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Background Waiting times for hospital appointments, treatment and/or surgery have become a major political and health service problem, leading to national maximum waiting times and policies to reduce waiting times. Quantitative studies have documented waiting times for various types of surgery and longer waiting times in public vs private hospitals. However, very little qualitative research has explored patient experiences of waiting, how this compares between public and private hospitals, and the implications for trust in hospitals and healthcare professionals. The aim of this paper is to provide a deep understanding of the impact of waiting times on patient trust in public and private hospitals. Methods A qualitative study in South Australia, including 36 in-depth interviews (18 from public and 18 from private hospitals). Data collection occurred in 2012–13, and data were analysed using pre-coding, followed by conceptual and theoretical categorisation. Results Participants differentiated between experiences of ‘waiting for’ (e.g. for specialist appointments and surgery) and ‘waiting in’ (e.g. in emergency departments and outpatient clinics) public and private hospitals. Whilst ‘waiting for’ public hospitals was longer than private hospitals, this was often justified and accepted by public patients (e.g. due to reduced government funding), therefore it did not lead to distrust of public hospitals. Private patients had shorter ‘waiting for’ hospital services, increasing their trust in private hospitals and distrust of public hospitals. Public patients also recounted many experiences of longer ‘waiting in’ public hospitals, leading to frustration and anxiety, although they rarely blamed or distrusted the doctors or nurses, instead blaming an underfunded system and over-worked staff. Doctors and nurses were seen to be doing their best, and therefore trustworthy. Conclusion Although public patients experienced longer ‘waiting for’ and ‘waiting in’ public hospitals, it did not lead to widespread distrust in public hospitals or healthcare professionals. Private patients recounted largely positive stories of reduced ‘waiting for’ and ‘waiting in’ private hospitals, and generally distrusted public hospitals. The continuing trust by public patients in the face of negative experiences may be understood as a form of exchange trust norm , in which institutional trust is based on base-level expectations of consistency and minimum standards of care and safety. The institutional trust by private patients may be understood as a form of communal trust norm , whereby trust is based on the additional and higher-level expectations of flexibility, reduced waiting and more time with healthcare professionals.

Women veterans are three to four times more likely than non-veteran women to become homeless. However, their risk factors for homelessness have not been defined. Case-control study of non-institutionalized homeless women veterans (n533) and age-matched housed women veterans (n=165). Health, health care, and factors associated with homelessness were assessed using multiple logistic regression with a Monte Carlo algorithm to estimate exact standard errors of the model coefficients and p-values. Characteristics associated with homelessness were sexual assault during military service, being unemployed, being disabled, having worse overall health, and screening positive for an anxiety disorder or post-traumatic stress disorder. Protective factors were being a college graduate or married. Efforts to assess housed women veterans' risk factors for homelessness should be integrated into clinical care programs within and outside the Veterans Administration. Programs that work to ameliorate risk factors may prevent these women's living situations from deteriorating over time.

Background The multidisciplinary approach in the management of Amyotrophic Lateral Sclerosis (ALS) has been shown to provide superior care to devolved care, with better survival, improved quality of care, and quality of life. Access to expert multidisciplinary management should be a standard for patients with ALS. This analysis explores the patient journey from symptom onset and first engagement with health services, to the initial visit to a specialist ALS Multidisciplinary Clinic (MDC) in Dublin, Ireland. Methods A retrospective exploratory multi-method study details the patient journey to the MDC. Data from medical interviews and systematic chart review identifies interactions with the health services and key timelines for thirty five new patients presenting with a diagnosis of ALS during a 6 month period in 2013. Results The time from first symptom to diagnosis was a mean of 16 months (median 13 months), with a mean interval of 19 months (median 14.6) from first symptoms to arrival at the MDC. The majority of patients were seen by a general practitioner, and subsequently by neurology services. There was an average of four contacts with health services and 4.8 investigations/tests, prior to their first Clinic visit. On the first visit to the MDC patients are linked into an integrated ‘system’ that can provide specialist care and link with voluntary, palliative and community services as required. Conclusions Engagement with a multidisciplinary team has implications for service utilization and quality of life of patients and their families. We have demonstrated that barriers exist that delay referral to specialist services. Comprehensive data recording and collection, using multiple data sources can reconstruct the timelines of the patient journey, which can in turn be used to identify pathways that can expedite early referral to specialist services.

Background The London 2012 Summer Olympic Games involved 10 568 elite athletes representing 204 competing nations. To manage the varied healthcare needs of this diverse population, a Polyclinic was constructed in the athletes’ village. Aim This work aims to summarise the usage of the Polyclinic by competing athletes and the facilities available to them. Methods All Polyclinic encounters were entered into a database from which data were exported for the time frame 28 July–12 August 2012, inclusive to cover the first to last full day of competition. Only Polyclinic data involving accredited athletes were analysed. All types of encounters were collected for analysis, not just sports-related issues. Results There were a total of 3220 encounters within the Polyclinic. This figure combines medical consultations, radiology/pathology investigations and prescriptions dispensed. Of these 3220 encounters, there were 2105 medical consultations; musculoskeletal comprised the greatest number (52%), followed by dental (30%) and ophthalmic (9%). The most frequently used imaging modality was MRI and diagnostic CT was used the least. After correction for multiple entries, Africa provided the largest proportion of athletes attending the Polyclinic (44%) and Europe the least (9%). Peak usage of all facilities was seen around days 9 and 10 of competition, reflecting the busiest time of the competition and the largest number of athletes in the village. Conclusions The Polyclinic managed a wide variety of both sports-related and non-sports-related injuries and illnesses. The breadth of specialists available for consultation was appropriate as was the ease of access to them. The radiology department was able to satisfy the demand, as were the pharmacy and pathology services. We would recommend a similar structure of facilities and available expertise in one clinic when planning future mass participation sporting events.

High rates of patient attrition from care between HIV testing and antiretroviral therapy (ART) initiation have been documented in sub-Saharan Africa, contributing to persistently low CD4 cell counts at treatment initiation. One reason for this is that starting ART in many countries is a lengthy and burdensome process, imposing long waits and multiple clinic visits on patients. We estimated the effect on uptake of ART and viral suppression of an accelerated initiation algorithm that allowed treatment-eligible patients to be dispensed their first supply of antiretroviral medications on the day of their first HIV-related clinic visit. RapIT (Rapid Initiation of Treatment) was an unblinded randomized controlled trial of single-visit ART initiation in two public sector clinics in South Africa, a primary health clinic (PHC) and a hospital-based HIV clinic. Adult (≥18 y old), non-pregnant patients receiving a positive HIV test or first treatment-eligible CD4 count were randomized to standard or rapid initiation. Patients in the rapid-initiation arm of the study (\"rapid arm\") received a point-of-care (POC) CD4 count if needed; those who were ART-eligible received a POC tuberculosis (TB) test if symptomatic, POC blood tests, physical exam, education, counseling, and antiretroviral (ARV) dispensing. Patients in the standard-initiation arm of the study (\"standard arm\") followed standard clinic procedures (three to five additional clinic visits over 2-4 wk prior to ARV dispensing). Follow up was by record review only. The primary outcome was viral suppression, defined as initiated, retained in care, and suppressed (≤400 copies/ml) within 10 mo of study enrollment. Secondary outcomes included initiation of ART ≤90 d of study enrollment, retention in care, time to ART initiation, patient-level predictors of primary outcomes, prevalence of TB symptoms, and the feasibility and acceptability of the intervention. A survival analysis was conducted comparing attrition from care after ART initiation between the groups among those who initiated within 90 d. Three hundred and seventy-seven patients were enrolled in the study between May 8, 2013 and August 29, 2014 (median CD4 count 210 cells/mm3). In the rapid arm, 119/187 patients (64%) initiated treatment and were virally suppressed at 10 mo, compared to 96/190 (51%) in the standard arm (relative risk [RR] 1.26 [1.05-1.50]). In the rapid arm 182/187 (97%) initiated ART ≤90 d, compared to 136/190 (72%) in the standard arm (RR 1.36, 95% confidence interval [CI], 1.24-1.49). Among 318 patients who did initiate ART within 90 d, the hazard of attrition within the first 10 mo did not differ between the treatment arms (hazard ratio [HR] 1.06; 95% CI 0.61-1.84). The study was limited by the small number of sites and small sample size, and the generalizability of the results to other settings and to non-research conditions is uncertain. Offering single-visit ART initiation to adult patients in South Africa increased uptake of ART by 36% and viral suppression by 26%. This intervention should be considered for adoption in the public sector in Africa. ClinicalTrials.gov NCT01710397, and South African National Clinical Trials Register DOH-27-0213-4177.

Background Few peer-reviewed publications have taken a longitudinal or systems approach to mental healthcare (MH) utilization in low- and middle-income countries. We analyzed: (1) outpatient ICD-10 diagnoses over time and by gender; and (2) health facility determinants of MH service utilization. Methods We reviewed a census of 15,856 outpatient psychiatric consultations conducted at Ministry clinics in Sofala province, Mozambique from January 2012-June 2014. Generalized estimating equations were used to model facility determinants of ICD-10 diagnoses. Results Across the period, 48.9 % of consults were for epilepsy, 22.4 % for schizophrenia/delusional disorders, and 8.8 % for neurotic/stress-related disorders. The proportion of schizophrenia/delusional disorders has decreased over time (32 % in 2012; 13 % in 2014, p  = 0.003), in favor of greater diversity of diagnoses. Epilepsy has increased significantly in absolute and proportional terms. Women are more likely to present for neurotic/stress-related conditions (12.8 % of consults for women, 5.7 % for men, p  < 0.001), while men are more likely to present for substance use (1.9 % for women, 6.4 % for men, p  < 0.001). Clinics with more psychiatric technicians have a 2.1-fold (CI: 1.2, 3.6) increased rate of schizophrenia/delusional disorder diagnoses. Rural clinics saw a higher proportion of epilepsy cases and a lower proportion of organic, substance use, schizophrenia, and mood disorder cases. Discussion and Conclusions Outpatient MH service provision is increasing in Mozambique, although currently focuses on epilepsy and schizophrenia/delusional disorders. Mid-level psychiatric providers appear to be associated with a higher proportion of schizophrenia/delusional disorder diagnoses. Due to diagnostic or utilization differences, rural clinics may be missing important cases of organic, substance use, schizophrenia, and mood disorders. Models and decision-support tools for mental healthcare integration with primary care practice are needed in Mozambique to allow further scale-up of mental health services.

Background There is very little published work on the visual needs of homeless people. This paper is the first study to investigate the visual needs of homeless people in the UK. Although similar work has been done in other countries, this study is unique because the United Kingdom is the only country with a National Health Service which provides free healthcare at the point of access. This study analysed the refractive status of the sample used, determined the demographics of homeless people seeking eye care and established if there is a need for community eye health with access to free spectacle correction in East London. Methods This retrospective case study analysed the clinical records of 1,141 homeless people using the Vision Care for Homeless People services at one of their clinics in East London. All eye examinations were carried out by qualified optometrists and, where appropriate, spectacles were dispensed to patients. Data captured included age, gender, ethnicity and refractive error. Results were analysed using two-sample t-tests with Excel and Minitab. Results Demographics of age, gender and ethnicity are described. Spherical equivalents (SE) were calculated from prescription data available for 841 clinic users. Emmetropia was defined as SE–0.50DS to +1DS, myopia as SE < −0.50DS, and hyperopia as SE > +1DS. The majority of clinic users were male (79.2 %, n  = 923). Approximately 80 % ( n  = 583) of clinic users were white, 10 % ( n  = 72) were ‘black’, 4 % ( n  = 29) ‘Asian’ and the remaining 5.6 % ( n  = 40) were of ‘mixed ethnicity’ and ‘other’ groups. The mean age of females attending the clinic was significantly lower than that of males (45.9 years, SD = 13.8 vs’ 48.4 years, SD = 11.8) when analysed using a two-sample t -test (t (317) = 2.44, p  = 0.02). One third of service users were aged between 50–59 years. Myopia and hyperopia prevalence rates were 37.0 % and 21.0 % respectively. A total of 34.8 % of homeless people were found to have uncorrected refractive error, and required spectacle correction. Conclusions This study has identified a high proportion of uncorrected refractive error in this sample and therefore a need for regular eye examinations and provision of refractive correction for homeless people.

Objective Health care utilization studies of mental disorders focus largely on the ICD-9 category 290–319, and do not generally include analysis of visits for mental health problems identified under V-code categories. Although active duty service members represent a large young adult employed population who use mental health services at similar rates as age-matched civilian populations, V-codes are used in a larger proportion of mental health visits in military mental health care settings than in civilian settings. However, the utilization of these diagnoses has not been systematically studied. The purpose of this study is to characterize outpatient behavioral health visits in military health care facilities prior to Operation Iraqi Freedom, including the use of diagnoses outside of the ICD-9 290–319 range, in order to evaluate the overall burden of mental health care. This study establishes baseline rates of mental health care utilization in military mental health clinics in 2000 and serves as a comparison for future studies of the mental health care burden of the current war. Methods All active duty service members who received care in military outpatient clinics in 2000 ( n  = 1.35 million) were included. Primary diagnoses were grouped according to mental health relevance in the following categories: mental disorders (ICD-9 290–319), mental health V-code diagnoses (used primarily by behavioral health providers that were indicative of a potential mental health problem), and all other diagnoses. Rates of service utilization within behavioral health clinics were compared with rates in other outpatient clinics for each of the diagnostic groups, reported as individuals or visits per 1,000 person-years. Cox proportional hazard regression was used to produce hazard ratios as measures of association between each of the diagnostic groups and attrition from military service. Time to attrition in months was the difference between the date of military separation and the date of first clinic visit in 2000. Data were obtained from the Defense Medical Surveillance System. Results The total number of individuals who utilized behavioral health services in 2000 was just over 115 per 1,000 person-years, almost 12% of the military population. Out of every 1,000 person-years, 57.5 individuals received care from behavioral health providers involving an ICD-9 290–319 mental disorder diagnosis, and an additional 26.7 per 1,000 person-years received care in behavioral health clinics only for V-code diagnoses. Attrition from service was correlated with both categories of mental health-related diagnoses. After 1 year, approximately 38% of individuals who received a mental disorder diagnosis left the military, compared with 23% of those who received mental health V-code diagnoses and 14% of those who received health care for any other reason (which included well visits for routine physicals). Conclusions This study establishes baseline rates of pre-war behavioral healthcare utilization among military service members, and the relationship of mental health care use and attrition from service. The research indicates that in the military population the burden of mental illness in outpatient clinics is significantly greater when V-code diagnoses are included along with conventional mental disorder diagnostic codes.

Background China, like other countries, is facing a growing burden of chronic disease but the prevalence of multimorbidity and implications for the healthcare system have been little researched. We examined the epidemiology of multimorbidity in southern China in a large representative sample. The effects of multimorbidity and other factors on usual source of healthcare were also examined. Methods We conducted a large cross-sectional survey among approximately 5% (N = 162,464) of the resident population in three prefectures in Guangdong province, southern China in 2011. A multistage, stratified random sampling was adopted. The study population had many similar characteristics to the national census population. Interviewer-administered questionnaires were used to collect self-report data on demographics, socio-economics, lifestyles, healthcare use, and health characteristics from paper-based medical reports. Results More than one in ten of the total study population (11.1%, 95% confidence interval (CI) 10.6 to 11.6) had two or more chronic conditions from a selection of 40 morbidities. The prevalence of multimorbidity increased with age (adjusted odds ratio (aOR) = 1.36, 95% CI 1.35 to 1.38 per five years). Female gender (aOR = 1.70, 95% CI 1.64 to 1.76), low education (aOR = 1.26, 95% CI 1.23 to 1.29), lack of medical insurance (aOR = 1.79, 95% CI 1.71 to 1.89), and unhealthy lifestyle behaviours were independent predictors of multimorbidity. Multimorbidity was associated with the regular use of secondary outpatient care in preference to primary care. Conclusions Multimorbidity is now common in China. The reported preferential use of secondary care over primary care by patients with multimorbidity has many major implications. There is an urgent need to further develop a strong and equitable primary care system.

Background Provision of eye care services for competitors and their support teams has become an integral part of the modern Olympic Games. Aim To describe the organisation of the eye clinic at London 2012 over a 4-week period and provide outline audit data. Methods The clinic employed multidisciplinary eye care professionals and utilised state-of-the-art instrumentation to provide the highest level of eye care. Results A total of 1406 patients from 154 countries attended the clinic over the Olympic Games, of which, 276 were competitors. All individuals received a comprehensive refractive and ocular health examination. Minor ocular injuries, glaucoma, diabetic retinopathy and macular degeneration were among the conditions detected and managed. Most patients attended the clinic to have their refractive status checked: 973 spectacles and 50 pairs of contact lenses were dispensed. Conclusions It is hoped that this account of the provision of eye care at London 2012 will assist with the planning of this service at future events.