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All patients are not the same: An audit comparing the public and private sectors
Abstract
Background
It is acknowledged that a variety of patient factors are known to influence consultation length as well as outcomes and complication rates following surgery. As little research has been published in this area, our aim was to compare the prevalence of such factors amongst foot and ankle surgical patients treated in the private and public sectors.
Methods
Information was prospectively collected on 100 consecutive new patients presenting to foot and ankle clinics in private practice, a trauma center and a metropolitan hospital. Data was collected for age, primary pathology, availability of home support, employment status, necessity for interpreter, smoking status, presence of diabetes and ASA (American Society of Anesthesiologists) status.
Results
Statistically significant differences were found between the private and public patients for availability of home support, employment status and necessity for an interpreter. When compared with the other two sets of patients, the trauma center had a greater proportion of smokers and diabetics. In addition, a higher ASA grade was observed.
Conclusion
A statistically significant difference in patient factors was noted between patients treated in the public and private sector and between a trauma center and a metropolitan hospital. We believe that careful consideration of these issues is needed when interpreting clinical outcomes and assessing potential service provision.
Study design
Cohort study.
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Background:
Little data are available to prioritize quality improvement initiatives in shoulder surgery.
Purpose:
To stratify the risk for 30-day postoperative morbidity in commonly performed surgical procedures about the shoulder completed in a hospital setting and to determine patient factors associated with major complications.
Study design:
Cohort study; Level of evidence, 3.
Methods:
This retrospective study utilized the National Surgical Quality Improvement Program (NSQIP) database from the years 2005 to 2010. Using Current Procedural Terminology codes, the database was queried for shoulder cases that were divided into 7 groups: arthroscopy without repair; arthroscopy with repair; arthroplasty; clavicle/acromioclavicular joint (AC) open reduction and internal fixation (ORIF)/repair; ORIF of proximal humeral fracture; open tendon release/repair; and open shoulder stabilization. The primary end point was any major complication, with secondary end points of incisional infection, return to the operating room, and venothromboembolism (VTE), all within 30 days of surgery.
Results:
Overall, 11,086 cases were analyzed. The overall major complication rate was 2.1% (n = 234). Factors associated with major complications on multivariate analysis included: procedure performed (P < .001), emergency case (P < .001), pulmonary comorbidity (P < .001), preoperative blood transfusion (P = .033), transfer from an outside institution (P = .03), American Society of Anesthesiologists (ASA) score (P = .006), wound class (P < .001), dependent functional status (P = .027), and age older than 60 years (P = .01). After risk adjustment, open shoulder stabilization was associated with the greatest risk of major complications relative to arthroscopy without repair (odds ratio [OR], 5.56; P = .001), followed by ORIF of proximal humerus fracture (OR, 4.90; P < .001) and arthroplasty (OR, 4.40; P < .001). These 3 groups generated over 60% of all major complications. Open shoulder stabilization had the highest odds of reoperation (OR, 8.34; P < .001), while ORIF of proximal humerus fracture had the highest risk for VTE (OR, 6.47; P = .001) compared with the reference group of arthroscopy without repair.
Conclusion:
Multivariable analysis of the NSQIP database suggests that open shoulder stabilization, ORIF for proximal humerus fractures, and shoulder arthroplasty are associated with the highest risk of major complications within 30 days after shoulder surgery in a hospital setting. Age, functional status, ASA score, pulmonary comorbidity, emergency case, preoperative blood transfusion, and transfer from an outside institution are patient variables that significantly influence complication risk.
Background:
Miscommunication in the healthcare sector can be life-threatening. The rising number of migrant patients and foreign-trained staff means that communication errors between a healthcare practitioner and patient when one or both are speaking a second language are increasingly likely. However, there is limited research that addresses this issue systematically. This protocol outlines a hospital-based study examining interactions between healthcare practitioners and their patients who either share or do not share a first language. Of particular interest are the nature and efficacy of communication in language-discordant conversations, and the degree to which risk is communicated. Our aim is to understand language barriers and miscommunication that may occur in healthcare settings between patients and healthcare practitioners, especially where at least one of the speakers is using a second (weaker) language.
Methods/design:
Eighty individual interactions between patients and practitioners who speak either English or Chinese (Mandarin or Cantonese) as their first language will be video recorded in a range of in- and out-patient departments at three hospitals in the Metro South area of Brisbane, Australia. All participants will complete a language background questionnaire. Patients will also complete a short survey rating the effectiveness of the interaction. Recordings will be transcribed and submitted to both quantitative and qualitative analyses to determine elements of the language used that might be particularly problematic and the extent to which language concordance and discordance impacts on the quality of the patient-practitioner consultation.
Discussion:
Understanding the role that language plays in creating barriers to healthcare is critical for healthcare systems that are experiencing an increasing range of culturally and linguistically diverse populations both amongst patients and practitioners. The data resulting from this study will inform policy and practical solutions for communication training, provide an agenda for future research, and extend theory in health communication.
Previous studies conducted in Australian hospital settings suggest high variability in assessments, investigations, and management of diabetic foot infections and poor adherence to widely accessible evidence-based protocols and guidelines. Diabetic foot complications require a multidisciplinary approach and often involve both medical and surgical teams during inpatient care.
The aim of this clinical audit was to better understand the scope of diabetes-related foot complications, evaluate whether current assessment and management strategies are in line with best practice guidelines, and to formulate future models of care.
A retrospective review of patients was carried out between 12 July 2012 and 11 July 2013. Recorded assessments of inpatient care, including risk factors, surgery, length of stay, interdepartmental referrals, and antibiotic administration were reviewed.
There were 24 admissions in 12 months (total patients n=19). Fifty-eight per cent of patients were admitted to the medical ward. More than one-quarter had evidence of osteomyelitis. While one patient required intensive care unit (ICU) management, there was no inpatient mortality. Two patients experienced significant delay to undergo initial surgical intervention presumably because of failed medical treatment. Clinical data was recorded poorly, especially regarding neuropathy, HbA1c, and clinical examination findings. Twelve per cent of patients did not undergo any follow-up. The average length of stay was 12 days. One-half of the cohort was not evaluated by the endocrinology department.
This audit highlights the need for improved care for patients with diabetic foot complications and better coordination among the multidisciplinary teams involved.
The Charlson Comorbidity Index (CCI) originally was developed to predict mortality within 1 year of hospital admission in patients without trauma. As it includes factors associated with medical and surgical complexities, it also may be useful as a predictive tool for hospital readmission after orthopaedic surgery, but to our knowledge, this has not been studied.
We asked whether an increased score on the CCI was associated with (1) readmission, (2) an increased risk of surgical site infection or other adverse events, (3) transfusion risk, or (4) mortality after orthopaedic surgery.
A total of 30,129 orthopaedic surgeries performed between 2008 and 2011 without any orthopaedic surgery in the preceding 30 days were analyzed. International Classification of Diseases, 9(th) Revision codes were used to identify diagnoses, procedures, surgery-related adverse events, surgical site infection, and comorbidities as listed in the updated and reweighted CCI. A total of 913 patients (3.0%) were readmitted within 30 days after discharge; in 393 (1.4%) patients adverse events occurred; 417 patients (1.4%) had a surgical site infection develop; 211 (0.7%) needed transfusions, and 56 (0.2%) died within 30 days after surgery. Ordinary least squares regression analyses were used to determine whether the CCI was associated with these outcomes.
The CCI accounted for 10% of the variation in readmissions. Every point increase in CCI score added an additional 0.45% risk in readmission for patients undergoing arthroplasty, 0.63% for patients undergoing trauma surgery, and 0.9% risk for patients undergoing spine surgery (all p < 0.01). The CCI was not associated with surgical site infection or other adverse events, but accounted for 8% of the variation in transfusion rate and 10% of the variation in mortality within 30 days of surgery.
The CCI can be used to estimate the risk of readmission after arthroplasty, hand and upper extremity surgery, spine surgery, and trauma surgery. It also can be used to estimate the risk of transfusion after arthroplasty, spine, trauma, and oncologic orthopaedic surgery and the risk of mortality after shoulder, trauma, and oncologic orthopaedic surgery.
Level IV, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
Many foreign patients attending our pain clinic are unable to understand one of the four Swiss national languages and are also unable to speak English. Therefore, communication with these patients can be very difficult or even impossible. Consequently, diagnosis and treatment may also prove difficult. Recognizing that language barriers can have deleterious effects, the use of an interpreter is at times the only way to communicate, however, the financial responsibility becomes that of the health care provider.
The aim of this paper was to study the aspects of communication with immigrants and to discuss the effect of language difficulties on the organizational structure of a pain clinic. In our analysis, we prospectively included all patients attending our pain clinic between January 1st and December 31st, 2006 and 2008. The mother tongue, rather than the nationality, of the patients and their ability to communicate was registered.
In 2006, the communication of 92% of the patients was "good" or "very good". Communication was extremely difficult or impossible in 6% to 7%. No statistically significant difference was found between the number of consultations per patient per mother tongue, irrespective of the patient's ability to communicate. Additionally, the consultation times were significantly shorter in patients with a poor ability to communicate.
In 6% to 7% of our pain patients, communication was impossible or extremely difficult. Language barriers can be problematic in all cultures and consultation situations. The average consultation length may be associated with better outcomes in chronic pain patients.
Objective:
To investigate the role of advancing age on postoperative complications and revision surgery following fusion for scoliosis.
Methods:
A retrospective, cohort study was performed using the Thomson Reuters MarketScan® database, examining patients with adult scoliosis who underwent spinal fusion from 2000-2009. Primary outcomes included infection, hemorrhage and pulmonary embolism (PE) within 90 days of surgery, and re-fusion. The effect of increasing age was estimated using odds ratio of complications in a multivariate logistic regression analysis, while a Cox proportional hazard model estimated the hazard ratio of re-fusion.
Results:
A total of 8432 patients were included in this study. Overall, the average age was 53.3 years, with 26.90% males and 39% with a Charlson Comorbidity Score of ≥1. The majority of patients had commercial insurance (66.81%), with 26.03% and 7.16% covered by Medicare and Medicaid, respectively. Increasing age (per 5-year increment) was a significant predictor of hemorrhagic complication (OR 1.06; CI 1.01, 1.11; p=0.0196), PE (OR 1.09; CI 1.03, 1.16; p=0.0031), infection (OR 1.04; CI 1.01, 1.07; p=0.0053) and re-fusion (HR 1.07; CI 1.02, 1.13; p=0.0103).
Conclusion:
In this study, age was associated with increased risk of hemorrhage, PE, infection and re-fusion. With the aging population, the role of patient age on post-operative healing and outcomes deserves deeper investigation following repair of AIS.
Funding source/insurance status has been associated with disparity in the management and outcomes of cardiovascular disease, with poorer outcomes among disadvantaged groups. Using proposed quality indicators for permanent pacemaker (PPM) implantation and administrative data, this study aimed to determine whether quality indicator-based outcomes of PPM implantation were comparable for publicly- and privately-funded patients within Australia's two-tier health system.
A population-based cohort study of adults implanted with a PPM between 1995 and 2009 in Western Australia. The association of funding outcomes derived from linked administrative data was tested in multivariate logistic regression models.
There were 9,748 PPMs implanted, 48% being among privately-funded patients. The mean age was 75 years for both public and private patients. Private patients had better health status (fewer with cardiac conditions and lower non-cardiac comorbidity scores), were less likely to be an emergency admission (33% vs 60% p<0.001) and more likely to have dual- or triple-chamber pacing. Mean length of stay was significantly greater for private patients (4.3 (SD 6.3) vs 5.1 (6.8) days <0.001), related to longer elective admissions. Crude mortality was lower for private patients in-hospital (0.7 vs 1.3%), 30-day post-procedure (1.3 vs 2.1%), and at one year (7.3 vs 9.5%). Emergency admission, comorbidity and other demographic and clinical factors, not funding source, were significant predictors of these outcomes.
There was no difference between publicly- and privately-funded patients in study outcomes, after adjustment for demographic and clinical factors. The exception was longer hospital stay for elective PPM among privately-funded patients.
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The aim of this study was to assess whether current unemployment was associated with poor oral health and whether there was a difference in oral health according to the duration of the current unemployment.
As part of the Health 2000 Survey in Finland (a nationwide comprehensive health examination survey), we used its data based on interviews, questionnaires, and clinical oral examinations of the 30- to 63-year-old respondents (n = 4773). Current employment status was measured in its dichotomous form, employed versus unemployed, and length of current unemployment was classified into four categories. We measured oral health in terms of numbers of missing teeth, of sound teeth, of filled teeth, of decayed teeth, and of teeth with deepened periodontal pockets (≥4 mm, ≥6 mm). Poisson regression models were fitted for all oral health outcomes except number of decayed teeth, for which negative binomial regression model was used. Oral health-related behaviors and sociodemographic and socioeconomic factors were added to the analyses.
The unemployed subjects had higher numbers of missing teeth, of decayed teeth, and of teeth with periodontal pockets than the employed ones. The association remained consistent even after adjustments. Oral health-related behaviors seemed to mediate the association. We found no association between unemployment and number of sound teeth. Current long-term unemployment showed stronger association with poor oral health than short-term among women.
The unemployed can be considered as a risk group for poor oral health. Oral healthcare should be reoriented toward those who are unemployed.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Cigarette smoking is known to increase perioperative complication rates, but no study to date has examined its effect specifically in forefoot surgery. The purpose of this study was to determine whether cigarette smoking increased complications after forefoot surgery.
The records of 602 patients who had forefoot surgery between 2008 and 2010, and for whom smoking status was known, were reviewed. Patients were categorized into 3 groups based on smoking status: active smoker, smoker in the past, or nonsmoker. Medical records were reviewed for occurrence of complications, including nonunion, delayed union, delayed wound healing, infection, and persistent pain.
Active smokers were found to have a notably higher complication rate (36.4%) after forefoot surgery than patients who previously (16.5%) or never (8.5%) smoked. Patients who continued to smoke in the perioperative period had the highest percentage of delayed union (3.0%), infection (9.1%), delayed wound healing (10.6%), and persistent pain (15.2%). Active cigarette smokers were 4.3 times more likely to have a complication than nonsmokers. Patients who smoked at any point in the past but quit prior to surgery were 1.9 times more likely than nonsmokers to incur a complication. The average time of smoking cessation for patients who had smoked at any point in the past but had quit prior to surgery was 17 years. For active smokers, those with a complication smoked an average of 18 cigarettes daily, while those without a complication smoked 14 cigarettes daily.
Before forefoot surgery, surgeons should educate patients who smoke about their increased risk of complications and encourage smoking cessation.
Level III, retrospective comparative study.
© The Author(s) 2015.
Objective:
In Australia, access to dental care has been available through several different pathways: (1) private practice; (2) public clinics; (3) Aboriginal Medical Services (AMS)-based clinics; and (4) until recently, the Chronic Disease Dental Scheme (CDDS). The aim of the present study was to compare the types of dental services most commonly delivered in the various clinical pathways based on the hypothesis that disease-driven care should lead to similar mixes of dental care provided.
Methods:
Data from a series of previously published sources was used to identify and compare the most commonly performed dental procedures in the different pathways. A comparison was also made with the available international data (US).
Results:
There was a marked difference between service mixes provided through the four pathways. Patients obtaining dental care through AMS-based and public pathways had more extractions and less restorative and preventive care compared with private and CDDS pathways. Compared with the international data, dental service mixes in Australia were found to be not as evenly distributed. Value of care provided through private and CDDS pathways were two- to threefold higher than that of AMS-based and public pathways.
Conclusion:
The data indicate that the original hypothesis that the disease-driven care should lead to similar mixes of provided dental care, is not supported.
The association of hyperglycemia with postoperative infectious complications after foot and ankle surgery has been well studied. However, many surgeons in their current practice use the somewhat arbitrary cutoff of 7% glycosylated hemoglobin (HbA1c) as the level above which surgery is considered unsafe and conducive to complications. Our goal in the present study was to assess the relationship between the HbA1c levels and the rate of postoperative infection to begin to determine whether 7% is a suitable cutoff or whether this level needs to be reevaluated. Furthermore, we were interested in the general trends relating to the infection rates and preoperative HbA1c levels. Our preliminary, subjective, analysis has indicated that infection rates increase steadily as the HbA1c increases toward 7.3%, increase rapidly at an HbA1c of 7.3% to 9.8%, and then level off. Additional study is warranted to better understand the role played by other covariates in determining the infection rate and to investigate whether patient selection has influenced the appearance of decreased infection rates at high HbA1c levels. Additional study could also assess similar relationships for other types of complication, such as nonunion, and perhaps examine different foot and ankle procedures in isolation.
1. A common statistical flaw in articles submitted to or published in biomedical research journals is to test multiple null hypotheses that originate from the results of a single experiment without correcting for the inflated risk of type 1 error (false positive statistical inference) that results from this. Multiple comparison procedures (MCP) are designed to minimize this risk. The present review focuses on pairwise contrasts, the most common sort of multiple comparisons made by biomedical investigators.
Patients with diabetes mellitus (DM) are believed to have higher complication rates when undergoing ankle and hindfoot fusions, but data is lacking. The purpose of this study was to compare the postoperative outcomes of major foot and ankle arthrodeses in patients with and without DM. Another goal was to evaluate what effect glycemic control had on the outcomes of patients with diabetes.
A retrospective review of charts from operative years 2005 to 2010 was performed. Inclusion criteria encompassed patients requiring major hindfoot and/or ankle fusion. Exclusion criteria included any patient who did not have at least 6-month followup. Seventy four patients with DM were matched with 74 non-DM patients based on age, gender, and length of surgery. Significance was set at p < 0.05 with associated 95% confidence intervals.
The overall complication rate was found to be significantly higher in patients with DM, a history of tobacco use, and peripheral neuropathy. The postoperative infection rate was found to be significantly higher in patients with DM, poor long-term glucose control (Hgb A1c levels greater than or equal to 7%), a history of tobacco use, peripheral artery disease, and peripheral neuropathy. Our rate of noninfectious complications was found to be significantly higher in patients with DM, poor short-term glucose control (a preoperative glucose greater than 200 mg/dL), a history of tobacco use, and previous solid organ transplantation. Patients greater than or equal to 65 years of age were significantly associated with fewer overall complications and postoperative infections.
This study confirmed our hypothesis that patients with DM were at increased risk for postoperative complications after foot and/or ankle arthrodesis when compared to patients without DM. A secondary finding of this study demonstrated patients with poor short- and long-term glucose control experienced more complications.
Symptomatic osteoarthritis can be a painful, costly and debilitating condition. Whilst there is a substantial body of literature surrounding osteoarthritis of the knee, there is less reported research on the hip joint, especially pertaining to physiotherapy intervention. This descriptive study aimed to describe current physiotherapy management of osteoarthritis of the hip by Australian physiotherapists in private practice and acute hospital settings.
Cross-sectional survey.
A questionnaire was administered to 364 public and private practitioners in the state of Victoria.
A response rate of 66% was achieved. Physiotherapists working in the private and public sectors reported frequent use of manual therapy (78% and 87%, respectively), aquatic therapy (82% and 58%, respectively) and home exercise programmes (88% and 80%, respectively). Class-based physiotherapy is employed less frequently (44% and 28%, respectively). Strengthening exercises are the most common treatment technique.
The widespread use of exercise and manual therapy in the management of osteoarthritis of the hip is highlighted. There was little difference in overall physiotherapy management between the public and private settings. The results identify interventions commonly used in clinical practice. The need for further research to evaluate the effectiveness of frequently used interventions is also highlighted.
This study aims to explore the trend in spine fusion surgery in Australia over the past 10 years, and to explore the possible influence of health insurance status (private versus public) on the rate of surgery.
Data pertaining to the rate of lumbar spine fusion from 1997 to 2006 were collected from Inpatient Statistics Collection of NSW Health, Medicare Australia Statistics and the Australian Bureau of Statistics. Data on total hip and total knee arthroplasties were collected to provide a comparator.
The number of publicly performed spinal fusion procedures increased by 2% from 1997 to 2006. In comparison, privately performed spinal fusion procedures increased by 167% over the same 10-year period. In 2006, spine fusion surgery was 10.8 times more likely to be done in the private sector than in the public sector, compared with corresponding figures of 4.2 times and 3.0 times for knee replacement and hip replacement, respectively. Waiting list data showed no increase in demand for spine fusion surgery in the public sector.
There is a disproportionately high rate of lumbar spine fusion surgery performed in the private sector, given the rate of private insurance. The rate of increase was found to be higher than that for hip or knee arthroplasty procedures. Possible explanations for this difference include: over-servicing in the private sector, under-servicing in the public sector, differences in medical referral patterns, surgeon and patient preferences and financial incentives.
This paper reports the first results from a survey of unemployment in Southeastern Michigan. The study includes samples of currently unemployed, previously unemployed and stably employed respondents. Special efforts were made to obtain information about the context surrounding each job loss reported, thus allowing the explicit analysis of selection bias in the estimation of unemployment effects. The analysis documents the substantial influences that unemployment has on self-reported physical health, somatization, anxiety, and depression that cannot be explained by selection bias.
In a prospective study of 6301 surgical patients in a university hospital, we examined the strength of association between
ASA physical status classification and perioperative risk factors, and postoperative outcome, using both univariate analysis
and calculation of the odds ratio of the risk of developing a postoperative complication by means of a logistic regression
model. Univariate analysis showed a significant correlation (P < 0.05) between ASA class and perioperative variables (intraoperative
blood loss, duration of postoperative ventilation and duration of intensive care stay), postoperative complications and mortality
rate. Univariate analysis of individual preoperative risk factors demonstrated their importance in the development of postoperative
complications in the related organ systems. Estimating the increased risk odds ratio for single variables, we found that the
risk of complication was influenced mainly by ASA class IV (risk odds ratio = 4.2) and ASA class III (risk odds ratio = 2.2).
We conclude that ASA physical status classification was a predictor of postoperative outcome.
Changes in the structure of the health care system have placed unprecedented stress on the surgeon-patient relationship. The essential trust placed in the surgeon by her patients has been weakened by changes in the structure and financing of the health care system. This article considers the historical and ethical foundation of the surgeon-patient relationship and proposes that the primary moral obligation of surgeons is to strengthen and earn patient trust. By improving communication skills, enhancing ethical education, serving as consistent advocates for patients, and conducting patient-focused outcome research, the surgical community can meet its moral obligation by increasing trust in the surgeon-patient relationship.
To assess the extent to which variations in episiotomy rates in Australian hospitals are justified by clinical variables and to further explore the relationships between episiotomy, insurance status, perineal trauma and outcomes for babies.
A retrospective analysis of anonymous medical record data using logistic regression models, aimed at identifying factors influencing both episiotomy rates and outcomes for babies.
A large regional public hospital, New South Wales, Australia.
The study sample consisted of 2028 women who delivered vaginally during a 12 month period during 1996-1997.
After controlling for clinical and other factors privately insured women were estimated to be up to twice as likely to experience episiotomy as publicly insured women. This difference most plausibly reflects differences in labour management styles between obstetricians and midwives. Other significant contributors to episiotomy were instrumental delivery, indications of possible fetal distress and lower parity. Severe perineal trauma (third degree tear) was found to be positively associated with episiotomy. Furthermore, the incidence of additional tears requiring suture was also substantially higher among privately insured women, the net effect being that these women had a substantially lower chance of achieving an intact perineum. Neither episiotomy nor insurance status had any significant effect on the well-being of babies.
Private health insurance appears to deny many women the opportunity of achieving normal vaginal delivery with intact perineum. Episiotomy rates amongst privately insured women in Australia may be higher than is clinically appropriate, and severe perineal trauma within this study was associated with this practice.
The provision of adequate information in a clear and sensitive manner can improve cancer patients' experience of care. Satisfaction with the cancer consultation may impact on satisfaction with care in general and adjustment to the disease. This study aims to identify factors that influence patient and clinician satisfaction with the cancer consultation and whether satisfaction can be improved with communication skills training. 160 doctors from 34 UK cancer centres participated. Half were randomized to attend a communication skills training course. Patient satisfaction data are presented at baseline and following a communication skills course or in the case of the control doctors, three months after baseline. Clinicians also rated their satisfaction with the consultations. Overall patient satisfaction was not related to the speciality, seniority or sex of the clinician or patient, site of primary cancer or type of treatment. Satisfaction was related to patients' age, psychological morbidity and, most significantly, satisfaction with the length of wait in clinic. Clinician satisfaction was not related to age, sex or cancer site but clinicians were less satisfied following consultations with patients being treated palliatively. Communication skills training had a non-significant positive effect on patient satisfaction. The subtle benefits of improved communication may be overshadowed by practical problems such as waiting too long to see the doctor, which have an adverse effect on satisfaction.
To compare cataract surgeons' predictions of patient responses to patients' actual responses on 13 factors that are important to patients about to have cataract surgery and are likely to affect their satisfaction.
Day-stay cataract surgery units at a large private hospital and a large public hospital.
Patients (private and public) were asked to rate the importance of 13 factors regarding their cataract treatment. All cataract surgeons who regularly treated cataract patients in a large metropolitan city were randomized to a public or private group and sent the same 13 factors. The surgeons were asked to rate how important each factor is to their public or private patients, as appropriate.
Eighty-one patients and 77 doctors responded to the survey. Overall, doctors predicted that all items would be more important to private patients than to public patients, even though no significant difference existed between the patient groups. Doctors correctly identified public patients' priorities but underestimated the magnitude of overall importance. In contrast, doctors recognized the magnitude of overall importance to private patients but misjudged many priorities. Doctors underestimated the importance to patients of nonsurgical characteristics such as seeing the same doctor, having a pleasant location for appointments, and waiting time for surgery.
This study demonstrates significant discordance between patients' priorities when having cataract surgery and their doctors' perception of those priorities. These differences could be explained by doctors' stereotypes of public patients and insufficient appreciation of the nonmedical aspects of patient care.
Refugees and asylum seekers face a number of barriers to accessing health care and improved health status. These include language difficulties, financial need and unemployment, cultural differences, legal barriers and a health workforce with generally low awareness of issues specific to refugees. Importantly, current Australian government migration and settlement policy also impacts on access to health and health status. An adequate understanding of these 'hurdles to health' is a prerequisite for health providers and health service managers if they are to tailor health care and services appropriately. We include tables of available resources and entitlements to health care according to visa category to assist providers and managers.
To measure the independent effect on length of general-practice consultations of a range of characteristics of the general practitioner (GP), practice, patient and consultation, as a basis for considering future GP workforce needs.
Secondary analysis of data from the BEACH (Bettering the Evaluation and Care of Health) study.
Data were obtained from 1904 GPs Australia-wide on 70,758 consultations between 1 January 2001 and 31 December 2002; all consultations that were claimable from the Australian Government's Medicare system as General Practice Attendances and had recorded start and finish times were included.
Characteristics of the GP, practice, patient and consultation that were significantly related to consultation length, determined by multiple regression analysis.
The following variables had an independent positive effect on consultation length: GP female, older, graduated in Australia, FRACGP-qualified, and in rural practice; patient female, older, new to practice, with higher socioeconomic status, no health concession card, more reasons for encounter, and more problems managed; and management of specific problem types (social, psychological and female genital problems), management of chronic disease, and provision of clinical treatments.
The independent relationship of some GP, practice, patient and consultation characteristics with length of consultation may affect future GP supply. These factors should be considered in modelling future general practice workforce needs.