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BMC Health Services Research publishes original research articles in all aspects of health services research.

Publications in this journal

• Summarizing activity limitations in children with chronic illnesses living in the community: A measurement study of scales using supplemented interRAI suit items

  Authors: Phillips, Patnaik, Moudouni, Naiser, Dyer, Hawes, Founier, Miller, Elliot

  BMC Health Services Research.

• Information seeking for making evidence-informed decisions: a social network analysis on the staff of a public health department in Canada.

  Authors: Reza Yousefi-Nooraie, Maureen Dobbins, Melissa Brouwers, Patricia Wakefield

  BMC health services research. 12(1):118.

  ABSTRACT: BACKGROUND: Social network analysis is an approach to study the interactions and exchange of resources among people. It can help understanding the underlying structural and behavioralABSTRACT: BACKGROUND: Social network analysis is an approach to study the interactions and exchange of resources among people. It can help understanding the underlying structural and behavioral complexities that influence the process of capacity building towards evidence-informed decision making. A social network analysis was conducted to understand if and how the staff of a public health department in Ontario turn to peers to get help incorporating research evidence into practice. METHODS: The staff were invited to respond to an online questionnaire inquiring about information seeking behavior, identification of colleague expertise, and friendship status. Three networks were developed based on the 170 participants. Overall shape, key indices, the most central people and brokers, and their characteristics were identified. RESULTS: The network analysis showed a low density and localized information-seeking network. Interpersonal connections were mainly clustered by organizational divisions; and people tended to limit information-seeking connections to a handful of peers in their division. However, recognition of expertise and friendship networks showed more cross-divisional connections. Members of the office of the Medical Officer of Health were located at the heart of the department, bridging across divisions. A small group of professional consultants and middle managers were the most-central staff in the network, also connecting their divisions to the center of the information-seeking network. In each division, there were some locally central staff, mainly practitioners, who connected their neighboring peers; but they were not necessarily connected to other experts or managers. CONCLUSIONS: The methods of social network analysis were useful in providing a systems approach to understand how knowledge might flow in an organization. The findings of this study can be used to identify early adopters of knowledge translation interventions, forming Communities of Practice, and potential internal knowledge brokers.

• Accessing maternal and child health services in Melbourne, Australia: Reflections from refugee families and service providers.

  Authors: Elisha Riggs, Elise Davis, Lisa Gibbs, Karen Block, Jo Szwarc, Sue Casey, Philippa Duell-Piening, Elizabeth Waters

  BMC health services research. 12(1):117.

  ABSTRACT: BACKGROUND: Often new arrivals from refugee backgrounds have experienced poor health and limited access to healthcare services. The maternal and child health (MCH) service in Victoria,ABSTRACT: BACKGROUND: Often new arrivals from refugee backgrounds have experienced poor health and limited access to healthcare services. The maternal and child health (MCH) service in Victoria, Australia, is a joint local and state government operated, cost-free service available to all mothers of children aged 0-6 years. Although well-child healthcare visits are useful in identifying health issues early, there has been limited investigation in the use of these services for families from refugee backgrounds. This study aims to explore experiences of using MCH services, from the perspective of families from refugee backgrounds and service providers. METHODS: We used a qualitative study design informed by the socioecological model of health and a cultural competence approach. Two geographical areas of Melbourne were selected to invite participants. Seven focus groups were conducted with 87 mothers from Karen, Iraqi, Assyrian Chaldean, Lebanese, South Sudanese and Bhutanese backgrounds, who had lived an average of 4.7 years in Australia (range one month-18 years). Participants had a total of 249 children, of these 150 were born in Australia. Four focus groups and five interviews were conducted with MCH nurses other healthcare providers and bicultural workers. RESULTS: Four themes were identified: facilitating access to MCH services; promoting continued engagement with the MCH service; language challenges; and what is working well and could be done better. Several processes were identified that facilitated initial access to the MCH service but there were implications for continued use of the service. The MCH service was not formally notified of new parents arriving with young children. Pre-arranged group appointments by MCH nurses for parents who attended playgroups worked well to increase ongoing service engagement. Barriers for parents in using MCH services included access to transportation, lack of confidence in speaking English and making phone bookings. Service users and providers reported that continuity of nurse and interpreter is preferred for increasing client-provider trust and ongoing engagement. CONCLUSIONS: Although participants who had children born in Melbourne had good initial access to, and experience of, using MCH services, significant barriers remain. A systems-oriented, culturally competent approach to service provision would improve the service utilisation experience for parents and providers, including formalising links and notifications between settlement services and MCH services.

• Impact of data source and time reference of functional status on hospital mortality prediction.

  Authors: Woan Shin Tan, Yew Yoong Ding, Wai Fung Chong, Jam Chin Tay, Jackie Yu-Ling Tan

  BMC health services research. 12(1):115.

  ABSTRACT: BACKGROUND: The study objective was to compare physical function documented in the medical records with interview data, and also to evaluate hospital mortality predictions usingABSTRACT: BACKGROUND: The study objective was to compare physical function documented in the medical records with interview data, and also to evaluate hospital mortality predictions using pre-admission and on-admission functional status derived from these two data sources. METHODS: A prospective cohort study of 1402 subjects aged 65 years and older to the general medicine department of an acute care hospital was conducted. Patient-reported pre-admission and onadmission functional status for impairment in any of the five activities of daily living (ADLs) items (feeding, dressing, grooming, toileting and bathing), transferring and walking, were compared with those extracted from the medical records. For the purpose of mortality prediction, pre-admission and on-admission impairment in transferring from the two data sources were included in separate multivariable logistic regression models. We used a variable selection method that combines bootstrap resampling with stepwise backward elimination. RESULTS: For all ADL categories, the agreement between the data sources was good for pre-admission functional status (k: 0.53-0.75) but poor for on-admission status (k: 0.18-0.31). Onadmission impairment was higher in the medical records than at interview for all basic ADLs. Using interview data as the gold standard, although sensitivity for pre- and on-admission ADLs was high (59-93%), specificity for on-admission status was poor (30-37%). The preadmission models using interview data predicted mortality better than the model using medical records (c-statistic: 0.83 versus 0.82). Similar results were found for models incorporating on-admission functional status (c-statistic: 0.84 versus 0.81). However, the differences between the four models were not statistically significant. CONCLUSION: Medical records can be a good source for pre-admission functional status but on-admission functional impairment was over-reported in the medical records. The discriminatory power of the hospital mortality prediction model was significantly improved with the incorporation of functional status information but it was not significantly affected by their time reference or source of data.

• Measuring data reliability for preventive services in electronic medical records.

  Authors: Michelle Greiver, Jan Barnsley, Richard H Glazier, Bart J Harvey, Rahim Moineddin

  BMC health services research. 12(1):116.

  ABSTRACT: BACKGROUND: Improvements in the quality of health care services are often measured using data present in medical records. Electronic Medical Records (EMRs) contain potentially valuable newABSTRACT: BACKGROUND: Improvements in the quality of health care services are often measured using data present in medical records. Electronic Medical Records (EMRs) contain potentially valuable new sources of health data. However, data quality in EMRs may not be optimal and should be assessed. Data reliability (are the same data elements being measured over time?) is a prerequisite for data validity (are the data accurate?). Our objective was to measure the reliability of data for preventive services in primary care EMRs during the transition to EMR. METHODS: Our data sources were randomly selected eligible patients' medical records and data obtained from provincial administrative datasets. Eighteen community-based family physicians in Toronto, Ontario that implemented EMRs starting in 2006 participated in this study. We measured the proportion of patients eligible for a service (Pap smear, screening mammogram or influenza vaccination) that received the service. We compared the change in rates of selected preventive services calculated from the medical record audits with the change in administrative datasets. RESULTS: In the first year of EMR use (2006) services decreased by 8.7% more (95% CI 11.0%- 6.4%, p < 0.0001) when measured through medical record audits as compared with administrative datasets. Services increased by 2.4% more (95% CI 0%-4.9%, p = 0.05) in the medical record audits during the second year of EMR use (2007). CONCLUSION: There were differences between the change measured through medical record audits and administrative datasets. Problems could include difficulties with organizing new data entry processes as well as continued use of both paper and EMRs. Data extracted from EMRs had limited reliability during the initial phase of EMR implementation. Unreliable data interferes with the ability to measure and improve health care quality.

• Disease management projects and the Chronic Care Model in action: baseline qualitative research.

  Authors: Bethany Hipple Walters, Samantha A Adams, Anna P Nieboer, Roland Bal

  BMC health services research. 12(1):114.

  ABSTRACT: BACKGROUND: Disease management programs, especially those based on the Chronic Care Model (CCM), are increasingly common in the Netherlands. While disease management programs have beenABSTRACT: BACKGROUND: Disease management programs, especially those based on the Chronic Care Model (CCM), are increasingly common in the Netherlands. While disease management programs have been well-researched quantitatively and economically, less qualitative research has been done. The overall aim of the study is to explore how disease management programs are implemented within primary care settings in the Netherlands; this paper focuses on the early development and implementation stages of five disease management programs in the primary care setting, based on interviews with project leadership teams. METHODS: At the five sites, eleven semi-structured interviews were conducted at the five selected sites with sixteen professionals interviewed; all project leaders were interviewed. The interviews focused on each project's chosen chronic illness (diabetes, eating disorders, COPD, multimorbidity, CVRM) and project plan, barriers to development and implementation, the project leaders' action and reactions, as well as their roles and responsibilities, and disease management strategies. Analysis was inductive and interpretive, based on the content of the interviews. After analysis, the results of this research on disease management programs and the Chronic Care Model are viewed from a traveling technology framework. RESULTS: This analysis uncovered four themes that can be mapped to disease management and the Chronic Care Model: (1) changing the health care system, (2) patient-centered care, (3) technological systems and barriers, and (4) integrating projects into the larger system. Project leaders discussed the paths, both direct and indirect, for transforming the health care system to one that addresses chronic illness. Patient-centered care was highlighted as needed and a paradigm shift for many. Challenges with technological systems were pervasive. Project leaders managed the expenses of a traveling technology, including the social, financial, and administration involved. CONCLUSIONS: At the sites, project leaders served as travel guides, assisting and overseeing the programs as they traveled from the global plans to local actions. Project leaders, while hypothetically in control of the programs, in fact shared control of the traveling of the programs with patients, clinicians, and outside consultants. From this work, we can learn what roadblocks and expenses occur while a technology travels, from a project leader's point of view.

• Acceptability - a neglected dimension of access to health care: findings from a study on childhood convulsions in rural Tanzania.

  Authors: Angel Dillip, Sandra Alba, Christopher Mshana, Manuel Hetzel, Christian Lengeler, Iddy Mayumana, Alexander Schulze, Hassan Mshinda, Mitchell G Weiss, Brigit Obrist

  BMC health services research. 12(1):113.

  ABSTRACT: BACKGROUND: Acceptability is a poorly conceptualized dimension of access to health care. Using a study on childhood convulsion in rural Tanzania, we examined social acceptability from aABSTRACT: BACKGROUND: Acceptability is a poorly conceptualized dimension of access to health care. Using a study on childhood convulsion in rural Tanzania, we examined social acceptability from a user perspective. The study design is based on the premise that a match between health providers' and clients' understanding of disease is an important dimension of social acceptability, especially in trans-cultural communication, for example if childhood convulsions are not linked with malaria and local treatment practices are mostly preferred. The study was linked to health interventions with the objective of bridging the gap between local and biomedical understanding of convulsions. METHODS: The study combined classical ethnography with the cultural epidemiology approach using EMIC (Explanatory Model Interview Catalogue) tool. EMIC interviews were conducted in a 2007/08 convulsion study (n = 88) and results were compared with those of an earlier 2004/06 convulsion study (n = 135). Earlier studies on convulsion in the area were also examined to explore longer-term changes in treatment practices. RESULTS: The match between local and biomedical understanding of convulsions was already high in the 2004/06 study. Specific improvements were noted in form of (1) 46% point increase among those who reported use of mosquito nets to prevent convulsion (2) 13% point decrease among caregivers who associated convulsion with 'evil eye and sorcery', 3) 14% point increase in prompt use of health facility and 4)16% point decrease among those who did not use health facility at all. Such changes can be partly attributed to interventions which explicitly aimed at increasing the match between local and biomedical understanding of malaria. Caregivers, mostly mothers, did not seek advice on where to take an ill child. This indicates that treatment at health facility has become socially acceptable for severe febrile with convulsion. CONCLUSION: As an important dimension of access to health care 'social acceptability' seems relevant in studying illnesses that are perceived not to belong to the biomedical field, specifically in trans-cultural societies. Understanding the match between local and biomedical understanding of disease is fundamental to ensure acceptability of health care services, successful control and management of health problems. Our study noted some positive changes in community knowledge and management of convulsion episodes, changes which might be accredited to extensive health education campaigns in the study area. On the other hand it is difficult to make inference out of the findings as a result of small sample size involved. In return, it is clear that well ingrained traditional beliefs can be modified with communication campaigns, provided that this change resonates with the beneficiaries.

• HIV/aids related home based care practices among primary health care workers in Ogun state, Nigeria.

  Authors: Amoran Olorunfemi E, Ogunsola Elijah O, Salako Albert O, Alausa Ok O

  BMC health services research. 12(1):112.

  ABSTRACT: BACKGROUND: HIV/AIDS is fast becoming a chronic disease with the advent of antiretroviral drugs, therefore making home based care key in the management of chronically ill HIV/AIDS patient.ABSTRACT: BACKGROUND: HIV/AIDS is fast becoming a chronic disease with the advent of antiretroviral drugs, therefore making home based care key in the management of chronically ill HIV/AIDS patient. The objective of this study was to determine the perception and practice of health care workers on HIV/AIDS related home based care in the health facilities in Ogun state, Nigeria. METHODS: This study is an analytical cross-sectional study. A multistage cluster sampling technique was used to obtain a representative sample of the primary health care workers in Ogun state. An interviewer administered structured questionnaire was administered by trained health workers to elicit the required information. Result A total of 350 health care workers were interviewed, 70% of the respondents could adequately describe the components of home based care. Only 38.7% were aware of the National guideline on home based care practices and 17.1% believe that home based care will not significantly improve the prognosis of PLWAs. Few 19.1% had ever been trained or ever involved 16.6% in home based care practices. Only 20 [5.7%] are involved on a weekly basis, 16 [4.6%] monthly and 22 [6.3%] quarterly. Reasons given for non implementation of home based care are inadequate number of healthcare workers 45%, lack of political will 24.4%, lack of implementation by facility managers 14% and inadequate funds 16.6%. Factors that were significantly associated with the practice of home based care were perception of its relevance in improving prognosis [OR = 54.21, C.I = 23.22-129.52] and presence of a support group in the facility [OR = 4.80, C.I = 2.40-9.57]. There was however no statistically significant relationship between adequate knowledge of home based care [OR = 0.78, C.I = 0.39-1.54] and previous training on home based care (OR = 1.43, C.I = 0.66- 3.06]. CONCLUSION: The practice of home based care for HIV/AIDS among the study population is low and it is greatly influenced by perception of its effectiveness and relevance. The study recommends that the health care workers should be adequately educated on the importance of home based care in the management of chronic illnesses in order to enhance its practice.

• Community-based post-stroke service provision and challenges: a national survey of managers and inter-disciplinary healthcare staff in Ireland.

  Authors: Anne Hickey, Frances Horgan, Desmond O'Neill, Hannah McGee, On Behalf Of The Steering Committee Of The Irish National Audit Inasc

  BMC health services research. 12(1):111.

  ABSTRACT: BACKGROUND: The extent of stroke-related disability typically becomes most apparent after patient discharge to the community. Maximising rehabilitation input at this point can minimise theABSTRACT: BACKGROUND: The extent of stroke-related disability typically becomes most apparent after patient discharge to the community. Maximising rehabilitation input at this point can minimise the impact of disability. As part of the Irish National Audit of Stroke Care (INASC), a national survey of community-based allied health professionals and public health nurses was conducted. The aim was to document the challenges to service availability for patients with stroke in the community and to identify priorities for service improvement. METHODS: The study was a cross-sectional tailored interview survey with key managerial and service delivery staff. As comprehensive listings of community-based health professionals involved in stroke care were not available, a cascade approach to information gathering was adopted. Representative regional managers for services incorporating stroke care (N=7) and disciplinary allied health professional and public health nurse managers (N=25) were interviewed (94% response rate). RESULTS: Results indicated a lack of formal, structured community-based services for stroke, with no designated clinical posts for stroke care across disciplines nationally. There was significant regional variation in availability of allied health professionals. Considerable inequity was identified in patient access to stroke services, with greater access, where available, for older patients (>65 years). The absence of a stroke strategy and stroke prevalence statistics were identified as significant impediments to service planning, alongside organisational barriers limiting the recruitment of additional allied health professional staff, and lack of sharing of discipline-specific information on patients. CONCLUSIONS: This study highlighted major gaps in the provision of inter-disciplinary team community-based services for people with stroke in one country. Where services existed, they were generic in nature, rarely inter-disciplinary in function and deficient in input from salient disciplines. Challenges to optimal care included the need for strategic planning; increased funding of healthcare staff; increased team resources and teamwork; and removal of service provision barriers based on age. There were notably many challenges beyond funding. Similar evaluations in other healthcare systems would serve to provide comparative lessons to serve to tackle this underserved aspect of care for patients with stroke and their families.

• "Completely out-at-sea" with "two-gender medicine": A qualitative analysis of physician-side barriers to providing healthcare for transgender patients.

  Authors: John W Snelgrove, Amanda M Jasudavisius, Bradley W Rowe, Evan M Head, Greta R Bauer

  BMC health services research. 12(1):110.

  ABSTRACT: BACKGROUND: Members of the transgender community have identified healthcare access barriers, yet a corresponding inquiry into healthcare provider perspectives has lagged. Our aim was toABSTRACT: BACKGROUND: Members of the transgender community have identified healthcare access barriers, yet a corresponding inquiry into healthcare provider perspectives has lagged. Our aim was to examine physician perceptions of barriers to healthcare provision for transgender patients. METHODS: This was a qualitative study with physician participants from Ontario, Canada. Semi-structured interviews were used to capture a progression of ideas related to barriers faced by physicians when caring for their trans patients. Qualitative data were then transcribed verbatim and analysed with an emergent grounded theory approach. RESULTS: A total of thirteen (13) physician participants were interviewed. Analysis revealed healthcare barriers that grouped into five themes: Accessing resources, medical knowledge deficits, ethics of transition-related medical care, diagnosing vs. pathologising trans patients, and health system determinants. A centralising theme of "not knowing where to go or who to talk to" was also identified. CONCLUSIONS: The findings of this study show that physicians perceive barriers to the care of trans patients, and that these barriers are multifactorial. Access barriers impede physicians when referring patients to specialists or searching for reliable treatment information. Clinical management of trans patients is complicated by a lack of knowledge, and by ethical considerations regarding treatments--which can be unfamiliar or challenging to physicians. The disciplinary division of responsibilities within medicine further complicates care; few practitioners identify trans healthcare as an interest area, and there is a tendency to overemphasise trans status in mental health evaluations. Failure to recognise and accommodate trans patients within sex-segregated healthcare systems leads to deficient health policy. The findings of this study suggest potential solutions to trans healthcare barriers at the informational level--with increased awareness of clinical guidelines and by including trans health issues in medical education--and at the institutional level, with support for both trans-focused and trans-friendly primary care models.

• A teachable moment communication process for smoking cessation talk: description of a group randomized clinician-focused intervention.

  Authors: Susan A Flocke, Elizabeth Antognoli, Mary M Step, Sybil Marsh, Theodore Parran, Mary Jane Mason

  BMC health services research. 12(1):109.

  ABSTRACT: BACKGROUND: Effective clinician-patient communication about health behavior change is one of the most important and most overlooked strategies to promote health and prevent disease.ABSTRACT: BACKGROUND: Effective clinician-patient communication about health behavior change is one of the most important and most overlooked strategies to promote health and prevent disease. Existing guidelines for specific health behavior counseling have been created and promulgated, but not successfully adopted in primary care practice. Building on work focused on creating effective clinician strategies for prompting health behavior change in the primary care setting, we developed an intervention intended to enhance clinician communication skills to create and act on teachable moments for smoking cessation. In this manuscript, we describe the development and implementation of the Teachable Moment Communication Process (TMCP) intervention and the baseline characteristics of a group randomized trial designed to evaluate its effectiveness. METHODS: This group randomized trial includes thirty-one community-based primary care clinicians practicing in Northeast Ohio and 840 of their adult patients. Clinicians were randomly assigned to receive either the Teachable Moments Communication Process (TMCP) intervention for smoking cessation, or the delayed intervention. The TMCP intervention consisted of two, 3-hour educational training sessions including didactic presentation, skill demonstration through video examples, skills practices with standardized patients, and feedback from peers and the trainers. For each clinician enrolled, 12 patients were recruited for two time points. Pre- and post-intervention data from the clinicians, patients and audio-recorded clinicianpatient interactions were collected. At baseline, the two groups of clinicians and their patients were similar with regard to all demographic and practice characteristics examined. Both physician and patient recruitment goals were met, and retention was 96% and 94% respectively. DISCUSSION: Findings support the feasibility of training clinicians to use the Teachable Moments Communication Process. The next steps are to assess how well clinicians employ these skills within their practices and to assess the effect on patient outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT01575886.

• Impact of organizational factors on adherence to laboratory testing protocols in adult HIV care in Lusaka, Zambia.

  Authors: Sarang Deo, Stephanie M Topp, Andrew O Westfall, Matimbo M Chiko, Chibesa S Wamulume, Mary Morris, Stewart Reid

  BMC health services research. 12(1):106.

  ABSTRACT: BACKGROUND: Previous operational research studies have demonstrated the feasibility of large-scale public sector ART programs in resource-limited settings. However, organizational andABSTRACT: BACKGROUND: Previous operational research studies have demonstrated the feasibility of large-scale public sector ART programs in resource-limited settings. However, organizational and structural determinants of quality of care have not been studied. METHODS: Using data on 13 urban HIV treatment facilities in Zambia, we use multivariate regression models to assess the impact of structural determinants on health workers' adherence to national guidelines for conducting laboratory tests such as CD4, hemoglobin and liver function and WHO staging during initial and follow-up visits as part of Zambian HIV care and treatment program. RESULTS: CD4 tests were more routinely ordered during initial history and physical (IHP) than followup (FUP) visits (85.5 % vs. 93.0 %; p < 0.01). More physical space, higher staff turnover and greater facility experience with ART was associated with greater odds of conducting tests. Higher staff experience decreased the odds of conducting CD4 tests in FUP (OR 0.93; p <0.05) and WHO staging in IHP visit (OR 0.90; p < 0.05) but increased the odds of conducting hemoglobin test in IHP visit (OR 1.05; p < 0.05). Higher staff burnout increased the odds of conducting CD4 test during FUP (OR 1.14; p < 0.05) but decreased the odds of conducting hemoglobin test in IHP visit (0.77; p < 0.05) and CD4 test in IHP visit (OR 0.78; p < 0.05). CONCLUSION: Physical space plays an important role in ensuring high quality care in resource-limited setting. In the context of protocolized care, new staff members are likely to be more diligent in following the protocol verbatim rather than relying on memory and experience thereby improving adherence. Future studies should use prospective data to confirm the findings reported here.

• Assessing barriers to health insurance and threats to equity in comparative perspective: The Health Insurance Access Database.

  Authors: Amelie Quesnel-Vallee, Emilie Renahy, Tania Jenkins, Helen Cerigo

  BMC health services research. 12(1):107.

  ABSTRACT: BACKGROUND: Typologies traditionally used for international comparisons of health systems often conflate many system characteristics. To capture policy changes over time and by service inABSTRACT: BACKGROUND: Typologies traditionally used for international comparisons of health systems often conflate many system characteristics. To capture policy changes over time and by service in health systems regulation of public and private insurance, we propose a database containing explicit, standardized indicators of policy instruments. METHODS: The Health Insurance Access Database (HIAD) will collect policy information for ten OECD countries, over a range of eight health services, from 1990-2010. Policy indicators were selected through a comprehensive literature review which identified policy instruments most likely to constitute barriers to health insurance, thus potentially posing a threat to equity. As data collection is still underway, we present here the theoretical bases and methodology adopted, with a focus on the rationale underpinning the study instruments. RESULTS: These harmonized data will allow the capture of policy changes in health systems regulation of public and private insurance over time and by service. The standardization process will permit international comparisons of systems' performance with regards to health insurance access and equity. CONCLUSION: This research will inform and feed the current debate on the future of health care in developed countries and on the role of the private sector in these changes.

• Violence towards health care workers in a Public Health Care Facility in Italy: a repeated crosssectional study.

  Authors: Nicola Magnavita, Tarja Heponiemi

  BMC health services research. 12(1):108.

  ABSTRACT: BACKGROUND: Violence at work is one of the major concerns in health care activities. The aim of this study was to identify the prevalence of physical and non-physical violence in a generalABSTRACT: BACKGROUND: Violence at work is one of the major concerns in health care activities. The aim of this study was to identify the prevalence of physical and non-physical violence in a general health care facility in Italy and to assess the relationship between violence and psychosocial factors, thereby providing a basis for appropriate intervention. METHODS: All health care workers from a public health care facility were invited to complete a questionnaire containing questions on workplace violence. Three questionnaire-based crosssectional surveys were conducted. The response rate was 75 % in 2005, 71 % in 2007, and 94 % in 2009. The 2009 questionnaire contained the VIF (Violent Incident Form) for reporting violent incidents, the DCS (demand/control/support) model for job strain, the Colquitt 20 item questionnaire for perceived organizational justice, and the GHQ12 General Health Questionnaire for the assessment of mental health. RESULTS: One out of ten workers reported physical assault, and one out of three exposure to nonphysical violence in the workplace in the previous year. Nurses and physicians were the most exposed occupational categories, whereas the psychiatric and emergency departments were the services at greatest risk of violence. Workers exposed to non-physical violence were subject to high job strain, low support, low perceived organizational justice, and high psychological distress. CONCLUSIONS: Our study shows that health care workers in an Italian local health care facility are exposed to violence. Workplace violence was associated with high demand and psychological disorders, while job control, social support and organizational justice were protective factors.

• Building a house on shifting sand: methodological considerations when evaluating the implementation and adoption of national electronic health record systems.

  Authors: Amirhossein Takian, Dimitra Petrakaki, Tony Cornford, Aziz Sheikh, Nicholas Barber

  BMC health services research. 12(1):105.

  ABSTRACT: BACKGROUND: A commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments' healthcare reform strategies. The resulting politically-initiatedABSTRACT: BACKGROUND: A commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments' healthcare reform strategies. The resulting politically-initiated largescale or national EHR endeavors are challenging because of their ambitious agendas of change, the scale of resources needed to make them work, the (relatively) short timescales set, and the large number of stakeholders involved, all of whom pursue somewhat different interests. These initiatives need to be evaluated to establish if they improve care and represent value for money. METHODS: Critical reflections on these complexities in the light of experience of undertaking the first national, longitudinal, and sociotechnical evaluation of the implementation and adoption of England's National Health Service's Care Records Service (NHS CRS). Results/discussion We advance two key arguments. First, national programs for EHR implementations are likely to take place in the shifting sands of evolving sociopolitical and sociotechnical and contexts, which are likely to shape them in significant ways. This poses challenges to conventional evaluation approaches which draw on a model of baseline operations intervention changed operations (outcome). Second, evaluation of such programs must account for this changing context by adapting to it. This requires careful and creative choice of ontological, epistemological and methodological assumptions. SUMMARY: New and significant challenges are faced in evaluating national EHR implementation endeavors. Based on experiences from this national evaluation of the implementation and adoption of the NHS CRS in England, we argue for an approach to these evaluations which moves away from seeing EHR systems as Information and Communication Technologies (ICT) projects requiring an essentially outcome-centred assessment towards a more interpretive approach that reflects the situated and evolving nature of EHR seen within multiple specific settings and reflecting a constantly changing milieu of policies, strategies and software, with constant interactions across such boundaries.

• Using routine data to monitor inequalities in an acute trust: a retrospective study.

  Authors: Katharine M Langford, Alex Bottle, Paul P Aylin, Helen Ward

  BMC health services research. 12(1):104.

  ABSTRACT: BACKGROUND: Reducing inequalities is one of the priorities of the National Health Service. However, there is no standard system for monitoring inequalities in the care provided by acuteABSTRACT: BACKGROUND: Reducing inequalities is one of the priorities of the National Health Service. However, there is no standard system for monitoring inequalities in the care provided by acute trusts. We explore the feasibility of monitoring inequalities within an acute trust using routine data. METHODS: A retrospective study of hospital episode statistics from one acute trust in London over three years (2007 to 2010). Waiting times, length of stay and readmission rates were described for seven common surgical procedures. Inequalities by age, sex, ethnicity and social deprivation were examined using multiple logistic regression, adjusting for the other socio-demographic variables and comorbidities. Sample size calculations were computed to estimate how many years of data would be ideal for this analysis. RESULTS: This study found that even in a large acute trust, there was not enough power to detect differences between subgroups. There was little evidence of inequalities for the access, process and outcome measures examined, statistically significant differences by age, sex, ethnicity or deprivation were only found in 11 out of 80 analyses. Bariatric surgery patients who were black African or Caribbean were more likely than white patients to experience a prolonged wait (longer than 64 days, aOR = 2.47, 95% CI: 1.36-4.49). Following a coronary angioplasty, patients from more deprived areas were more likely to have had a prolonged length of stay (aOR = 1.66, 95% CI: 1.25-2.20). CONCLUSIONS: This study found difficulties in using routine data to identify inequalities on a trust level. There was little evidence of inequalities in waiting time, length of stay or readmission rates by sex, ethnicity or social deprivation, although some differences were identified which warrant further investigation. Even with three years of data from a large trust there was insufficient power to detect inequalities by procedure. Data will therefore need to be pooled from multiple trusts to detect inequalities.

• Population health status of South Asian and African-Caribbean communities in the United Kingdom.

  Authors: Melanie Calvert, Helen Duffy, Nick Freemantle, Russell Davis, Gregory Yh Lip, Paramjit Gill

  BMC health services research. 12(1):101.

  ABSTRACT: BACKGROUND: Population health status scores are routinely used to inform economic evaluation and evaluate the impact of disease and/or treatment on health. It is unclear whether the healthABSTRACT: BACKGROUND: Population health status scores are routinely used to inform economic evaluation and evaluate the impact of disease and/or treatment on health. It is unclear whether the health status in black and minority ethnic groups are comparable to these population health status data. The aim of this study was to evaluate health-status in South Asian and African-Caribbean populations. METHODS: Cross-sectional study recruiting participants aged [greater than or equal to] 45 years (September 2006 to July 2009) from 20 primary care centres in Birmingham, United Kingdom.10,902 eligible subjects were invited, 5,408 participated (49.6%). 5,354 participants had complete data (49.1%) (3442 South Asian and 1912 African-Caribbean). Health status was assessed by interview using the EuroQoL EQ-5D. RESULTS: The mean EQ-5D score in South Asian participants was 0.91 (standard deviation (SD) 0.18), median score 1 (interquartile range (IQR) 0.848 to 1) and in African-Caribbean participants the mean score was 0.92 (SD 0.18), median 1 (IQR 1 to 1). Compared with normative data from the UK general population, substantially fewer African-Caribbean and South Asian participants reported problems with mobility, usual activities, pain and anxiety when stratified by age resulting in higher average health status estimates than those from the UK population. Multivariable modelling showed that decreased health-related quality of life (HRQL) was associated with increased age, female gender and increased body mass index. A medical history of depression, stroke/transient ischemic attack, heart failure and arthritis were associated with substantial reductions in HRQL. CONCLUSIONS: The reported HRQL of these minority ethnic groups was substantially higher than anticipated compared to UK normative data. Participants with chronic disease experienced significant reductions in HRQL and should be a target for health intervention.

• Outcomes of prolonged mechanic ventilation: a discrimination model based on longitudinal health insurance and death certificate data.

  Authors: Hsin-Ming Lu, Likwang Chen, Jung-Der Wang, Mei-Chuan Hung, Ming-Shian Lin, Yuan-Horng Yan, Cheng-Ren Chen, Po-Sheng Fan, Lynn Chu Huang, Ken N Kuo

  BMC health services research. 12(1):100.

  ABSTRACT: BACKGROUND: This study investigated prognosis among patients under prolonged mechanical ventilation (PMV) through exploring the following issues: (1) post-PMV survival rates, (2) factorsABSTRACT: BACKGROUND: This study investigated prognosis among patients under prolonged mechanical ventilation (PMV) through exploring the following issues: (1) post-PMV survival rates, (2) factors associated with survival after PMV, and (3) the number of days alive free of hospital stays requiring mechanical ventilation (MV) care after PMV. METHODS: This is a retrospective cohort study based on secondary analysis of prospectively collected data in the national health insurance system and governmental data on death registry in Taiwan. It used data for a nationally representative sample of 25,482 patients becoming under PMV (> = 21 days) during 1998-2003. We calculated survival rates for the 4 years after PMV, and adopted logistic regression to construct prediction models for 3-month, 6-month, 1-year, and 2-year survival, with data of 1998-2002 for model estimation and the 2003 data for examination of model performance. We estimated the number of days alive free of hospital stays requiring MV care in the immediate 4-year period after PMV, and contrasted patients who had low survival probability with all PMV patients. RESULTS: Among these patients, the 3-month survival rate was 51.4%, and the 1-year survival rate was 31.9%. Common health conditions with significant associations with poor survival included neoplasm, acute and unspecific renal failure, chronic renal failure, non-alcoholic liver disease, shock and septicaemia (odd ratio < 0.7, p <0.05). During a 4-year follow-up period for patients of year 2003, the mean number of days free of hospital stays requiring MV was 66.0 in those with a predicted 6-month survival rate <10%, and 111.3 in those with a predicted 2-year survival rate <10%. In contrast, the mean number of days was 256.9 in the whole sample of patients in 2003. CONCLUSIONS: Neoplasm, acute and unspecific renal failure, shock, chronic renal failure, septicemia, and non-alcoholic liver disease are significantly associated with lower survival among PMV patients. Patients with anticipated death in a near future tend to spend most of the rest of their life staying in hospital using MV services. This calls for further research into assessing PMV care need among patients at different prognosis stages of diseases listed above.

• "I know it's bad for me and yet I do it": exploring the factors that perpetuate smoking in Aboriginal Health Workers - a qualitative study.

  Authors: Anna P Dawson, Margaret Cargo, Harold Stewart, Alwin Chong, Mark Daniel

  BMC health services research. 12(1):102.

  ABSTRACT: BACKGROUND: Aboriginal Health Workers (AHWs) have a mandate to deliver smoking cessation support to Aboriginal people. However, a high proportion of AHWs are smokers and this underminesABSTRACT: BACKGROUND: Aboriginal Health Workers (AHWs) have a mandate to deliver smoking cessation support to Aboriginal people. However, a high proportion of AHWs are smokers and this undermines their delivery of smoking cessation programs. Smoking tobacco is the leading contributor to the burden of disease in Aboriginal Australians and must be prevented. Little is known about how to enable AHWs to quit smoking. An understanding of the factors that perpetuate smoking in AHWs is needed to inform the development of culturally relevant programs that enable AHWs to quit smoking. A reduction of smoking in AHWs is important to promote their health and also optimise the delivery of smoking cessation support to Aboriginal clients. METHODS: We conducted a fundamental qualitative description study that was nested within a larger mixed method participatory research project. The individual and contextual factors that directly or indirectly promote (i.e. perpetuate) smoking behaviours in AHWs were explored in 34 interviews and 3 focus groups. AHWs, other health service staff and tobacco control personnel shared their perspectives. Data analysis was performed using a qualitative content analysis approach with collective member checking by AHW representatives. RESULTS: AHWs were highly stressed, burdened by their responsibilities, felt powerless and undervalued, and used smoking to cope with and support a sense of social connectedness in their lives. Factors directly and indirectly associated with smoking were reported at six levels of behavioural influence: personal factors (e.g. stress, nicotine addiction), family (e.g. breakdown of family dynamics, grief and loss), interpersonal processes (e.g. socialisation and connection, domestic disputes), the health service (e.g. job insecurity and financial insecurity, demanding work), the community (e.g. racism, social disadvantage) and policy (e.g. short term and insecure funding). CONCLUSIONS: An extensive array of factors perpetuated smoking in AHWs. The multitude of personal, social and environmental stressors faced by AHWs and the accepted use of communal smoking to facilitate socialisation and connection were primary drivers of smoking in AHWs in addition to nicotine dependence. Culturally sensitive multidimensional smoking cessation programs that address these factors and can be tailored to local needs are indicated.

• The health services burden of heart failure: an analysis using linked population health data-sets.

  Authors: Jane Robertson, Patrick McElduff, Sallie-Anne Pearson, David A Henry, Kerry J Inder, John R Attia

  BMC health services research. 12(1):103.

  ABSTRACT: BACKGROUND: The burden of patients with heart failure on health care systems is widely recognised, although there have been few attempts to quantify individual patterns of care andABSTRACT: BACKGROUND: The burden of patients with heart failure on health care systems is widely recognised, although there have been few attempts to quantify individual patterns of care and differences in health service utilisation related to age, socio-economic factors and the presence of comorbidities. The aim of this study was to assess the typical profile, trajectory and resource use of a cohort of Australian patients with heart failure using linked population-based, patient-level data. METHODS: Using hospital separations (Admitted Patient Data Collection) with death registrations (Registry of Births, Deaths and Marriages) for the period 2000-2007 we estimated age- and gender-specific rates of index admissions and readmissions, risk factors for hospital readmission, mean length of stay (LOS), median survival and bed-days occupied by patients with heart failure in New South Wales, Australia. RESULTS: We identified 29,161 index admissions for heart failure. Admission rates increased with age, and were higher for males than females for all age groups. Age-standardised rates decreased over time (256.7 to 237.7/100,000 for males and 235.3 to 217.1/100,000 for females from 2002-3 to 2006-7; p = 0.0073 adjusted for gender). Readmission rates (any cause) were 27% and 73% at 28-days and one year respectively; readmission rates for heart failure were 11% and 32% respectively. All cause mortality was 10% and 28% at 28 days and one year. Increasing age was associated with more heart failure readmissions, longer LOS and shorter median survival. Increasing age, increasing Charlson comorbidity score and male gender were risk factors for hospital readmission. Cohort members occupied 954,888 hospital beddays during the study period (any cause); 383,646 bed-days were attributed to heart failure admissions. CONCLUSIONS: The rates of index admissions for heart failure decreased significantly in both males and females over the study period. However, the impact on acute care hospital beds was substantial, with heart failure patients occupying almost 200,000 bed-days per year in NSW over the five year study period. The strong age-related trends highlight the importance of stabilising elderly patients before discharge and community-based outreach programs to better manage heart failure and reduce readmissions.

• A four-year, systems-wide intervention promoting interprofessional collaboration.

  Authors: Jeffrey Braithwaite, Mary Westbrook, Peter Nugus, David Greenfield, Joanne Travaglia, William Runciman, A Ruth Foxwell, Rosalie A Boyce, Timothy Devinney, Johanna Westbrook

  BMC health services research. 12(1):99.

  ABSTRACT: BACKGROUND: A four-year action research study was conducted across the Australian Capital Territory health system to strengthen interprofessional collaboration (IPC) though multipleABSTRACT: BACKGROUND: A four-year action research study was conducted across the Australian Capital Territory health system to strengthen interprofessional collaboration (IPC) though multiple intervention activities. METHODS: We developed 272 substantial IPC intervention activities involving 2,407 face-to-face encounters with health system personnel. Staff attitudes toward IPC were surveyed yearly using Heinemann et al's Attitudes toward Health Care Teams and Parsell and Bligh's Readiness for Interprofessional Learning scales (RIPLS). At study's end staff assessed whether project goals were achieved. RESULTS: Of the improvement projects, 76 exhibited progress, and 57 made considerable gains in IPC. Educational workshops and feedback sessions were well received and stimulated interprofessional activities. Over time staff scores on Heinemann's Quality of Interprofessional Care subscale did not change significantly and scores on the Doctor Centrality subscale increased, contrary to predictions. Scores on the RIPLS subscales of Teamwork & Collaboration and Professional Identity did not alter. On average for the assessment items 33% of staff agreed that goals had been achieved, 10% disagreed, and 57% checked neutral. There was most agreement that the study had resulted in increased sharing of knowledge between professions and improved quality of patient care, and least agreement that between-professional rivalries had lessened and communication and trust between professions improved. CONCLUSIONS: Our longitudinal interventional study of IPC involving multiple activities supporting increased IPC achieved many project-specific goals. However, improvements in attitudes over time were not demonstrated and neutral assessments predominated, highlighting the difficulties faced by studies targeting change at the systems level and over extended periods.

• Cost-effectiveness analysis of neonatal hearing screening program in china: Should universal screening be prioritized?

  Authors: Li-Hui Huang, Luo Zhang, Ruo-Yan Gai Tobe, Fang-Hua Qi, Long Sun, Yue Teng, Qing-Lin Ke, Fei Mai, Xue-Feng Zhang, Mei Zhang [......] Hong-Hui Li, Yan-Qing Gu, Sai-Nan Xu, Xiao-Yan Yue, Xiao-Dong Li, Bei-Er Qi, Xiao-Huan Cheng, Wei Tang, Ling-Zhong Xu, De-Min Han

  BMC health services research. 12(1):97.

  ABSTRACT: BACKGROUND: Neonatal hearing screening (NHS) has been routinely offered as a vital component of early childhood care in developed countries, whereas such a screening program is still at theABSTRACT: BACKGROUND: Neonatal hearing screening (NHS) has been routinely offered as a vital component of early childhood care in developed countries, whereas such a screening program is still at the pilot or preliminary stage as regards its nationwide implementation in developing countries. To provide significant evidence for health policy making in China, this study aims to determine the cost-effectiveness of NHS program implementation in case of eight provinces of China. METHODS: A cost-effectiveness model was conducted and all neonates annually born from 2007 to 2009 in eight provinces of China were simulated in this model. The model parameters were estimated from the established databases in the general hospitals or maternal and child health hospitals of these eight provinces, supplemented from the published literature. The model estimated changes in program implementation costs, disability-adjusted life years (DALYs), average cost-effectiveness ratio (ACER), and incremental cost-effectiveness ratio (ICER) for universal screening compared to targeted screening in eight provinces. RESULTS AND DISCUSSION: A multivariate sensitivity analysis was performed to determine uncertainty in health effect estimates and cost-effectiveness ratios using a probabilistic modeling technique. Targeted strategy trended to be cost-effective in Guangxi, Jiangxi, Henan, Guangdong, Zhejiang, Hebei, Shandong, and Beijing from the level of 9%, 9%, 8%, 4%, 3%, 7%, 5%, and 2%, respectively; while universal strategy trended to be cost-effective in those provinces from the level of 70%, 70%, 48%, 10%, 8%, 28%, 15%, 4%, respectively. This study showed although there was a huge disparity in the implementation of the NHS program in the surveyed provinces, both universal strategy and targeted strategy showed cost-effectiveness in those relatively developed provinces, while neither of the screening strategy showed cost-effectiveness in those relatively developing provinces. This study also showed that both strategies especially universal strategy achieve a good economic effect in the long term costs. CONCLUSIONS: Universal screening might be considered as the prioritized implementation goal especially in those relatively developed provinces of China as it provides the best health and economic effects, while targeted screening might be temporarily more realistic than universal screening in those relatively developing provinces of China.

• Unintentional non-adherence to chronic prescription medications: How unintentional is it really?

  Authors: Abhijit S Gadkari, Colleen A McHorney

  BMC health services research. 12(1):98.

  ABSTRACT: BACKGROUND: Unintentional non-adherence has been characterized as passively inconsistent medication-taking behavior (forgetfulness or carelessness). Our objectives were to: (1) study theABSTRACT: BACKGROUND: Unintentional non-adherence has been characterized as passively inconsistent medication-taking behavior (forgetfulness or carelessness). Our objectives were to: (1) study the prevalence and predictors of unintentional non-adherence; and (2) explore the interrelationship between intentional and unintentional non-adherence in relation to patients' medication beliefs. METHODS: We conducted a cross-sectional survey of adults with asthma, hypertension, diabetes, hyperlipidemia, osteoporosis, or depression from the Harris Interactive Chronic Illness Panel. The analytic sample for this study included 24,017 adults who self-identified themselves as persistent to prescription medications for their index disease. They answered three questions on unintentional non-adherence (forgot, ran out, being careless), 11 questions on intentional non-adherence, and three multi-item scales assessing perceived need for medication (k = 10), perceived medication concerns (k = 6), and perceived medication affordability (k = 4). Logistic regression was used to model predictors of each unintentional non-adherence behavior. Baron and Kenny's regression approach was used to test the mediational effect of unintentional non-adherence on the relationship between medication beliefs and intentional non-adherence. Bootstrapping was employed to confirm the statistical significance of these results. RESULTS: For the index disease, 62% forgot to take a medication, 37% had run out of the medication, and 23% were careless about taking the medication. Common multivariate predictors (p < .001) of the three behaviors were: (1) lower perceived need for medications; (2) more medication affordability problems; (3) worse self-rated health; (4) diabetes or osteoporosis (relative to hypertension); and (5) younger age. Unique statistically-significant predictors of the three behaviors were: (a) 'forgot to take medications' - greater concerns about the index medication and male gender; (b) 'run out of medications' - non-white race, asthma, and higher number of total prescription medications; (c) 'being careless' - greater medication concerns. Mediational tests confirmed the hypothesis that the effect of medication beliefs (perceived need, concerns, and affordability) on intentional non-adherence is mediated through unintentional non-adherence. CONCLUSIONS: For our study sample, unintentional non-adherence does not appear to be random and is predicted by medication beliefs, chronic disease, and sociodemographics. The data suggests that the importance of unintentional non-adherence may lie in its potential prognostic significance for future intentional non-adherence. Health care providers may consider routinely inquiring about unintentional non-adherence in order to proactively address patients' suboptimal medication beliefs before they choose to discontinue therapy all together.

• Incentive payments are not related to expected health gain in the pay for performance scheme for UK primary care: cross-sectional analysis.

  Authors: Robert Fleetcroft, Nicholas Steel, Richard Cookson, Simon Walker, Amanda Howe

  BMC health services research. 12(1):94.

  ABSTRACT: BACKGROUND: The General Medical Services primary care contract for the United Kingdom financially rewards performance in 19 clinical areas, through the Quality and Outcomes Framework.ABSTRACT: BACKGROUND: The General Medical Services primary care contract for the United Kingdom financially rewards performance in 19 clinical areas, through the Quality and Outcomes Framework. Little is known about how best to determine the size of financial incentives in pay for performance schemes. Our aim was to test the hypothesis that performance indicators with larger population health benefits receive larger financial incentives. METHODS: We performed cross sectional analyses to quantify associations between the size of financial incentives and expected health gain in the 2004 and 2006 versions of the Quality and Outcomes Framework. We used non-parametric two-sided Spearman rank correlation tests. Health gain was measured in expected lives saved in one year and in quality adjusted life years. For each quality indicator in an average sized general practice we tested for associations first, between the marginal increase in payment and the health gain resulting from a one percent point improvement in performance and second, between total payment and the health gain at the performance threshold for maximum payment. RESULTS: Evidence for lives saved or quality adjusted life years gained was found for 28 indicators accounting for 41% of the total incentive payments. No statistically significant associations were found between the expected health gain and incentive gained from a marginal 1% increase in performance in either the 2004 or 2006 version of the Quality and Outcomes Framework. In addition no associations were found between the size of financial payment for achievement of an indicator and the expected health gain at the performance threshold for maximum payment measured in lives saved or quality adjusted life years. CONCLUSIONS: In this subgroup of indicators the financial incentives were not aligned to maximise health gain. This disconnection between incentive and expected health gain risks supporting clinical activities that are only marginally effective, at the expense of more effective activities receiving lower incentives. When designing pay for performance programmes decisions about the size of the financial incentive attached to an indicator should be informed by information on the health gain to be expected from that indicator.

• Is telemonitoring an option against shortage of physicians in rural regions? Attitude towards telemedical devices in the North Rhine-Westphalian health survey, Germany.

  Authors: Claudia Terschuren, Monika Mensing, Odile C L Mekel

  BMC health services research. 12(1):95.

  ABSTRACT: BACKGROUND: General practitioners (GP) in rural areas of Germany are struggling to find successors for their private practices. Telemonitoring at home offers an option to support remainingABSTRACT: BACKGROUND: General practitioners (GP) in rural areas of Germany are struggling to find successors for their private practices. Telemonitoring at home offers an option to support remaining GPs and specialists in ambulatory care. METHODS: We assessed the knowledge and attitude towards telemedicine in the population of North Rhine-Westphalia (NRW), Germany, in a population-based telephone survey. RESULTS: Out of 2,006 participants, 734 (36.6%) reported an awareness of telemedical devices. Only 37 participants (1.8%) have experience in using them. The majority of participants were in favour of using them in case of illness (72.2%). However, this approval declined with age. These findings were similar in rural and urban areas. Participants who were in favour of telemedicine (n = 1,480) strongly agreed that they would have to see their doctor less often, and that the doctor would recognize earlier relevant changes in their vital status. Participants who disliked to be monitored by telemedical devices preferred to receive immediate feedback from their physician. Especially, the elderly fear the loss of personal contact with their physician. They need the direct patient-physician communication. CONCLUSIONS: The fear of being left alone with the technique needs to be compensated for today's elderly patients to enhance acceptance of home telemonitoring as support for remaining doctors either in the rural areas or cities.

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