Chapter 9 Summary PDF

CHAPTER 9 USING HEALTH SERVICES CHAPTER OUTLINE I. Types of Health Services A. Specialized Functions of Practitioners 1. Nature of specialization a. medical care system consists of large numbers of physicians of vario...

CHAPTER 9 USING HEALTH SERVICES CHAPTER OUTLINE I. Types of Health Services A. Specialized Functions of Practitioners 1. Nature of specialization a. medical care system consists of large numbers of physicians of various medical specialties i. as knowledge and skills grow and change, individual physicians can’t perform service of several specialties simultaneously with high degree of skill ii. as a result, patients are likely to receive care from multiple professionals 2. Advantage of a system organized by specialty a. allows patient to receive greatest level of expertise available for each aspect of treatment 3. Drawbacks a. lack of communication between specialists resulting in primary physician not having complete picture of case needs b. brief, impersonal contact with patient B. Office-Based and Inpatient Treatment 1. First contact with medical professional a. usually first meet with physician who may treat illness, refer to a specialist, or recommend hospitalization. 2. Hospital care a. most complex facilities in health care. i. generally used by patients with serious illness who require attention on continuous basis or require complex equipment or procedures ii. use array of sophisticated equipment and practitioners from many specialties. iii. provide care ranging from emergency care to prevention services. iv. may offer health promotion facilities v. may have specialized missions (e.g., caring for children or treating certain diseases such as cancer) 3. Nursing homes a. provide long-term and personal care. i. care given mostly to handicapped or frail elderly. ii. average size of facility is 100 bed home. iii. quality of care has been raised as a concern.  4. Outpatient or home health care a. recent trend due to health care costs and technological advances. i. technology examples: pacemakers or insulin pumps ii. patients tend to begin care on inpatient basis, then are discharged for home care b. advantages i. less expensive ii. patient can be at home and potentially return to work/school c. disadvantages i. lack of caregivers in the home setting ii. lack of transportation to clinic C. The American Health Care System 1. Paying for medical care a. insurance plans through employers b. Medicare/Medicaid for the elderly and low-income c. Over 15% of Americans not insured i. people of color are more likely to be uninsured 2. Fee-for-service programs a. patients choose own physicians who must accept insurance plan payment amount b. insurance pays certain percentage of fees 3. Managed-care programs a. members' choice of physicians and services restricted although 70% of employed Americans opt for managed-care b. physicians given financial incentives for cost-saving behaviors i. may foster suboptimal care c. health-maintenance organization (HMO) is one type of managed-care plan i. member can receive services from any affiliated physician at little to no additional fee but have annual fee ii. physicians paid salary or by number of patients seen/services conducted d. preferred provider organizations (PPOs) negotiate discounted fees with specific physicians. 4. Comparison of quality of care from HMO, PPO and fee-for-service a. problems with assessing quality i. plans vary in policies and structures ii. research on PPO and fee-for-service has been quasi- experimental and on large, well-established HMOs (not newly developed programs) b. experiences of HMO patients i. more trouble getting in to see doctor when ill ii. less likely to be admitted to hospital and leave earlier iii. more preventive exams/procedures iv. face obstacles in treatment but care is comparable v. less satisfaction with care but more satisfaction with cost  5. Criticisms/concerns about HMOs a. consumer groups find substantial variation across plans and urge potential members to choose from plans carefully b. although consumer ratings are available, there is reason to question their value 6. General evaluation of American health care a. care is among finest in world b. system has flaws i. skyrocketing costs ii. not accessible to people without insurance iii. so complex and has so many managed care options, decisions can be intimidating D. Health Care Systems in Other Countries 1. National health insurance programs exist in Canada and most of European Union a. system less complicated than in the U.S. but still has excellent care 2. Systems vary in structure and financing a. insurance may be provided by government or employers b. physicians may be employed by government or are in private practice c. Canadian system as an example i. provides coverage for everyone, financed by payroll taxes ii. provinces pay citizens medical bills, determine own policies, and negotiate with medical association on fees that will be charged iii. physicians are employed privately iv. aside from usual medical care, system also covers prescription drugs, long-term care and mental health services 3. Compared to U.S., other systems far less expensive in terms of costs per citizen and percentage of gross domestic product spent on health care. a. problems i. funding shortages contribute to long waits and inability to get needed treatment II. Perceiving and Interpreting Symptoms A. Section Introduction 1. Information learned from experiences with illness a. symptoms accompany illness b. certain symptoms reliably signal certain illnesses c. some symptoms more serious than others d. when symptoms go away, you’re well B. Perceiving Symptoms 1. Perceiving symptoms is more complicated than simply perceiving internal sensations. a. people are not accurate in assessments of internal states and external symptoms  b. perceiving symptoms vary across people and differ within the same person across time 2. Individual differences a. differences across people may be due to: i. simply having more symptoms ii. differing in experience of same symptom - evidence: pain research has found that almost all people have a uniform threshold for pain but differ in their tolerance of that pain iii. some people may notice the changes more quickly but may not be more accurate (i.e., overestimate the change) - internally focused people who seek treatment tend to have less severe illness and perceive recovery as slower 3. Competing environmental stimuli a. environments that contain a lot of sensory information or which are exciting are negatively related to symptom reporting. 4. Psychosocial influences a. role of cognitive factors demonstrated by impact of receiving placebo b. expectations influence symptom perception. i. example: misleading information regarding point in menstrual cycle affects symptoms reported c. Interaction of cognitive, social, and emotional factors is seen in medical student's disease and mass psychogenic illness. i. factors that contribute to these phenomena 1. vague, subjective nature of common physical symptoms 2. exaggeration of symptoms and their importance 3. modeling of reactions 4. feeling negative emotions such as stress 5. Gender and sociocultural differences a. women report discomfort at lower stimulus intensities and request termination of painful stimuli sooner than men i. explanation: sex hormones and sex-role beliefs b. people from different cultures differ in their reactions to and perceptions of illness symptoms. i. different cultural norms reinforce symptom experiences and symptom-reporting behavior. ii. examples: - Asian cultures report more physical symptoms with psychological bases - American pain patients report more impairment - African American heart attack patients’ symptoms less typical and delay getting treatment longer B. Interpreting and Responding to Symptoms 1. Prior experience with an illness may increase or decrease accuracy of interpretation of symptoms. a. symptoms may be interpreted as signs of stress 2. Commonsense models of illness are cognitive representations of  illness developed through direct experience or from available information about illness a. models affect health behavior i. incorrect information may contribute to not adopting preventive behavior, seeking treatment, following medical advice, or adapting well psychologically b. components of models i. illness identity – name and symptoms of disease ii. causes and underlying pathology – how one gets the disease and physiological events that occur with it iii. time line – prognosis including how long it takes symptoms to occur and last iv. consequence – seriousness, effects, outcome of illness c. many types of information used in constructing model i. example: prevalence information – rare diseases seen as more serious 3. Conflict theory: fear/stress may interfere with rational decision making. 4. Lay referral systems may provide advice and interpretation of symptoms. a. Information given i. help in interpreting symptom ii. advice about seeking medical attention iii. recommended remedies iv. advice on consulting another in lay referral network who has experience with the symptom III. Using and Misusing Health Services A. Section Introduction 1. Pharmacists are frequently the first "medical" contact for many people a. may recommend over-the-counter medications or seeing a physician if condition doesn’t improve 2. Although people generally try to avoid having to see physician, physician contact averages six per year per person 3. Reasons for contact with a physician a. acute conditions i. examples: flu, common cold, fractures or dislocations, sprains or strains, wounds, and ear infections b. chronic conditions i. examples: hypertension, orthopedic problems, arthritis, diabetes, asthma and heart disease B. Who Uses Health Services? 1. Age and gender a. age i. young children and elderly use services more frequently b. gender i. more women than men see physician.  ii. possible explanations 1. higher actual frequency of symptoms. 2. less hesitancy to admit symptoms. 3. socialization of gender roles. 2. Sociocultural factors in using health services a. surveys on usage rates conclude that: i. usage increases with income ii. low income persons more likely to use outpatient clinics and emergency rooms for care, probably because they’re less likely to have regular physician iii. although SES gap in usage still exists, this has declined since Medicare/Medicaid were introduced b. because patients must cover costs not covered by insurance or may not have insurance at all, low income influences using health services i. low income related to: - greater frequency of illness and longer hospital stays - less knowledge about and seeking prevention care - poor access to health counseling services - lower beliefs in susceptible to illness - feeling less welcomed by health care professionals - experiencing language barriers c. distinguishing users from nonusers. i. users - children, women, elderly from upper SES. ii. nonusers - lower SES, minority, males in adolescence and early adulthood. C. Why People Use, Don't Use, and Delay Using Health Services 1. Ideas, beliefs, and using health services a. concerns about iatrogenic conditions, health problems that result from treatment errors or side effects, deter some from seeking treatment. b. patients may not trust practitioners, worry about confidentiality, or fear discrimination. 2. The health belief model and seeking medical care a. symptoms initiate decision-making about seeking care. i. threat perception of the symptom is a function of: - cues to action – symptoms, advice, information from media - perceived susceptibility – likelihood of contracting illness - perceived seriousness – physical and social consequences of illness ii. sum of perceived benefits and perceived barriers combine to determine likelihood of seeking care. b. support for model suggests a weak relationship; therefore, other factors are probably important determinants in seeking health care.  3. Social and emotional factors and seeking medical care a. emotional states such as anxiety , fear and expectation of pain and/or embarrassment may lead to avoidance of medical or dental care b. social factors i. seeing seeking help as a sign of weakness or a violation of social role contributes to delay ii. lay referral factors may contribute to help seeking - encouraging another to seek treatment may be a “social trigger” - example: sanctioning – asking/insisting that person have symptoms treated 4. Stages in delaying medical care a. treatment delay - time between noticing a symptom and seeking medical care. i. stages of treatment delay - appraisal delay - time to interpret symptom; affected most by sensory experience of symptom. - illness delay - time between recognizing one's ill and deciding to seek care; affected by thoughts about symptom. - utilization delay - time between deciding and actually seeking care; affected by perceptions of benefits/barriers. b. not having pain is a major factor in treatment delay, which is problematic since pain is not a symptom in many serious diseases c. advice: knowing symptoms of serious illness and realizing that some illnesses don’t have signs we often rely on is critical D. Using complementary and alternative medicine (CAM) 1. definitions: a. complementary: treatments used along with conventional medicine b. alternative: treatments used instead of conventional medicine c. five types of CAM i. manipulative and body-based methods – maneuver or move parts of body (e.g., chiropractic and massage procedures) ii. biologically based methods – materials found in nature (e.g., herbal products and dietary supplements) iii. mind-body interventions – enhancing body’s ability to manage body function and symptoms (e.g., progressive muscle relaxation and meditation) iv. energy therapies – hypothesized or known physical energy fields believed to exist and surround body v. alternative medicine systems – medical system that differ from and often precede traditional Western medicine; tend to use preceding methods (e.g., Chinese medicine and homeopathy) d. characteristics of people who use alternative medicine  methods i. most influenced by religious or cultural backgrounds that endorse these methods ii. in US, characteristics include - being well-educated - having beliefs consistent with method - having symptoms that haven't improved with use of conventional medicine. e. research on CAM i. surveys indicate most respondents satisfied with medical treatment and, if had used CAM, had gotten better results from medical treatments (improvements in only 10%-30% of cases, similar to placebo) - best CAM results were for chiropractic and deep-tissue massage for back pain ii. problem with CAM methods is little to no scientific evidence of safety or effectiveness - if sufficient evidence has been found, they get incorporated into traditional treatment (e.g., dietary supplements, biofeedback, deep tissue massage, relaxation) E. Problematic Health Service Usage 1. What constitutes misuse a. overuse – often thought to be due to hypochondriasis i. hypochondriasis - excessive worry about health, monitoring body sensations and believing one is ill despite evidence or reassurances to the contrary. ii. evidence that somatic complaints increases with neuroticism. iii. Increased physical complaints in the elderly are generally connected to real problems, not hypochondriasis 2. Some medical complaints, that may look like misuse of services, simply may not be currently confirmed by medical community a. example: chronic fatigue syndrome i. once thought to be a form of mononucleosis, then inconsistent support for it being linked to psychiatric disorder. IV. The Patient/Practitioner Relationship A. Patient Preferences for Participation in Medical Care 1. Patient/practitioner relationship depends on what patient wants and what practitioner provides 2. Patients differ in the degree they wish to participate in their medical care. a. most want to know about illness and how to treat it but some want more information 3. Factors associated with information/involvement needs a. gender – women want more information  b. age - elderly less likely to seek information and more likely to prefer physicians to make health-related decisions made for them c. receiving desired amount and type of participation enhances adjustment and satisfaction d. level of active/inactive involvement predicts adjustment during and speed of recovery 4. Practitioner inclination toward patient participation a. may be less inclined to share authority and decision making b. may have incorrect belief that clients unable to understand medical information and make good decisions 5. Outcomes of mismatches in patient/physician beliefs about desire for participation a. may cause patients to: i. experience more stress ii. not follow doctor’s directions iii. switch doctors 6. Conclusion: physicians need to assess and consider what patient wants B. The Practitioner's Behavior and Style 1. Byrne and Long’s analyses of practitioners’ style of interaction a. general finding: physicians’ interaction style tend to remain consistent across all clients treated b. types of interaction i. doctor-centered interaction style - questions requiring brief answers - focus on initial problem while ignoring other issues - focused on the link between problem and organic cause ii. patient-centered interaction style i. open-ended questions ii. opportunities for client to introduce new facts iii. avoids medical jargon iv. allows patients to participate in decision-making 2. Use of medical jargon may create confusion, incorrect ideas, and dissatisfaction a. McKinlay’s research on patient understanding of terms a. results indicated that only 39% understood all 13 words in study i. notably, physicians expected even less comprehension than that b. reasons for use of jargon i. habit ii. belief that patient doesn't need to know iii. belief about what benefits patient/medical staff - reduces stress in patient - keeps interaction short iv. elevates status of physician 3. Preferred characteristics in physicians include competence,  sensitivity, warmth, and concern a. characteristics are assessed by conversation and body language b. greater satisfaction ratings are given for physicians who give patients a chance to talk, take time to listen, give clear explanations, and project feeling of concern 4. Consequences of patient-centered behavioral style a. higher patient satisfaction ratings b. fewer appointment cancellations b. more significant diagnostic facts gained from their patients C. The Patient's Behavior and Style 1. Troublesome patient behavior a. Survey results from physicians indicate following patient behaviors are problematic i. expressing criticism of or anger toward physician ii. ignoring or not listening to advice iii. insisting on unnecessary tests, medications, or procedures iv. demanding inappropriate endorsement of disability claims v. sexual remarks or behaviors 2. Potential of malpractice makes physicians wary of patients and creates less job satisfaction 3. Other patient factors that interfere with patient-practitioner communications a. high level of or lack of realistic communication regarding distress about health (e.g., neuroticism or not talking about worries at all) b. vague, misleading, or unclear description of symptoms, affected by patient’s i. degree of attention to internal symptoms ii. commonsense models of illness, which may lead to reporting only what they believe is important iii. emphasizing or downplaying symptoms believed to signs of serious illness iv. limited grammar (if young) or different primary language from physician 4. Ways to improve communication a. interview training programs for physicians b. symptom checklists/questionnaires before doctor visits 5. Low follow-up feedback to physician can lead to assumptions that diagnosis was correct, treatment effective, and regimen completed as designed V. Compliance: Adhering to Medical Advice A. Section Introduction 1. Adherence and compliance a. definition: degree to which patients carry out prescribed treatments and behaviors. b. “adherence” is considered more satisfactory term since  ‘compliance” suggests a reluctant response to an authoritarian command B. Extent of the Nonadherence Problem 1. Difficulty with assessing rates of nonadherence a. failures to adhere occur for different types of medical advice b. advice may be violated in many different ways c. problems with how to assess nonadherence 2. Methods of assessing adherence a. physician estimates of adherence i. problem - practitioners don’t really know if patient is adhering; tend to overestimate compliance. b. patient self-report i. problem - patients tend overreport adherence due to lying or wishful thinking. ii. could be supplemented with verifying reports from family or objective methods. - pill or quantity accounting. - medication-recording dispensers. - biochemical tests. 3. Adherence rate to medical advice is roughly 40% and 60% overall a. varies with type of medical advice, duration of regimen, and purpose of treatment. b. adherence rates may overestimate due to motivation of people who agree to participate in studies and measurement insensitivity to forms of nonadherence. C. Why Patients Do and Do Not Adhere to Medical Advice 1. Section Introduction a. degree of adherence affected by: i. characteristics of the illness or regimen ii. characteristics of the person iii. characteristics of the patient/physician interaction 2. Medical regimens and illness characteristics a. Factors that contribute to lower adherence rates i. attempts to change long-standing personal habits ii. complex regimen with complicated tasks iii. long-term regimen iv. unaffordable or too expensive costs v. noticeable or worrisome side effects of treatment vi. low perception of the seriousness of illness by the patient 3. Age, gender, and sociocultural factors a. combination (i.e., interaction) of personal and demographic characteristics are associated with adherence b. patient age affects adherence, depending on type of illness c. adolescents less likely than others to comply with long-term treatments that single them out d. vision, hearing, and cognitive impairments in elderly may contribute to noncompliance. d. gender-influenced appearance concerns and cultural beliefs regarding "cure" may lead to nonadherence  4. Psychosocial aspects of the patient a. personal beliefs outlined in health belief model i. threatened person who believes benefits of regimen outweighs costs is more likely to be adherent b. rational nonadherence i. noncompliance that is deliberate and based on valid reasons - believing the medication isn't working - finding side effects to be troublesome - confusion about regimen - lack of money to engage in regimen - testing for recurring presence of illness c. cognitive and emotional factors i. information contained in Table 9.2 - patients forget most of what doctor tells them, but instructions/advice are forgotten more than other information - more information patient is told, more patient forgets - patients remember: what told first; what they consider important - intelligence and age of patient doesn’t influence how much they remember - moderate anxiety is related to best recall - more medical knowledge related to better recall d. self-efficacy beliefs and social support (either family, friends, or self-help) influences adherence D. Patient/Practitioner Interactions 1. Svarstad's findings regarding adherence to treatment regimen a. patients' knowledge about their treatment is often incomplete b. physicians often do not provide detailed information c. patients ask few questions d. more explicit directions resulted in higher compliance 2. Adherence and the patient/practitioner relationship a. patients of patient-centered physicians are more likely to adhere to advice. i. patients' satisfaction with physician behavioral style is related to higher compliance. E. Increasing Patient Adherence 1. Noncompliance and health outcomes a. hospital admissions higher for people who don’t follow regimen i. examples: higher mortality rates due to arrhythmia and kidney disease and HIV rebound. b. noncompliance is not always detrimental i. impact of noncompliance is greater for serious illness than less serious conditions ii. some treatments may result in iatrogenic conditions ii. some doctors may prescribe unnecessary medications c. compliance cut-off point for illnesses need to be established  as perfect adherence may not be necessary 2. Improving physicians' communication skills a. first step to correcting nonadherence may be to thoroughly explain and repeat instructions regarding regimen b. teaching physicians about the problems associated with adhering a regimen may result in more time spent on giving information to patients 3. Methods for presenting medical information a. simplifying verbal instructions by using clear language b. using specific and concrete statements c. breaking down complicated or long-term regimen into smaller segments d. emphasizing key information e. using simple, written instructions f. having patients repeat instructions 4. Improving psychosocial factors in patients a. one effective approach may be to have patient state explicitly that he or she will comply to regimen. b. for long-term or lifestyle change regimen, recruiting family or group support systems can provide instrumental and emotional support. c. behavioral methods used to promote adherence i. tailoring the regimen to be compatible to patient's habits and rituals ii. providing prompts and reminders iii. self-monitoring iv. behavioral contracting d. Advantages of behavioral methods i. active involvement of patient in design and execution of regimen ii. regimen carried be self-administered VI. Focusing on Prevention A. Section Introduction 1. Chronic care model a. current approach used in health care systems that focus on secondary and tertiary prevention b. application of chronic care model may be possible for primary prevention programs i. six features of chronic care model that need to be incorporated: - organization of care: explicit, obvious priority given to primary prevention - clinical information systems: data regarding need for preventive services in files - delivery-system design: prevention interventions designed by physicians and carried out by nonphysicians - decision support: guidelines, training, reminders to staff to identify patients who need prevention interventions - self-management support: information and referrals to clients and families - community resources: extend prevention to community self-help programs