Variation in referral rates to emergency departments and inpatient services from a GP out of hours service and the potential impact of alternative staffing models

IntroductionOut of hours (OOHs) primary care is a critical component of the acute care system overnight and at weekends. Referrals from OOH services to hospital will add to the burden on hospital assessment in the ED and on-call specialties.MethodsWe studied the variation in referral rates (to the ED and direct specialty admission) of individual clinicians working in the Oxfordshire, UK OOH service covering a population of 600 000 people. We calculated the referral probability for each clinician over a 13-month period of practice (1 December 2014 to 31 December 2015), stratifying by clinician factors and location and timing of assessment. We used Simul8 software to determine the range of hospital referrals potentially due to variation in clinician referral propensity.ResultsAmong the 119 835 contacts with the service, 5261 (4.4%) were sent directly to the ED and 3474 (3.7%) were admitted directly to specialties. More referrals were made to ED by primary care physicians if they did not work in the local practices (5.5% vs 3.5%, p=0.011). For clinicians with >1000 consultations, percentage of patients referred varied from 1% to 21% of consultations. Simulations where propensity to refer was made less extreme showed a difference in maximum referrals of 50 patients each week.ConclusionsThere is substantial variation in clinician referral rates from OOHs primary care to the acute hospital setting. The number of patients referred could be influenced by this variation in clinician behaviour. Referral propensity should be studied including casemix adjustment to determine if interventions targeting such behaviour are effective.

Changing behaviour, ‘more or less’: do implementation and de-implementation interventions include different behaviour change techniques?

Background Decreasing ineffective or harmful healthcare practices (de-implementation) may require different approaches than those used to promote uptake of effective practices (implementation). Few psychological theories differentiate between processes involved in decreasing, versus increasing, behaviour. However, it is unknown whether implementation and de-implementation interventions already use different approaches. We used the behaviour change technique (BCT) taxonomy (version 1) (which includes 93 BCTs organised into 12 groupings) to investigate whether implementation and de-implementation interventions for clinician behaviour change use different BCTs. Methods Intervention descriptions in 181 articles from three systematic reviews in the Cochrane Library were coded for (a) implementation versus de-implementation and (b) intervention content (BCTs) using the BCT taxonomy (v1). BCT frequencies were calculated and compared using Pearson’s chi-squared (χ2), Yates’ continuity correction and Fisher’s exact test, where appropriate. Identified BCTs were ranked according to frequency and rankings for de-implementation versus implementation interventions were compared and described. Results Twenty-nine and 25 BCTs were identified in implementation and de-implementation interventions respectively. Feedback on behaviour was identified more frequently in implementation than de-implementation (Χ2(2, n=178) = 15.693, p = .000057). Three BCTs were identified more frequently in de-implementation than implementation: Behaviour substitution (Χ2(2, n=178) = 14.561, p = .0001; Yates’ continuity correction); Monitoring of behaviour by others without feedback (Χ2(2, n=178) = 16.187, p = .000057; Yates’ continuity correction); and Restructuring social environment (p = .000273; Fisher’s 2-sided exact test). Conclusions There were some significant differences between BCTs reported in implementation and de-implementation interventions suggesting that researchers may have implicit theories about different BCTs required for de-implementation and implementation. These findings do not imply that the BCTs identified as targeting implementation or de-implementation are effective, rather simply that they were more frequently used. These findings require replication for a wider range of clinical behaviours. The continued accumulation of additional knowledge and evidence into whether implementation and de-implementation is different will serve to better inform researchers and, subsequently, improve methods for intervention design.

Missed Opportunities in Contraceptive Counselling: Findings from a European Survey-based Study with Simulated Patient Consultation

Background: Available evidence highlights unmet needs in contraceptive counselling practices. The aim of this study was to better understand current practices and clinician behaviour across Europe.Methods: This survey-based study used a novel, online approach to simulate contraceptive counselling discussions based on three, predefined patient types, each with a hidden need. Clinicians were asked to recommend a contraceptive method for their randomly assigned patient at two time points: 1) after a simulated discussion, during which they were given a brief patient profile and the opportunity to question their patient to obtain further information; 2) after they had been presented with a full patient profile. Descriptive statistics were used to analyse the clinicians’ counselling approach, how successful clinicians were at uncovering the hidden needs of their patients, and whether an understanding of these needs would cause clinicians to change their contraceptive recommendation. Results: In total, 661 clinicians from 10 European countries participated in the study, including obstetricians/gynaecologists, midwives and general practitioners. Clinician specialty varied by nation. Most clinicians (78.8% and 70.5%, respectively) failed to uncover the hidden needs of patients X and Y, both of whom had requested prescription renewals. By contrast, 63.4% of clinicians uncovered the hidden need of patient Z, who had requested a review of her contraceptive method. Clinicians who did uncover their patients’ hidden needs asked significantly more questions than those who did not (mean 5.1–7.8 vs 1.5–2.2). Clinicians were more likely to recommend a change of prescription once they had seen the full patient profile than after the simulated discussion (12.3–30.2% increase in prescription change), indicating that clinicians rely on their patients to speak up proactively about any concerns. Family planning and bleeding issues were frequently not discussed in consultations.Conclusions: Existing counselling practices appear insufficient to capture patient needs, with opportunities for shared decision-making and discussion being missed. Clinicians and contraceptive counselling services should aim to introduce more in-depth contraceptive counselling, incorporating clear, open-ended questions, to improve patient adherence and enhance reproductive planning. Women should be empowered to actively voice both their needs and any dissatisfaction with their current contraceptive.

The (non) use of prioritisation protocols by surgeons

Priority setting and rationing is a dominant feature of contemporary health policy. In New Zealand, clinical priority assessment criteria (CPAC) tools have been developed to make access to elective surgery more equitable and efficient. Research was undertaken to identify how surgeons used these tools in the consultation. Forty-seven consultations with 15 different surgeons have to date been video- and audio-recorded. There were no instances where CPAC tools were explicitly used in the consultation. Drawing on the methodology of conversation analysis and the concept of news delivery as developed by Maynard, this paper argues that the delivery of diagnoses and treatment plans can usefully be seen in part as the delivery of bad or good news. Using three case studies to illustrate the argument, it is suggested that the interactional work required in the delivery of such news challenges the ability of clinicians to use protocols such as CPAC. The analysis sheds light on important consultation processes that need to be more carefully considered when designing interventions to influence clinician behaviour. In order to influence the behaviour of clinicians to achieve policy goals, greater attention needs to be paid to the interactional demands of the consultation process. © 2010 The Authors. Journal compilation © 2010 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.

The (non) use of prioritisation protocols by surgeons

Priority setting and rationing is a dominant feature of contemporary health policy. In New Zealand, clinical priority assessment criteria (CPAC) tools have been developed to make access to elective surgery more equitable and efficient. Research was undertaken to identify how surgeons used these tools in the consultation. Forty-seven consultations with 15 different surgeons have to date been video- and audio-recorded. There were no instances where CPAC tools were explicitly used in the consultation. Drawing on the methodology of conversation analysis and the concept of news delivery as developed by Maynard, this paper argues that the delivery of diagnoses and treatment plans can usefully be seen in part as the delivery of bad or good news. Using three case studies to illustrate the argument, it is suggested that the interactional work required in the delivery of such news challenges the ability of clinicians to use protocols such as CPAC. The analysis sheds light on important consultation processes that need to be more carefully considered when designing interventions to influence clinician behaviour. In order to influence the behaviour of clinicians to achieve policy goals, greater attention needs to be paid to the interactional demands of the consultation process. © 2010 The Authors. Journal compilation © 2010 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.

Interventions to change clinician behaviour in relation to suicide prevention care in the emergency department: A scoping review protocol

Objective: This review aims to explore, characterize, and map the literature on interventions implemented to change emergency department (ED) clinicians’ behaviour related to suicide prevention using the Behaviour Change Wheel (BCW) as a guiding theoretical framework. Introduction: An ED is a critical place for suicide prevention. Yet, many patients who present with suicide-related thoughts and behaviours are discharged without proper assessment or appropriate treatment. Supporting clinicians (who provide direct clinical care, including nurses, physicians, allied health professionals) to make the desired behaviour change following evidence-based suicide prevention care is an essential step toward improving patient outcomes. However, reviews to date have yet to take a theoretical approach to investigate interventions implemented to change clinicians’ behaviour. Inclusion criteria: This review will consider literature that includes interventions that target ED clinicians’ behaviour change related to suicide prevention. Behaviour change refers to observable practice changes as well as proxy measures of behaviour change including knowledge and attitude. There are many ways in which an intervention can change clinicians’ behaviour (e.g., education, altering service delivery). This review will include a wide range of interventions that target behaviour change regardless of the type but exclude interventions that exclusively target patients.Methods: Multiple databases will be searched: PubMed, PsycInfo, CINAHL and Embase. We will also include grey literature, including Google search, ProQuest Dissertations and Theses Global, and Scopus conference papers. Full text of included studies will be reviewed, critically appraised and extracted. Extracted data will be coded to identify intervention functions using the BCW. Findings will be summarized in tables accompanied by narrative reports.

The social management of medical ethics in sport: confidentiality in English professional football

This paper examines one of the major ethical challenges in the practice of sports medicine, confidentiality. Drawing on interview and questionnaire data with doctors and physiotherapists working in English professional football clubs, it explores the degree to which ethical compliance has improved since the publication of, and publicity surrounding, an earlier study of medical practice in professional football conducted by Waddington and Roderick. Thus, it provides an updated empirical examination of the management of medical ethics in sport. The data illustrate how the physical and social environmental constraints of sports medicine practice impinge upon the protection of athlete-patient confidentiality, how ethical codes and conflicting obligations converge to shape clinician behaviour in relation to lifestyle and injury issues, and the ethically problematic contractual constraints under which clinicians and athletes operate. It demonstrates that medical ethical practice continues to be very variable and draws on Freidson’s work on medical ‘work settings’ to argue that there is a need to augment existing confidentiality policies with more structurally oriented approaches to ensure both professional autonomy and medical ethical compliance in sport.

Can images of pain enhance patient–clinician rapport in pain consultations?

A variety of treatment outcomes in chronic pain are influenced by patient–clinician rapport. Patients often report finding it difficult to explain their pain, and this potential obstacle to mutual understanding may impede patient–clinician rapport. Previous research has argued that the communication of both patients and clinicians is facilitated by the use of pain-related images in pain assessments. This study investigated whether introducing pain-related images into pain assessments would strengthen various components of patient–clinician rapport, including relative levels of affiliation and dominance, and interpersonal coordination between patient and clinician behaviour. Videos of 35 pain assessments in which pain images were present or absent were used to code behavioural displays of patient and clinician rapport at fixed intervals across the course of the assessment. Mixed modelling was used to examine patterns of patient and clinician affiliation and dominance with consultation type (Image vs Control) as a moderator. When pain images were present, clinicians showed more affiliation behaviour over the course of the consultation and there was greater correspondence between the affiliation behaviour of patient and clinician. However, relative levels of patient and clinician dominance were unaffected by the presence of pain images in consultations. Additional analyses revealed that clinicians responded directly to patients’ use of pain images with displays of affiliation. Based on the results of this study, we recommend further investigation into the utility and feasibility of incorporating pain images into pain assessments to enhance patient–clinician communication.