explores the lessons learned in the research
endeavour. The Working Paper provides
summaries of previously published articles and presentations generated from the
research program. Highlighted is the
development of the Woman Abuse Screening Tool (WAST) and Woman Abuse Screening
Tool – Short (WAST-Short) specifically the evaluation of the tools’
psychometric properties in English, French and Spanish. Finally, the application of the WAST and
WAST-Short in the family practice setting demonstrates both their usefulness
and acceptance by women patients and their family physicians.
ASSESSING COMMUNICATION
BETWEEN PATIENTS AND PHYSICIANS: THE MEASURE OF PATIENT-CENTERED COMMUNICATION
J.B. Brown, M. Stewart, B.L. Ryan
December 2001
EXECUTIVE SUMMARY
For over two decades the
Patient-Doctor Communication Group at the Centre for Studies in Family
Medicine, The University of Western Ontario has concentrated on the
development, research and dissemination of the Patient-Centered Clinical Method
(PCCM). Since our initial publications
in 1986, the method has evolved considerably.
The clinical method currently consists of six interactive Components
that integrate the conventional medical model with an approach that endeavours
to understand the patient's unique illness experience. The first Component is the exploration of
two conceptualizations of ill health - disease and illness. In addition to assessing the disease
process, by history and physical examination, the physician actively seeks to
enter the patient's world - to understand their unique illness experience. The second interactive Component of the
patient-centered method is the integration of these concepts of disease and
illness with an understanding of the whole person. This includes an awareness of the patient's position in the life
cycle and the context in which they live (i.e. family, work, culture). Finding common ground between the physician
and the patient is the third Component of the method and consists of three key
areas: the patient and physician mutually defining the problem; establishing
the goals of treatment and/or management; and identifying the roles to be
assumed by both. The fourth Component
emphasizes the importance of using each encounter as an opportunity for
prevention and health promotion. The
fifth Component takes into consideration that each contact with the patient
should be used to build on the patient-physician relationship as a basis of
their continuing work together. The
sixth Component requires that, throughout the process, the physician is
realistic about time, availability and accessibility of resources, and amount
of emotional and physical energy needed.
This paper describes the Measure of Patient-Centered Communication (MPCC) which reflects the first three Components of the PCCM. The document provides an overview of the PCCM as well as a manual which includes working definitions for each component to be measured; examples; coding and scoring procedures; and coding forms.
HEALING PARTNERSHIPS BETWEEN
PATIENTS AND FAMILY DOCTORS : AN ASPECT OF QUALITY CARE
M. Stewart
November 1998
EXECUTIVE SUMMARY
Quoting from patients' stories of sickness, from studies using in-depth
interviews, and from valid epidemiological research, this presentation will
argue for the broadest possible definition of quality of care. In order to meet
the expressed needs of patients and to become true partners in care, patient-doctor
relationships will require : listening carefully to patients'
experiences ; offering empathy, support and compassion ; engendering
trust ; sharing power and control of both the interaction and the
decisions ; and, in short, finding common ground with patients.
GUIDELINES FOR THE USE OF THE
ELECTRONIC DATA BASE IN FERNS (Family medicine Educational Research Networks
for Service)
Thomas Freeman
April 1996
EXECUTIVE SUMMARY
Rapid advances in information technology make it possible to store and
sort massive amounts of personal health care data. In Family Medicine this
presents both opportunity and danger. The opportunity lies in being able to
undertake research investigations previously impractical due to the relative
rarity of some conditions in any individual practice by linking databases from
a number of practice sites. Paradoxically the ease of access provided by these
electronic databases which make this type of research brings with it increased
danger in the form of greater vulnerability to breaches of patient
confidentiality and privacy.
In order to derive as much benefit as possible from these technological
developments, the Department of Family Medicine of The University of Western
Ontario developed guidelines for the use of electronic database in the Family
Medicine Educational Research Networks for Service
(FERNS). These guidelines were developed with awareness of the existing
legislative climate and the expectation that government legislation will
eventually be enacted pertaining to electronic data bases in health care. The
opportunity to interact with these involved in developing this legislation and
with the Assistant Privacy Commissioners of Ontario (Ann Cavoukian) helped us
to try to anticipate the requirements of future legislative changes.
The guidelines are organized under the following headings :
1.Notification and Consent
2. Confidentiality, Provisions and Practices
3. Accountability
4. Provisions for Security of Data
a. Overall responsibility
b. Physical security
c. Electronic security
d. Access to health information
5. Ownership and responsibility for oversight of data
6. Disclosure practices and transfer of data to a central site
7. Complaints, remedies and sanctions
The history and expected outcomes of the Family Medicine Education
and Research Network for Service (FERNS) is described in
detail.
The guidelines require informing patients of the uses made of the health
care pertinent to their medical care. The ethical issues regarding research on
computerized data from the offices of family physicians is dealt with in three
parts : a) the main ethical issues raised by FERNS ; summarizing some
of the relevant arguments in the literature and providing justification for the
guidelines, b) an analytic framework within which to examine the ethical issues
arising from FERNS and c) a brief analysis of the key ethical values and
principles at stake in FERNS.
ASSESSING COMMUNICATION
BETWEEN PATIENTS AND DOCTORS: A MANUAL FOR SCORING PATIENT-CENTRED
COMMUNICATION
Judith Belle Brown, Ph. D.
Moira Stewart, Ph. D.
Suzan Tessier, M. A.
August, 1995
EXECUTIVE SUMMARY:
For over a decade the Patient-Doctor Communication Group at the Centre
for Studies in Family Medicine, The University of Western Ontario has
concentrated on the development, research and dissemination of the
Patient-Centred Clinical Model (PCCM). Since our initial publications in 1986,
the model has evolved considerably. The clinical method currently consists of
six interactive Components that integrate the conventional medical model with
an approach that endeavours to understand the patient's unique illness
experience. The first Component is the exploration of two conceptualizations of
ill health - disease and illness. In addition to assessing the disease process,
by history and physical examination, the physician actively seeks to enter the
patient' s world - to understand their unique illness experience. The second
interactive Component of the patient-centred method is the integration of these
concepts of disease and illness with an understanding of the whole person. This
includes an awareness of the patient's position in the life cycle and the
context in which they live (i.e. family, work, culture). Finding common ground
between the doctor and the patient is the third Component of the method and
consists of three key areas: the patient and physician mutually defining the
problem; establishing the goals of treatment and/or management; and identifying
the roles to be assumed by both. The fourth Component emphasizes the importance
of using each encounter as an opportunity for prevention and health promotion.
The fifth Component takes into consideration that each contact with the patient
should be used to build on the patient-doctor relationship as a basis of their
continuing work together. The sixth Component requires that, throughout the
process, the doctor is realistic about time, availability and accessibility of
resources, and amount of emotional and physical energy needed.
With the evolution of the theoretical model the scoring method
previously developed to measure patient-centredness during the early 1980's is
no longer adequate. This paper describes the development of a new procedure for
assessing patient-centred communication which reflects the first three
Components of the PCCM. The document provides an overview of the PCCM
definitions for each component to be measured, examples, and coding and scoring
procedures.
PHYSICIAN SERVICES IN THE HOME: PLANNING FOR THE
INTEGRATED HOME CARE OF ACUTE AND COMPLEX ILLNESS
I. R. McWhinney, MD, FCFP, FRCP
March, 1995
EXECUTIVE SUMMARY:
The Federal/Provincial/Territorial Working Group on Home Care has
identified an increasing need for complex care in the home, requiring an
"Acute Care Substitution Model" of Home Care. This model, of which
Hospital in the Home (HITH) is an example, must have the following features:
* an integrated multi-professional team, including nurses, physicians,
physiotherapists, occupational therapists and social workers;
* a readily available homemaker service at all hours;
* ability to respond rapidly to referrals;
* capacity to respond quickly to crises in patients under care of the
organization;
* availability 24 hours a day, 7 days a week.
The world literature on HITH and similar projects is reviewed. Models of
acute home care in Canada are described and the five Ontario HITH projects are
assessed. Demographic and economic changes, and developments in home care
technology make it likely that all communities will need an HITH or similar
organisation. The limitations in the current services provided by Ontario Home
Care Programs should be removed when the Ontario Government's long term care
reforms are implemented, thus making it possible for communities to provide
home care for patients with acute an d complex illness. However, one obstacle
remains. No organization exists for integrating home care by family physicians
with those of the home care program. For acute care in the home it is essential
to have medical care available, with intake assessment and continuing care
provided as far as possible by the patient's own family doctor. It is also
essential to have, at all times, a deputy on call who has access to the
patient's record and who will visit the home.
The proposal provides a framework for a HITH or similar organization in
London, a city of 315,000. A key element is the appointment of a full-time
medical director to provide leadership. Since this would be a pioneering
venture, an evaluation and research unit should be built into the HITH from the
beginning. To conform with the nomenclature of home care in Canada (see pages 1
and 2) we have used the term Acute Home Care Program (AHCP) in the proposal.
Hospital in the home (HITH) is an example of an AHCP.
ACHIEVING THE TRANSITION FROM
HOSPITAL TO HOME: HOW OLDER PATIENTS AND THEIR CAREGIVERS EXPERIENCE THE
DISCHARGE PROCESS
Carol L. McWilliam, M.Sc.N., Ed.D. et. al.
December, 1993
EXECUTIVE SUMMARY:
High health care costs and limited bed availability promote earlier
discharge of hospital patients, who frequently return home with continued care
needs. Because individuals 65 years and older have approximately twice as many hospital
admissions and over twice as long an average length of stay, older patients are
often affected by this health care trend. In our area, family physicians and
other health professionals have expressed increasing concern about the
interface between hospital services and home care delivery, fearing that older
patients in particular may be having difficulty in making this transition.
Phenomenological study of the everyday experience of all involved in
delivering health care has the potential to illuminate factors which escape
scrutiny in traditional research and program evaluation approaches. This
two-phased investigation therefore applied phenomenological research
methodology to explore factors other than medical condition and treatments
which contributed to the discharge experiences of 12 rural and 9 urban
patients. Specifically, the research question asked: What factors other than
diagnosis and treatment protocol contribute to the timing of discharge from
hospital and the perceived adequacy of post-discharge care?
Interpretive research methods included document review, observation and
in-depth interviews of all key participants. Over the two phases of the
research, the purposefully selected sample consisted of a total of 21 patients
over 65 years of age, and a change in sample of 22 informal caregivers, and 117
professionals and health care administrators involved in their care in the
hospital and/or home setting. An immersion and crystallization analysis
approach was used to identify three major themes which characterized discharge
and readmission challenges: (1) professionally democratized order in the rural
setting, versus bureaucratized order in the urban setting; (2) the
disempowering process of interaction between both professional and family caregivers
and older patients; and ultimately, (3) medicalization of care. These three
factors combined to create 12 discharge delays for the 21 cases followed and re
-admissions to hospital for 6 of the 21 patients during the 10-day
post-discharge follow-up period. Findings suggest that to address such factors,
health care system planners, administrators and professionals alike need to
openly question their customarily narrow focus on individual organizational and
role efficiency, dispense with the traditional hierarchical approaches, and
begin to function as a collaborative team on which the patient is an equal
member. The merits of efficient bed utilization, hospitalization, and
opportunistic intervention might best be brought into open question routinely.
Patients' own mindsets and sense of purpose in life require careful assessment
in planning and implementing care. All professionals, patients, and the public
in general require much better education about the full range of existing
services and how to access them. System-wide approaches to tracking patients,
and to planning, implementing, and evaluating health care delivery need to be
put in place.
HOME VISITS BY PHYSICIANS: RECENT
TRENDS AND FUTURE NEEDS
Hemali Kulatilaka, M.Sc., MPA
Ian R. McWhinney, M.D., FCFP, FRCP
March, 1992
EXECUTIVE SUMMARY:
Using information from national health surveys and from the literature, this
report reviews trends in home visits* by physicians, in Canada, United States,
and Britain, between 1969 and 1989. Until 1982 the rate of home visits per
physician and per member of the population decreased steadily. This was the
continuation of a decline which began in the 1950's. Beginning in 1982, data
from the U.S. Health Interview Survey shows an upturn in the home visit rate
and this trend continues in the 1989 survey. Using the population as the
denominator, the home visit rate declined from .083 per person per year in
1971, to .039 in 1975, and .031 in 1980. In 1982-83, however, the rate
increased to 0.101 visits per person per year, and in 1989 to 0.116.
In Canada, the National Health Survey of 1978-79 showed a home visit
rate of 0.075 per person per year - much higher than the U.S. rate in 1980. The
rate for Ontario in 1978-79 (0.073) was similar to the national figure. Using
April data from the Ontario Health Insurance Plan (OHIP), the rate was 0.051 in
1985 and 0.061 in 1988. Assuming that all other factors remain constant at 1989
levels, we have calculated the home visit per person rate for the years 2001
and 2011, given the projected age distribution of the Ontario population. The
rates for those years based on 1988 OHIP levels would be 0.070 and 0.079, and
based on 1989 U.S. levels 0.116 and 0.127. The home visit rate for individual
physicians will depend on such factors as the age structure and location of the
practice.
In all three countries, about half of all home visits are paid to patients
over the age of 65. The relationship between age and home visit rate, however,
is not a simple one. In the U.S., for example, an increase in the elderly
population has been associated, at different times, with both a decrease and an
increase in the home visit rate. The following additional factors must be taken
into account when estimating future trends:
1.
The availability of acute and
long term care beds. Between 1975 and 1987, the number of public hospital beds
in Ontario declined by 23%. Extended care beds decreased by 8% during the same
period. With no relaxation in fiscal pressures, the bed to population ratio is
likely to continue falling in the next two decades, thus increasing the demand
for home visits by physicians.
2.
The developing roles of other
health professionals, especially nurses. Already, nurses are shouldering much
of the responsibility for home care in Ontario Home Care Programs. It is
doubtful whether physicians' contribution to home care can be further reduced,
without jeopardizing the quality of the medical care provided in the home. The
involvement of physicians is especially important in the home care of patients
with acute, or unstable chronic, conditions.
3.
Developments in technology.
New technologies can either enhance home care or create a need for more
hospital beds. In the recent past, technologies like coronary care, renal
dialysis and organ transplantation have often had a centripetal effect. Some of
the newer technologies are likely to act more centrifugally by enhancing communication
and increasing the scope of home monitoring. New surgical techniques are
reducing the length of hospital stay. It is now common for intravenous
antibiotics, cancer chemotherapy and parenteral nutrition to be provided in the
home. Laboratory services, radiology and electrocardiography are available in
the home. Our prediction is that, on balance, technology will tend to increase
the need for the involvement of physicians in home care.
4.
Changing patterns of
morbidity. With the aging of the population, the trend towards an increase in
the prevalence of chronic disease is likely to increase the need for home care.
With stable chronic disease this will have most impact on nursing services.
Unstable chronic conditions will require more services from physicians.
5.
The economics of medical
practice. Caring for a patient at home involves the physician in time consuming
activities, many of which, like phone calls, team meetings and travel, are not
remunerated. Since they do not provide continuing care, and usually refer
seriously ill patients to hospital, house call agencies are not at this
disadvantage. The home care provided by physicians is, therefore, often being
done at a loss to themselves, a situation likely to put a brake on development.
In Ontario, the potential remuneration for a home visit was increased by the
addition of the category "House Call Assessment" to the 1991 fee
schedule.
6.
The organization of medical
care. Family physicians can only offer home visits for patients living within a
reasonable distance from their offices. When home visits were declining,
practices tended to become geographically dispersed, thus putting many patients
out of reach of home visits. When patients join a practice there may be no
clear understanding as to whether the doctor will do home visits if it becomes
necessary. If home care is to become integral to medical practice, some
geographical concentration will be necessary, as well as a clear understanding
by patients of what they can expect. Group practice may enhance family
physicians' ability to do home visits, by ensuring coverage of patients in the
office and in hospital while home visits are being done. Some home medical care
can be provided by specialised services operating from a hospital base.
Oncologists can provide cancer chemotherapy, infectious disease specialists,
intravenous antibiotics, and so on. The result, however, is likely to be a
fragmentary organization, appropriate only for certain specific needs. The
ideal organization for home visits, in our view, is one which integrates
nursing, medical and social services, and services by the patient's own family
physician and the appropriate specialists. Commercial home visit services have
recently emerged in Ontario cities. Since these provide no continuity of care,
and act in isolation from hospitals, home care programs and family physicians,
they will, in our view, make little contribution to developments in home care.
7.
The education of physicians.
The concentration of medical education in the hospital has tended to produce
physicians who are ill prepared to care for patients in their homes. Even
family medicine residency programs have been slow to emphasise training in home
care. If this is not to act as a brake on development, medical schools will
need to produce graduates who expect to care for patients at home and feel
confident in their ability to do so.
8.
Physicians can make little
impact on home care unless they are part of an organization, as they are in the
hospital. Home care programs and "hospitals at home" are examples of
such organizations. Whether these organizations are able to develop will depend
on the resources allocated to them. Ultimately, therefore, the future of home
care, and the physician's role in it, depends on policy decisions made by the
provincial government.
* All the sources of data identified home visits separately from visits
to patients in nursing homes.
