Working Paper Series
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
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
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.
V.R. Velamoor, J.D. Mendonca, B. Hennen, A. Grindrod
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
J.B. Brown, B.L. Ryan
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.
J.B. Brown, M. Stewart, B.L. Ryan
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.
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.
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
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.
Judith Belle Brown, Ph. D.
Moira Stewart, Ph. D.
Suzan Tessier, M. A.
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.
I. R. McWhinney, MD, FCFP, FRCP
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.
Carol L. McWilliam, M.Sc.N., Ed.D. et. al.
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.
Hemali Kulatilaka, M.Sc., MPA
Ian R. McWhinney, M.D., FCFP, FRCP
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.
Centre for Studies in Family Medicine, 245-100 Collip
Circle, UWO Research Park, London, Ontario, Canada N6G 4X8
is maintained by the Centre for Studies in Family Medicine at The University of Western Ontario. Contact
Person: Cathy Thorpe.