Family Practice Vol. 17, No. 5, 389-393
© Oxford University Press 2000
Observational study of home visits in Slovene general practice: patient characteristics, practice characteristics and health care utilization
Department of Family Medicine, Medical Faculty, University of Ljubljana, 4280 Kranjska Gora, Slovenia.
Kersnik J. Observational study of home visits in Slovene general practice: patient characteristics, practice characteristics and health care utilization. Family Practice 2000; 17: 389–393.
Received 10 December 1999; Revised 19 April 2000; Accepted 16 May 2000.
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Abstract |
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Background. Home visits are an important way of delivering primary health care, but there is a long-term decrease in home visit rates in many countries.
Objective.The aim of this study was to evaluate patient characteristics, morbidity, functional status, quality of life, satisfaction with care, practice characteristics and health care utilization in general practice patients visited at home at least once in a study year.
Methods.The design of the study was a cross-sectional survey of the patients of a stratified sample of 36 GP offices in Slovenia using a self-administered questionnaire. Sixty consecutive patients in sampled practices contacting the doctor in the office in the study period in March 1998 were included in the analyis. The age, sex, educational status, residence, presence of chronic condition, measures of anxiety or depressive symptoms, rates of patients who expressed a need for emergency care in 1 year, rates of self-care, measures of functional status, quality of life, satisfaction with care, rates of using GP practice visits and out-of-hours services and rates of using specialist or hospital services were recorded in a home-visited group versus a non-visited group.
Results. A total of 277 patients (15.4%) were reported to have at least one visit in the study year. Patients visited in their homes were older, predominantly female, better educated, had lower perceptions of their functional status and well-being and they used primary health services more frequently than others. Their GPs were more likely to be males, and were more likely to practise in rural areas, in solo practices as private practitioners.
Conclusion.Home visits remain an important part of GP work in countries in transition, such as Slovenia, especially for more seriously ill patients.
Keywords. GPs, home visits, questionnaire, Slovenia.
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Introduction |
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Home visits are an important way of delivering primary health care services.1 The rates of home visits vary between different countries and also within each national health care system.2–6 There has been a long-term decrease in rates of home visits over time.1
Slovenia has undergone considerable political and economic changes that are reflected in the organization of health care.7 We lacked comprehensive data on home visiting rates. The data on home visits depend on the way in which this type of service is delivered in the health care system. Slovenia, as one of the former Yugoslav republics, is considered to have very low rates of home visits.8 This is only partly true.2 Home visits in Slovenia are delivered in three ways: (i) as part of a routine service to the patients during the GPs' normal working hours; (ii) as a part of an additional service outside working hours; and (iii) in connection with the statutory outof-hours services run by GPs during the night and at weekends.9 The national statistics are based on the first two categories,10 and the doctors pay attention only to the second type of home visits because these are based on a fee for service. A large number of the home visits during the night, at weekends and on public holidays, i.e. during the formal out-of-hours services, are missed in reporting home visiting rates in Slovenia, since these types of visits are neither part of the national statistics nor paid separately. In fact, the emergency medical services are also part of a GP's routine responsibility, contributing additional home visits.
In several surveys, a lot of attention has been paid to the utilization and delivery of home visits;1–4,9,11–19 however, to our knowledge, there have not been any surveys carrried out from the patient's perspective on the influence of the patient characteristics, the practice characteristics and the health care utilization style of the patients receiving a home visit.5
We conducted this survey to show the percentage of general practice patients receiving home visits in one study year and to determine the characteristics of those patients and of their GPs.
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Patients and methods |
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Sampling
A representative sample of Slovene GPs (15 male and 21 female physicians) from the national register10 were approached. To ensure participation of patients from different environments all over the country, we stratified them according to the type of the practice, i.e. working in a group or in a solo practice, working in a practice in the town with 30 000 inhabitants or more, or working in a rural area. One GP from a stratified sample of 36 practices all over Slovenia was approached to participate in the study. A comparison was made of the practices in the sample and the data on GP practices from the national registry. The sample of practices did not differ from the main characteristics and is representative of general practice in Slovenia.10
In March 1998, 60 consecutive adult patients who attended each practice on a randomly allocated day were offered a questionnaire in a pre-paid envelope to fill in it at home. Patients with reading problems or severely mentally disturbed patients were excluded (there were eight such cases). A total of 2160 patients were approached. The patients returned the questionnaires to the research unit by mail. After 14 days, if necessary, they were sent a reminder. An analysis of non-responders was made according to age and sex, and the differences were not statistically significant.
Questionnaire
A self-administered questionnaire was prepared from the validated and tested instruments EUROPEP questionnaire on patient satisfaction,17 EuroQol 5D instrument for measuring well-being and functional status,18–21 Duke-AD instrument for measuring symptoms of anxiety and depression22 and questions on the use of health care services, patient demographic, socio-economic and health characteristics, as well their attitude towards and experiences with health services. The instrument was translated into Slovene following a structured procedure: three forward and two backward translations with a consensus meeting of the translators to develop the final version of translated instruments. The reliability of the instruments was tested by calculating Cronbach's alpha for the questionnaire scales: patient satisfaction scale 0.93 for the entire instrument, 0.88 for the communication subscale, 0.86 for the technical subscale, 0.89 for the physicians' attitude subscale, 0.78 for the information giving subscale, 0.73 for the organizational subscale, health status 0.84 for the entire instrument, well-being 0.71 for the entire instrument, and Duke-AD 0.74 for the entire instrument.
Analysis
The data were entered into a computer using an Epi-Info statistical package, and descriptive statistics comparing the population subgroups were computed. Comparisons of the two groups (visited at home/not visited) were by chi-squared tests for the categorical variables and Mann–Whitney U-tests for the continuous variables. The reliability of the instruments was calculated using the SPSS statistical package.
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Results |
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A total of 1809 (83.8%) questionnaires were returned in the study period. Of these, 277 (15.4%) reported to have had 1–9 home visits in the study year, 485 home visits all together, mean 1.8. The patients visited at home were older than the rest of the patients (median 61 years versus 48 years; P < 0.001). In the group of patients visited at home, 71.5% were female; 66.2% of patients visited at home had received secondary or higher education; 28.9% were registered with a GP in a town, 65.7% with a solo practitioner, 30.7% with a private practitioner and 48.4% with a male GP; 72.5% had a chronic condition, 73.0% expressed a need for emergency care and 55.6% also used a walk in out-of-hours service in the study year. The results are shown in Tables 1 and 2
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The results show that the (i) patient characteristics, i.e. higher age, female sex, higher educational attainment; (ii) doctors' characteristics, i.e. male GP, longer time in the same practice, higher rates of home visits reported by the physicians, fewer phone calls regarding patients; (iii) organizational aspects, i.e. visiting GP in rural area, solo GP, private GP; (iv) patients' disease characteristics, i.e. present chronic condition, expressed need for emergency medical care, worse functional status, worse self-assessed well-being, higher satisfaction with communication aspects, empathic attitude, lower satisfaction with practice organization; and (v) higher utilization of GP services and higher use of out-of-hours services are significant predictors of being visited at home. Use of specialist or hospital services did not differ between the group of patients who were visited in their homes and the group who were not.
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Discussion |
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The present study has some weak points. We used the approach of asking patients about their experiences using home visits instead of using claims or chart data. The self-reported figures carry the possibility of recall bias that cannot be completely excluded. Whether and to what extent the recall bias contributed to the observed excess visiting amongst those with higher educational attainment cannot be estimated from our data and should be studied in future research. On the other hand, more highly educated people are more aware of their rights regarding health services and more reluctant to demand a home visit. A home visit for patients who are not confined to bed due to terminal illness or other severe conditions is regarded as a non-standard service by GPs. We could not examine the impact of the communication style on the GPs' decision to visit the patient in his/her home. The patients in this study were visited by other GPs besides their own GP, so this means that we were unable to check the figures from their medical records. Because we asked patients about all the home visits they had in one year, we cannot compare our figures with national health statistics figures that show only home visits during normal working hours. On the other hand, asking patients opens up some new areas: we identified all types of home visits (during working hours, outside working hours, during night service and emergency call visits), and thus we can compare patients' subjective experiences and evaluations of health care provision.5 A possible response bias is relatively small due to the high response rates. Another bias is possible due to a sampling procedure that excludes patients who are not able to visit GPs' practice because they are confined to bed or for other reasons, patients younger than 18 years and healthy non-users of GP services.
The study shows that surprisingly large numbers of GPs' patients receive home visits in 1 year. These findings are in contrast to the common beliefs about home visits in Slovenia.8 The older age and predominantly female sex of our patients who received a home visit are in agreement with the findings of other authors.1 The disproportionate use of home visits by patients with a higher level of education could show social injustice towards poorer populations, a finding in disagreement with Aylin.1 Patients living in rural areas (Aylin found higher provision in urban areas1), and patients registered with male practitioners, with solo practitioners and with private practitioners have a better chance of being visited at home, showing that organizational aspects of GP services play a role in home visiting rates. The presence of a chronic condition,1 lower scores for functional status, a lower score for well-being and expressed need for emergency treatment also play a significant role in being visited at home. On the contrary, the presence of signs of anxiety and depression are inversely associated with home visiting rates, indicating that the patients visited in their homes are of worse physical health, suffer mainly from chronic physical problems and were experiencing a sudden change in health status perceptions. The very common opinion of the GPs that some patients who demand home visits are heart-sink patients cannot be proven using our data.23 The ill health of patients visited in their homes can also be explained by the higher use of other primary health care services. In spite of lower functional health status, they do not use specialist and hospital services more often; showing the possible health policy benefit of home visits, in place of in-patient care at least for defined groups of primary care patients and disease entities. Lower rates of self-treatment can show an area requiring investigation for further rationalization of the home visits burden. Patient satisfaction with the communication aspect of GP work is higher in the home-visited group, indicating the importance of a holistic approach by GPs, with a variety of primary health services for the benefit of the patients, including home visits.24 Dissatisfaction with organizational aspects of GP work can confirm patients' expectations for a broad range of GP services.5
Conclusions
Home visits remain an important part of GP work in countries in transition such as Slovenia. The study confirms some well-known findings of other authors and shows distinctive features of home visits in Slovenia. The patients visited in their homes are older, predominantly female, have a higher educational status, their GPs are more likely to be male, to not work in a town, to work in solo practices and to work as private practitioners. The patients using home visits are more ill and use primary health services more frequently than others. Inequalities in provision of home visits and the possible benefits of home visits should be examined in detail in further studies.
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