Patient assessment within the context of healthcare delivery packages: A comparative analysis.

BACKGROUND: Due to an increased focus on productivity and cost-effectiveness, many countries across the world have implemented a variety of tools for standardizing diagnostics and treatment. In Denmark, healthcare delivery packages are increasingly used for assessment of patients. A package is a tool for creating coordination, continuity and efficient pathways; each step is pre-booked, and the package has a well-defined content within a predefined category of diseases. The aim of this study was to investigate how assessment processes took place within the context of healthcare delivery packages. METHODS: The study used a constructivist Grounded Theory approach. Ethnographic fieldwork was carried out in three specialized units: a mental health unit and two multiple sclerosis clinics in Southern Denmark, which all used assessment packages. Several types of data were sampled through theoretical sampling. Participant observation was conducted for a total of 126h. Formal and informal interviews were conducted with 12 healthcare professionals and 13 patients. Furthermore, audio recordings were made of 9 final consultations between physicians and patients; 193min of recorded consultations all in all. Lastly, the medical records of 13 patients and written information about packages were collected. The comparative, abductive analysis focused on the process of assessment and the work made by all the actors involved. In this paper, we emphasized the work of healthcare professionals. RESULTS: We constructed five interrelated categories: 1. "Standardized assessing", 2. "Flexibility", which has two sub-categories, 2.1. "Diagnostic options" and 2.2. "Time and organization", and, finally, 3. "Resisting the frames". The process of assessment required all participants to perform the predefined work in the specified way at the specified time. Multidisciplinary teamwork was essential for the success of the process. The local organization of the packages influenced the assessment process, most notably the pre-defined scope of relevant diseases targeted by the package. The inflexible frames of the assessment package could cause resistance among clinicians. Moreover, expert knowledge was an important factor for the efficiency of the process. Some types of organizational work processes resulted in many patients being assessed, but without being diagnosed with at package-relevant disease. CONCLUSION: Limiting the grounds for using specialist knowledge in structured health care delivery may affect specialists' sense of professional autonomy and can result in professionals employing strategies to resist the frames of the packages. Finally, when organizing healthcare delivery packages, it seems important to consider how to make the optimal use of specialist knowledge.

The role of assessment packages for diagnostic consultations: A conversation analytic perspective.

This article reports a conversation analysis of assessment package consultations. Healthcare delivery packages belong to a highly structured mode of healthcare delivery, in which specific courses of healthcare interventions related to assessment and treatment are predefined, both as to timing and content. Assessment packages are widely used in an increasing number of medical specialities; however, there is a lack of knowledge about how packaged assessment influences the interaction between doctor and patient. In this study, we investigate the final consultation in assessment packages, which is when the final clarification of the patient's symptoms takes place. The primary data of the study were eight audio recordings of consultations, and the secondary data were ethnographic field descriptions. In most consultations, packaged assessment was a resource as it provided fast and efficient clarification. In most cases, clarification was treated as good news since it either confirmed the absence of a serious disease or resulted in a diagnosis leading to relevant treatment offers. However, in some cases, clarification was not perceived as good news. This was the case in consultations with patients whose goal was to leave the consultation with clarification in the form of a definite diagnosis, but who were not offered such clarification. These patients negotiated the outcome of the consultation by applying implicit and explicit pressure, which induced the doctors to disregard the boundaries of the package and offer the patient more tests. The study highlights some of the problems related to introducing narrow, specialized package assessment.

[Social, economic and cultural aspects of whiplash syndrome]. / Sociale, økonomiske og kulturelle aspekter ved whiplash.

The sequelae following whiplash injuries (WL) entail considerable human costs and expenses for both treatment and social services, especially public income benefits. Frequently, many players are involved after WL and good intersectional collaboration is therefore essential to counter the WL patients' tendency not to return to their jobs. There is a need for further research i) to identify evidence-based prophylaxis and treatment, ii) to monitor medical diagnoses in relation to social benefits to support research opportunities and iii) to assess whether other social solutions comprise alternatives superior to current treatment and compensation options.

[Disability retirement pension for patients with syndrome diagnoses. A registry study on the basis of data from the Social Appeal Board]. / Førtidspension til patienter med syndromesygdomme. En registerundersøgelse på basis of oplysninger fra Den Sociale Ankestyrelse.

INTRODUCTION: Since the early 1990s, disability retirement pension may be granted on the basis of a syndrome diagnosis. Before the pension can be granted, local public authorities collect information on health and social matters and report to The Social Appeal Board. In 1998, a new diagnostic tool was introduced based on the International Statistical Classification of Diseases and Related Health Problems (ICD-10) diagnoses. The information available in The Social Appeal Board has made it possible to study the social consequences of a syndrome diagnosis. The purpose of the study was: 1) To estimate the incidence of patients granted disability retirement pension with the diagnoses whiplash, fibromyalgia, chronic pain disorder, chronic fatigue syndromee, chronic strain syndromee, and pelvic syndromee. 2) To estimate changes in the level of pension granted to patients with syndromee diagnosis. 3) To compare differences between patients with syndromee diagnosis granted disability retirement pension to patients with other diagnoses on the following parameters: sex, civil status, income when applying for pension, and attempts of rehabilitation. 4) To estimate comorbidity of psychiatric diagnosis in patients with syndromee diagnosis. MATERIAL AND METHODS: A register study of data on pension reported to The National Social Appeal Board in the period July 1st 1998 to December 31st, 2000. RESULTS: Of all patients granted pension in the period 8.3 per cent had a syndromee diagnosis, 11 per cent of the women and 5 per cent of the men. Both the relative and the absolute number of patients with syndromee diagnosis granted a pension were increasing. Comorbidity of psychiatric disorders was 3 per cent in the group with syndromee diagnosis. More patients with syndromee diagnosis than with other diagnoses had received sickness benefits and rehabilitation when pension was granted. DISCUSSION: The large number of patients with syndromee diagnosis granted pension calls for multidisciplinary prophylactic and treatment initiatives in order to reduce the number of patients in need of public support. The results are discussed in view of the new Pension's Act which will become effective as from January 1st, 2003.