Learning from the implementation of a surgical opioid reduction initiative in an integrated health system: a qualitative study among providers and patients.

BACKGROUND: Surgical opioid overprescribing can result in long-term use or misuse. Between July 2018 and March 2019, the multicomponent intervention, Minimizing Opioid Prescribing in Surgery (MOPiS) was implemented in the general surgery clinics of five hospitals and successfully reduced opioid prescribing. To date, various studies have shown a positive outcome of similar reduction initiatives. However, in addition to evaluating the impact on clinical outcomes, it is important to understand the implementation process of an intervention to extend sustainability of interventions and allow for dissemination of the intervention into other contexts. This study aims to evaluate the contextual factors impacting intervention implementation. METHODS: We conducted a qualitative study with semi-structured interviews held with providers and patients of the general surgery clinics of five hospitals of a single health system between March and November of 2019. Interview questions focused on how contextual factors affected implementation of the intervention. We coded interview transcripts deductively, using the Consolidated Framework for Implementation Research (CFIR) to identify the relevant contextual factors. Content analyses were conducted using a constant comparative approach to identify overarching themes. RESULTS: We interviewed 15 clinicians (e.g., surgeons, nurses), 1 quality representative, 1 scheduler, and 28 adult patients and identified 3 key themes. First, we found high variability in the responses of clinicians and patients to the intervention. There was a strong need for intervention components to be locally adaptable, particularly for the format and content of the patient and clinician education materials. Second, surgical pain management should be recognized as a team effort. We identified specific gaps in the engagement of team members, including nurses. We also found that the hierarchical relationships between surgical residents and attendings impacted implementation. Finally, we found that established patient and clinician views on opioid prescribing were an important facilitator to effective implementation. CONCLUSION: Successful implementation of a complex set of opioid reduction interventions in surgery requires locally adaptable elements of the intervention, a team-centric approach, and an understanding of patient and clinician views regarding changes being proposed.

The development of a safe opioid use agreement for surgical care using a modified Delphi method.

BACKGROUND: Opioids prescribed to treat postsurgical pain have contributed to the ongoing opioid epidemic. While opioid prescribing practices have improved, most patients do not use all their pills and do not safely dispose of leftovers, which creates a risk for unsafe use and diversion. We aimed to generate consensus on the content of a "safe opioid use agreement" for the perioperative settings to improve patients' safe use, storage, and disposal of opioids. METHODS: We conducted a modified three-round Delphi study with clinicians across surgical specialties, quality improvement (QI) experts, and patients. In Round 1, participants completed a survey rating the importance and comprehensibility of 10 items on a 5-point Likert scale and provided comments. In Round 2, a sub-sample of participants attended a focus group to discuss items with the lowest agreement. In Round 3, the survey was repeated with the updated items. Quantitative values from the Likert scale and qualitative responses were summarized. RESULTS: Thirty-six experts (26 clinicians, seven patients/patient advocates, and three QI experts) participated in the study. In Round 1, >75% of respondents rated at least four out of five on the importance of nine items and on the comprehensibility of six items. In Round 2, participants provided feedback on the comprehensibility, formatting, importance, and purpose of the agreement, including a desire for more specificity and patient education. In Round 3, >75% of respondents rated at least four out of five for comprehensibility and importance of all 10 updated item. The final agreement included seven items on safe use, two items on safe storage, and one item on safe disposal. CONCLUSION: The expert panel reached consensus on the importance and comprehensibility of the content for an opioid use agreement and identified additional patient education needs. The agreement should be used as a tool to supplement rather than replace existing, tailored education.

A mixed-method approach to generate and deliver rapid-cycle evaluation feedback: lessons learned from a multicenter implementation trial in pediatric surgery.

BACKGROUND: Rapid-cycle feedback loops provide timely information and actionable feedback to healthcare organizations to accelerate implementation of interventions. We aimed to (1) describe a mixed-method approach for generating and delivering rapid-cycle feedback and (2) explore key lessons learned while implementing an enhanced recovery protocol (ERP) across 18 pediatric surgery centers. METHODS: All centers are members of the Pediatric Surgery Research Collaborative (PedSRC, www.pedsrc.org ), participating in the ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) trial. To assess implementation efforts, we conducted a mixed-method sequential explanatory study, administering surveys and follow-up interviews with each center's implementation team 6 and 12 months following implementation. Along with detailed notetaking and iterative discussion within our team, we used these data to generate and deliver a center-specific implementation report card to each center. Report cards used a traffic light approach to quickly visualize implementation status (green = excellent; yellow = needs improvement; red = needs significant improvement) and summarized strengths and opportunities at each timepoint. RESULTS: We identified several benefits, challenges, and practical considerations for assessing implementation and using rapid-cycle feedback among pediatric surgery centers. Regarding potential benefits, this approach enabled us to quickly understand variation in implementation and corresponding needs across centers. It allowed us to efficiently provide actionable feedback to centers about implementation. Engaging consistently with center-specific implementation teams also helped facilitate partnerships between centers and the research team. Regarding potential challenges, research teams must still allocate substantial resources to provide feedback rapidly. Additionally, discussions and consensus are needed across team members about the content of center-specific feedback. Practical considerations include carefully balancing timeliness and comprehensiveness when delivering rapid-cycle feedback. In pediatric surgery, moreover, it is essential to actively engage all key stakeholders (including physicians, nurses, patients, caregivers, etc.) and adopt an iterative, reflexive approach in providing feedback. CONCLUSION: From a methodological perspective, we identified three key lessons: (1) using a rapid, mixed method evaluation approach is feasible in pediatric surgery and (2) can be beneficial, particularly in quickly understanding variation in implementation across centers; however, (3) there is a need to address several methodological challenges and considerations, particularly in balancing the timeliness and comprehensiveness of feedback. TRIAL REGISTRATION: NIH National Library of Medicine Clinical Trials. CLINICALTRIALS: gov Identifier: NCT04060303. Registered August 7, 2019, https://clinicaltrials.gov/ct2/show/NCT04060303.

Implementation science for quality improvement in pediatric surgery.

Despite the widespread integration of quality improvement principles into pediatric surgical practice, the actual adoption of evidence-based practices continues to be a challenge. The field of pediatric surgery, in particular, has been slow to adopt clinical pathways and protocols that lead to decreased practice variation and improved clinical outcomes. This manuscript provides an introduction to how implementation science principles into quality improvement efforts may optimize uptake of evidence-based practices, ensure success of these endeavors, and help assess the effectiveness of the interventions. Examples of implementation science application to pediatric surgical quality improvement endeavors are explored.

Association of Multimodal Pain Control with Patient-Reported Outcomes in Children Undergoing Surgery.

INTRODUCTION: Our aim was to describe practices in multimodal pain management at US children's hospitals and evaluate the association between non-opioid pain management strategies and pediatric patient-reported outcomes (PROs). METHODS: Data were collected as part of the 18-hospital ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) clinical trial. Non-opioid pain management strategies included use of preoperative and postoperative non-opioid analgesics, regional anesthetic blocks, and a biobehavioral intervention. PROs included perioperative nervousness, pain-related functional disability, health-related quality of life (HRQoL). Associations were analyzed using multinomial logistic regression models. RESULTS: Among 186 patients, 62 (33%) received preoperative analgesics, 186 (100%) postoperative analgesics, 81 (44%) regional anesthetic block, and 135 (73%) used a biobehavioral intervention. Patients were less likely to report worsened as compared to stable nervousness following regional anesthetic block (relative risk ratio [RRR]:0.31, 95% confidence interval [CI]:0.11-0.85), use of a biobehavioral technique (RRR:0.26, 95% CI:0.10-0.70), and both in combination (RRR:0.08, 95% CI:0.02-0.34). There were no associations of non-opioid pain control modalities with pain-related functional disability or HRQoL. CONCLUSION: Use of postoperative non-opioid analgesics have been largely adopted, while preoperative non-opioid analgesics and regional anesthetic blocks are used less frequently. Regional anesthetic blocks and biobehavioral interventions may mitigate postoperative nervousness in children. LEVEL OF EVIDENCE: III.

A qualitative examination of barriers and facilitators of pediatric enhanced recovery protocol implementation among 18 pediatric surgery services.

BACKGROUND: Enhanced recovery protocols (ERPs) are an evidence-based intervention to optimize post-surgical recovery. Several studies have demonstrated that the use of an ERP for gastrointestinal surgery results in decreased length of stay, shortened time to a regular diet, and fewer administered opioids, while also trending toward lower complication and 30-day readmission rates. Yet, implementation of ERPs in pediatric surgery is lagging compared to adult surgery. The study's purpose was to conduct a theory-guided evaluation of barriers and facilitators to ERP implementation at US hospitals with a pediatric surgery service. METHODS: We conducted semi-structured interviews at 18 hospitals with 48 participants, including pediatric surgeons, anesthesiologists, gastroenterologists, nurses, and physician assistants. Interviews were conducted online, audio-recorded, and transcribed verbatim. To identify barriers and facilitators to ERP implementation, we conducted an analysis using deductive logics based on the five Active Implementation Frameworks (AIFs). RESULTS: Effective practices (usable innovations) were challenged by a lack of compliance to ERP elements, and facilitators were having standardized protocols in place and organization support for implementation. Effective implementation (stages of implementation and implementation drivers) had widespread barriers to implementation across the stages from exploration to full implementation. Barriers included needing dedicated teams for ERP implementation and buy-in from hospital leadership. These items, when present, were strong facilitators of effective implementation, in addition to on-site, checklists, protected time to oversee ERP implementation, and order sets for ERP elements built into the electronic medical record. The enabling context (teams) focused on teams' engagement in ERP implementation and how they collaborated to implement ERPs. Barriers included having surgical team members resistant to change or who were not bought into ERPs in pediatric practice. Facilitators included engaging a multi-disciplinary team and engaging patients and families early in the implementation process. CONCLUSIONS: Barriers to ERP implementation in pediatric surgery highlighted can be addressed through providing guidelines to ERP implementation, team-based support for change management, and protocols for developing an ERP implementation team. Future steps are to apply and evaluate these strategies in a stepped-wedge, cluster randomized trial to increase the implementation of ERPs at these 18 hospitals.

Age- and Sex-Specific Needs for Children Undergoing Inflammatory Bowel Disease Surgery: A Qualitative Study.

INTRODUCTION: The use of enhanced recovery protocols (ERP) is extending to pediatric surgical populations, such as patients with inflammatory bowel diseases (IBDs). Given the variation in age- and sex-specific characteristics of pediatric IBD patients, it is important to understand the unique needs of subgroups, such as male versus female or preadolescent versus older patients, when implementing ERPs. We gathered clinician, patient, and caregiver perspectives on age- and sex-specific needs for children undergoing IBD surgery. METHODS: We used semistructured interviews and focus groups to assess ERP needs and perceived differences in needs between preadolescent (10-13 y), older (14-19 y), male, and female IBD patients. Participants included clinicians, patients who had recent IBD surgery, and patients' caregivers. RESULTS: Forty-eight clinicians, six patients, and eight caregivers participated. Three broad categories of themes emerged: concerns, needs, and experiences related to the (1) surgical care process; (2) continuum of IBD care; and (3) suggestions to make surgical care more patient centered. With regard to surgical care processes, stakeholders reported different communication needs for preadolescent and older children. Key themes about the continuum of IBD care were the need (1) for support from child life specialists and (b) to address young women's health issues. Suggestions to make surgical care more patient centered included providing older children with patient experiences that reflect their perspective as young adults. CONCLUSIONS: The findings highlight the need to adopt a patient-centered approach for ERP use that actively addresses age- and sex-specific factors while engaging patients and caregivers as partners with clinicians to improve surgical care for children with IBD.

Pilot implementation of opioid stewardship measures using the national surgical quality improvement program-pediatric platform.

INTRODUCTION: Data surrounding optimal pediatric postoperative opioid prescribing are incomplete. The objective of this study was to leverage the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatric (NSQIP-P) and assess feasibility of added data collection surrounding pediatric perioperative pain management practices including opioid prescribing at discharge. METHODS: Nineteen (19) novel data elements were added to NSQIP-P data collection of selected patients, ages 5-18 years, who had undergone surgery at a single, free-standing children's hospital. Metrics around data abstraction and completion of variables were collected. Univariate analyses (using Chi-square or Wilcoxon Rank Sum tests) and multiple logistic regressions were performed to describe predictors of opioid prescribing at discharge and to monitor adherence to Food and Drug Administration (FDA) prescribing recommendations. RESULTS: Median abstraction time of the novel variables decreased from 12 to 5 min per patient over 13 months with 94% variable completion rate. Of 878 patients, 302 (36.4%) were prescribed opioids at discharge. Factors associated with an opioid prescription included older age (p < 0.001), white race (p < 0.05), undergoing an orthopedic surgery (p < 0.001), and receiving a regional block perioperatively (p < 0.001). All opioid prescriptions met FDA guidelines with no patients receiving codeine, and 98% of patients receiving opioid prescriptions < 50 morphine milli-equivalents per day. CONCLUSION: Collecting data on current pain management practices, opioid prescribing, and adherence to safety recommendations is feasible using the NSQIP-P with little added burden. Further expansion of data collection is needed to develop generalizable optimal prescribing practices for post-discharge pain management for children.

A Missing Piece of the Puzzle: Patient and Provider Perspectives on Pain Management Needs and Opioid Prescribing in Inflammatory Bowel Disease Care.

Background: Recent data have shown high rates of opioid misuse among inflammatory bowel disease (IBD) patients. We conducted a qualitative study to explore IBD patient and provider perceptions and experiences with pain management and opioid prescribing. Methods: We conducted a focus group with IBD patients and semistructured interviews with IBD-focused physicians and nurses. We used an inductive approach for analysis and the constant comparison method to develop and refine codes and identify prominent themes. We analyzed interview and focus group data concurrently to triangulate themes. Results: Nine patients and 10 providers participated. We grouped themes into 3 categories: (1) current practices to manage pain; (2) perceived pain management challenges; and (3) suggestions to optimize pain management. In the first category (current practices), both patients and providers reported building long-term patient-provider relationships and the importance of exploring nonpharmacologic pain management strategies. Patients reported proactively trying remedies infrequently recommended by IBD providers. In the second category (pain management challenges), patients and providers reported concerns about opioid use and having limited options to treat pain safely. Patients discussed chronic pain and having few solutions to manage it. In the third category, providers shared suggestions for improvement such as increasing use of nonpharmacologic pain management strategies and enhancing care coordination. Conclusions: Despite some common themes between the 2 groups, we identified some pain management needs (eg, addressing chronic pain) that matter to patients but were seldom discussed by IBD providers. Addressing these areas of potential disconnect is essential to optimize pain management safety in IBD care.

Primary prevention of prescription opioid diversion: a systematic review of medication disposal interventions.

Background: In the U.S., 50-75% of nonmedical users of prescription opioids obtain their pills through diversion by friends or relatives. Increasing disposal of unused opioid prescriptions is a fundamental primary prevention strategy in combatting the opioid epidemic.Objectives: To identify interventions for disposal of unused opioid pills and assess the evidence of their effectiveness on disposal-related outcomes.Methods: A search of four electronic databases was conducted (October 2019). We included all empirical studies, systematic literature reviews, and meta-analyses about study medication disposal interventions in the U.S. Studies of disposal interventions that did not include opioids were excluded. We abstracted data for the selected articles to describe the study design, and outcomes. Further, we assessed the quality of each study using the NIH Study Quality Assessment Tools.Results: We identified 25 articles that met our inclusion criteria. None of the 13 studies on drug take-back events or the two studies on donation boxes could draw conclusions about their effectiveness. Although studies on educational interventions found positive effects on knowledge acquisition, they did not find differences in disposal rates. Two randomized controlled trials on drug disposal bags found higher opioid disposal rates in their intervention arms compared to the control arms (57.1% vs 28.6% and 33.3%, p = .01; and 85.7% vs 64.9%, p = .03).Conclusions: Peer-reviewed publications on opioid disposal interventions are limited and either do not address effectiveness or have conflicting findings. Future research should address these limitations and further evaluate implementation and cost-effectiveness.

A Mixed-Methods Evaluation of Clinician Education Modules on Reducing Surgical Opioid Prescribing.

BACKGROUND: In this study, we developed online interactive clinician education modules highlighting best practices to minimize opioid prescribing at discharge after surgery. The modules were implemented as part of a multicomponent quality improvement initiative across a six-hospital health system. This article describes the development and evaluation of this educational intervention. MATERIALS AND METHODS: Clinician education modules targeting surgical prescribers, nurses, and pharmacists were developed and implemented by an interdisciplinary team. Clinicians were invited to participate in an evaluation survey after completing the modules. Survey items assessed clinicians' rating of the module and intention to change clinical practice because of the module. Quantitative and qualitative survey responses were analyzed by the study team. RESULTS: A total of 2119 clinicians completed the module and 1831 of these clinicians (86.4%) completed the survey. Of clinicians completing the survey, 65.6% reported that they intend to change clinical practice after completing the module. Intended changes were related to increased knowledge and awareness, provider empowerment, opioid prescribing practices, nonopioid prescribing practices, and patient education. Many clinicians who indicated they do not intend to change practice reported that their clinical practices were already in line with module recommendations. Some clinicians did not perceive the module to be relevant to their role. CONCLUSIONS: Module completion was associated with the intention to improve clinical practice in areas related to provider empowerment, opioid prescribing, nonopioid prescribing, and patient education. Evaluation data will inform future module improvements. There is an opportunity to ensure that all clinicians, including those who are not prescribers, recognize their role in opioid stewardship.

The association between the workload of general practitioners and patient experiences with care: results of a cross-sectional study in 33 countries.

BACKGROUND: The workload of general practitioners (GPs) and dissatisfaction with work have been increasing in various Western countries over the past decades. In this study, we evaluate the relation between the workload of GPs and patients' experiences with care. METHODS: We collected data through a cross-sectional survey among 7031 GPs and 67,873 patients in 33 countries. Dependent variables are the patient experiences on doctor-patient communication, accessibility, continuity, and comprehensiveness of care. Independent variables concern the workload measured as the GP-reported work hours per week, average consultation times, job satisfaction (an indicator of subjective workload), and the difference between the workload measures of every GP and the average in their own country. Finally, we evaluated interaction effects between workload measures and what patients find important in a country and the presence of a patient-list system. Relationships were determined through multilevel regression models. RESULTS: Patients of GPs who are happier with their work were found to experience better communication, continuity, access, and comprehensiveness. When GPs are more satisfied compared to others in their country, patients also experience better quality. When GPs work more hours per week, patients also experience better quality of care, but not in the area of accessibility. A longer consultation time, also when compared to the national average, is only related to more comprehensive care. There are no differences in the relationships between countries with and without a patient list system and in countries where patients find the different quality aspects more important. CONCLUSIONS: Patients experience better care when their GP has more work hours, longer consultation times, and especially, a higher job satisfaction.

Communication between general practitioners and medical specialists in the referral process: a cross-sectional survey in 34 countries.

BACKGROUND: The communication of relevant patient information between general practitioners (GPs) and medical specialists is important in order to avoid fragmentation of care thus achieving a higher quality of care and ensuring physicians' and patients' satisfaction. However, this communication is often not carried out properly. The objective of this study is to assess whether communication between GPs and medical specialists in the referral process is associated with the organisation of primary care within a country, the characteristics of the GPs, and the characteristics of the primary care practices themselves. METHODS: An analysis of a cross-sectional survey among GPs in 34 countries was conducted. The odds ratios of the features that were expected to relate to higher rates of referral letters sent and communications fed back to GPs were calculated using ordered logistic multilevel models. RESULTS: A total of 7183 GPs from 34 countries were surveyed. Variations between countries in referral letters sent and feedback communication received did occur. Little of the variance between countries could be explained. GPs stated that they send more referral letters, and receive more feedback communications from medical specialists, in countries where they act as gatekeepers, and when, in general, they interact more with specialists. GPs reported higher use of referral letters when they had a secretary and/or a nurse in their practice, used health information technologies, and had greater job satisfaction. CONCLUSIONS: There are large differences in communication between GPs and medical specialists. These differences can partly be explained by characteristics of the country, the GP and the primary care practice. Further studies should also take the organisation of secondary care into account.

Evaluating the implementation and effectiveness of a multi-component intervention to reduce post-surgical opioid prescribing: study protocol of a mixed-methods design.

INTRODUCTION: Opioids prescribed after surgery accounted for 5% of the 191 million opioid prescriptions filled in 2017. Approximately 80% of the opioid pills prescribed by surgical care providers remain unused, leaving a substantial number of opioids available for non-medical use. We developed a multi-component intervention to address surgical providers' role in the overprescribing of opioids. Our study will determine effective strategies for reducing post-surgical prescribing while ensuring adequate post-surgery patient-reported pain-related outcomes, and will assess implementation of the strategies. METHODS AND ANALYSIS: The Minimising Opioid Prescribing in Surgery study will implement a multi-component intervention, in an Illinois network of six hospitals (one academical, two large community and three small community hospitals), to decrease opioid analgesics prescribed after surgery. The multi-component intervention involves four domains: (1) patient expectation setting, (2) baseline assessment of opioid use, (3) perioperative pain control optimisation and (4) post-surgical opioid minimisation. Four surgical specialities (general, orthopaedics, urology and gynaecology) at the six hospitals will implement the intervention. A mixed-methods approach will be used to assess the implementation and effectiveness of the intervention. Data from the network's enterprise data warehouse will be used to evaluate the intervention's effect on post-surgical prescriptions and a survey will collect pain-related patient-reported outcomes. Intervention effectiveness will be determined using a triangulation design, mixed-methods approach with staggered speciality-specific implementation for contemporaneous control of opioid prescribing changes over time. The Consolidated Framework for Implementation Research will be used to evaluate the site-specific contextual factors and adaptations to achieve implementation at each site. ETHICS AND DISSEMINATION: The study aims to identify the most effective hospital-type and speciality-specific intervention bundles for rapid dissemination into our 56-hospital learning collaborative and in hospitals throughout the USA. All study activities have been approved by the Northwestern University Institutional Review Board (ID STU00205053).

Minimizing Opioid Prescribing in Surgery (MOPiS) Initiative: An Analysis of Implementation Barriers.

BACKGROUND: The United States is in the midst of an opioid epidemic. In response, our institution developed the Minimizing Opioid Prescribing in Surgery (MOPiS) initiative. MOPiS is a multicomponent intervention including: (1) patient education on opioid safety and pain management expectations; (2) clinician education on safe opioid prescribing; (3) prescribing data feedback; (4) patient risk screening to assess for addictive behavior; and (5) optimizations to the electronic health record (EHR). We conducted a preintervention formative evaluation to identify barriers and facilitators to implementation. MATERIALS AND METHODS: We conducted 22 semistructured interviews with key stakeholders (surgeons, nurses, pharmacists, and administrators) at six hospitals within a single health care system. Interviewees were asked about perceived barriers and facilitators to the components of the intervention. Responses were analyzed to identify common themes using the Consolidated Framework for Implementation Research. RESULTS: We identified common themes of potential implementation barriers and classified them under 12 Consolidated Framework for Implementation Research domains and three intervention domains. Time and resource constraints (needs and resources), the modality of educational material (design quality and packaging), and prescribers' concern for patient satisfaction scores (external policy and incentives) were identified as the most significant structural barriers. Resident physicians, pharmacists, and pain specialists were identified as potential key facilitating actors to the intervention. CONCLUSIONS: We identified specific barriers to successful implementation of an opioid reduction initiative in a surgical setting. In our MOPiS initiative, a preintervention formative evaluation enabled the design of strategies that will overcome implementation barriers specific to the components of our initiative.

Are people's health care needs better met when primary care is strong? A synthesis of the results of the QUALICOPC study in 34 countries.

AIM: This article synthesises the results of a large international study on primary care (PC), the QUALICOPC study. BACKGROUND: Since the Alma Ata Declaration, strengthening PC has been high on the policy agenda. PC is associated with positive health outcomes, but it is unclear how care processes and structures relate to patient experiences. METHODS: Survey data were collected during 2011-2013 from approximately 7000 PC physicians and 70 000 patients in 34, mainly European, countries. The data on the patients are linked to data on the PC physicians within each country and analysed using multilevel modelling. FINDINGS: Patients had more positive experiences when their PC physician provided a broader range of services. However, a broader range of services is also associated with higher rates of hospitalisations for uncontrolled diabetes, but rates of avoidable diabetes-related hospitalisations were lower in countries where patients had a continuous relationship with PC physicians. Additionally, patients with a long-term relationship with their PC physician were less likely to attend the emergency department. Capitation payment was associated with more positive patient experiences. Mono- and multidisciplinary co-location was related to improved processes in PC, but the experiences of patients visiting multidisciplinary practices were less positive. A stronger national PC structure and higher overall health care expenditures are related to more favourable patient experiences for continuity and comprehensiveness. The study also revealed inequities: patients with a migration background reported less positive experiences. People with lower incomes more often postponed PC visits for financial reasons. Comprehensive and accessible care processes are related to less postponement of care. CONCLUSIONS: The study revealed room for improvement related to patient-reported experiences and highlighted the importance of core PC characteristics including a continuous doctor-patient relationship as well as a broad range of services offered by PC physicians.

Primary health care in transition: Variations in service profiles of general practitioners in Estonia and in Finland between 1993 and 2012.

INTRODUCTION: Since the early 1990s, the Estonian and Finnish health systems have undergone various changes which are expected to have impacted the type and range of services provided by general practitioners (GPs). OBJECTIVE: To compare GP services between Estonia and Finland in 1993 and 2012 and draw a parallel with transformations occurred in the health systems of both countries during these two decades. METHODS: Data were collected through surveys among 129 and 288 GPs from Estonia and Finland in 2012 and 139 Estonian and 239 Finnish GPs in 1993. Descriptive statistics were used to compare between countries and years. RESULTS: Between 1993 and 2012, the number of working hours per week and consultations per day increased in Estonia and decreased in Finland. In 2012, GPs in were more often the first contact for psychosocial and women´s and children´s in Estonia, whereas this decreased in Finland. The frequency of treating acute patients mostly decreased in both countries. We observed a decrease in medical procedures in Finland and an increase in Estonia. Finnish GPs still conducted more procedures in 2012. CONCLUSION: Due to partly opposite changes, the services provided by Finnish and Estonian GPs became more similar. Still, there are large differences in services provided, possibly arising from differences in the organisation of health services, the training of doctors and patients' preferences.

Patients' perception of communication at the interface between primary and secondary care: a cross-sectional survey in 34 countries.

BACKGROUND: Poor communication between general practitioners (GPs) and medical specialists can lead to poorer quality, and continuity, of care. Our study aims to assess patients' perceptions of communication at the interface between primary and secondary care in 34 countries. It will analyse, too, whether this communication is associated with the organisation of primary care within a country, and with the characteristics of GPs and their patients. METHODS: We conducted a cross-sectional survey among patients in 34 countries. Following a GP consultation, patients were asked two questions. Did they take to understand that their GP had informed medical specialists about their illness upon referral? And, secondly, did their GP know the results of the treatment by a medical specialist? We used multi-response logistic multilevel models to investigate the association of factors related to primary care, the GP, and the patient, with the patients' perceptions of communication at the interface between primary and secondary care. RESULTS: In total, 61,931 patients completed the questionnaire. We found large differences between countries, in both the patients' perceptions of information shared by GPs with medical specialists, and the patients' perceptions of the GPs' awareness of the results of treatment by medical specialists. Patients whose GPs stated that they 'seldom or never' send referral letters, also less frequently perceived that their GP communicated with their medical specialists about their illness. Patients with GPs indicating they 'seldom or never' receive feedback from medical specialists, indicated less frequently that their GP would know the results of treatment by a medical specialist. Moreover, patients with a personal doctor perceived higher rates of communication in both directions at the interface between primary and secondary care. CONCLUSION: Generally, patients perceive there to be high rates of communication at the interface between primary and secondary care, but there are large differences between countries. Policies aimed at stimulating personal doctor arrangements could, potentially, enhance the continuity of care between primary and secondary care.

GP Practices as a One-Stop Shop: How Do Patients Perceive the Quality of Care? A Cross-Sectional Study in Thirty-Four Countries.

OBJECTIVE: To contribute to the current knowledge on how a broad range of services offered by general practitioners (GPs) may contribute to the patient perceived quality and, hence, the potential benefits of primary care. STUDY SETTING: Between 2011 and 2013, primary care data were collected among GPs and their patients in 31 European countries, plus Australia, Canada, and New Zealand. In these countries, GPs are the main providers of primary care, mostly specialized in family medicine and working in the ambulatory setting. STUDY DESIGN: In this cross-sectional study, questionnaires were completed by 7,183 GPs and 61,931 visiting patients. Moreover, 7,270 patients answered questions about what they find important (their values). In the analyses of patient experiences, we adjusted for patients' values in each country to measure patient perceived quality. Perceived quality was measured regarding five areas: accessibility and continuity of care, doctor-patient communication, patient involvement in decision making, and comprehensiveness of care. The range of GP services was measured in relation to four areas: (1) to what extent they are the first contact to the health care system for patients in need of care, (2) their involvement in treatment and follow-up of acute and chronic conditions, in other words treatment of diseases, (3) their involvement in minor technical procedures, and (4) their involvement in preventive treatments. EXTRACTION METHODS: Data of the patients were linked to the data of the GPs. Multilevel modeling was used to construct scale scores for the experiences of patients in the five areas of quality and the range of services of GPs. In these four-level models, items were nested within patients, nested in GP practices, nested in countries. The relationship between the range of services and the experiences of patients was analyzed in three-level multilevel models, also taking into account the values of patients. PRINCIPAL FINDINGS: In countries where GPs offer a broader range of services patients perceive better accessibility, continuity, and comprehensiveness of care, and more involvement in decision making. No associations were found between the range of services and the patient perceived communication with their GP. The range of GP services mostly explained the variation between countries in the areas of patient perceived accessibility and continuity of care. CONCLUSIONS: This study showed that in countries where GP practices serve as a "one-stop shop," patients perceive better quality of care, especially in the areas of accessibility and continuity of care. Therefore, primary care in a country is expected to benefit from investments in a broader range of services of GPs or other primary care physicians.