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Journal ArticleDOI

Primary Care for Elderly People Why Do Doctors Find It So Hard

01 Dec 2002-Gerontologist (Oxford University Press)-Vol. 42, Iss: 6, pp 835-842
TL;DR: Much of the difficulty participants experienced could be facilitated by changes in the health care delivery system and in medical education, and the voices of these physicians and the model resulting from the analysis can inform change.
Abstract: Purpose: Many primary care physicians find caring for elderly patients difficult. The goal of this study was to develop a detailed understanding of why physicians find primary care with elderly patients difficult. Design and Methods: We conducted in-depth interviews with 20 primary care physicians. Using an iterative approach based on grounded theory techniques, a multidisciplinary team analyzed the content of the interviews and developed a conceptual model of the difficulty. Results: Three major domains of difficulty emerged: (i) medical complexity and chronicity, (ii) personal and interpersonal challenges, and (iii) administrative burden. The greatest challenge occurred when difficulty in more than one area was present. Contextual conditions, such as the practice environment and the physician’s training and personal values, shaped the experience of providing care and how difficult it seemed. Implications: Much of the difficulty participants experienced could be facilitated by changes in the health care delivery system and in medical education. The voices of these physicians and the model resulting from our analysis can inform such change.

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Citations
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Journal ArticleDOI
TL;DR: Physicians describe the complexity of decision making for older adult patients, and how this is influenced by a diverse range of factors, yet ultimately simplify the process by defaulting to number-based (age in years) guidelines and procedures.
Abstract: Older patients are major users of pharmacotherapy due to a higher incidence of health issues. However, there is evidence of age-biased prescribing, leading to over- or underprescribing of medication, and suboptimal clinical outcomes. Although many guidelines provide cautionary statements about the use of medicines in older patients, they fail to identify what this means in practice. There is no accepted definition of an older adult that appropriately characterises this patient group. As a result, there is potential for physicians to have variable interpretations of individuals within this patient population, leading to potential inconsistencies when making pharmacotherapeutic decisions. The aim of this study was to explore how Australian medical physicians practically defined an older adult patient in the context of providing pharmacotherapeutic care to this population. This was a two-stage study comprising a scenario-based questionnaire (quantitative phase) and semi-structured individual interviews (qualitative phase) with Australian physicians. Qualitative data was thematically analysed and manual inductive coding was used to generate core themes. A total of 15 physicians participated in the study. Overall, in regard to providing care to their older patients, the three key themes that emerged from physicians’ discussions were (1) using a number-based versus health status-based definition of an older patient; (2) patient ‘red flags’ influence prescribing decisions; and (3) lack of guideline support in prescribing for older patients. Most physicians ultimately defined older adult patients using a number-based description (i.e. age between 65 and 90 years) because they felt they needed some sort of ‘cut-off’ point to guide their decision making. However, in assessing an older patient, physicians considered a multitude of patient factors as influencers of their decision making during prescribing, including comorbidities, cognitive function, frailty, polypharmacy, etc., and did not solely focus on the patient’s age. Physicians describe the complexity of decision making for older adult patients, and how this is influenced by a diverse range of factors, yet ultimately simplify the process by defaulting to number-based (age in years) guidelines and procedures.

1 citations

01 May 2020
TL;DR: The AASD was piloted at the University of New South Wales (UNSW) (n=140, response rate 77%). Removal of a redundant item pair resulted in a 19-item instrument (Cronbach's α = 0.84).
Abstract: Attitudes of Australian medical students towards older people are important, as they can influence clinical practice. Initially I aimed to measure student attitude change after curriculum innovation. Literature review of Australian medical student attitudes revealed a gap for a valid, contemporary measure, inspiring the AASD. Review of international measures of student attitude identified semantic differential as the preferred instrument-type. A qualitative study of 151 medical students at the Universities of Wollongong (UOW) and Sydney (USYD) produced opposite word pairs for the AASD. The AASD was piloted at the University of New South Wales (UNSW), (n=140, response rate 77%). Removal of a redundant item pair resulted in a 19-item instrument (Cronbach’s α = 0.84). An AASD survey of New South Wales (NSW) medical students (n=321, response rate 72.6%) at UNSW, USYD, and UOW revealed: 1) A four-factor solution on exploratory factor analysis (Instrumentality (I), Personal Appeal (PA), Experience (E) and Sociability (S)), 2) No sequencing bias, 3) Cronbach’s α = 0.86, and 4) A positive mean AASD score (73.2/114), positive mean scores for three factors (PA, E and S) and negative mean I score. Female students had a significantly higher mean E score. Confirmatory factor analysis (CFA) demonstrated adequacy of fit for AASD survey data from outside NSW to our four-factor model. Melbourne University, University of Western Australia and University of Adelaide students (n=188, response rate 79%) had a mean AASD score (72.8/114) comparable to NSW data.

1 citations

Book ChapterDOI
01 Jan 2007
TL;DR: The demographic data that support the development of complex case management models will be described and some of the key elements that are integral to the provision of case management to elderly patients at the end-of-life are described.
Abstract: The number of chronically ill and disabled elderly people with complex medical, psychosocial and financial needs is rapidly growing The elderly population has been steadily increasing in the United States due to the efforts of modern medicine and disease prevention techniques The elderly will now live for three to six years prior to death with increasing levels of disability (Fried, 2002) The US health-service was designed several decades ago when life expectancy was shorter and the duration of disability before death was brief Its emphasis on curative and disease focused interventions is poorly aligned with the complex healthcare needs of the elderly and their caregivers Shorter lengths of stay in acute care hospitals and limitations in eligibility to even the most basic levels of homecare render frail elderly patients more susceptible to the complications of multiple competing chronic illnesses Increased disability, poly-pharmacy, strained resources and caregiver systems, limited knowledge and precarious decisional capacity are complications not addressed by traditional models of health-service, thus resulting in episodic, unplanned delivery of service and preventable hospitalizations with a focus on individual diagnoses In order that elderly patients may be better served, complex case management models will need to be integrated into primary care delivery and specialty palliative care programs across multiple healthcare settings In this chapter we will describe the demographic data that support the development of such models and some of the key elements that are integral to the provision of case management to elderly patients at the end-of-life

1 citations

Book ChapterDOI
01 Jan 2018
TL;DR: The need to prevent disability and functional decline in later life is growing as the population ages, multi-morbidity increases and healthcare resources are placed under ever-greater strain.
Abstract: The need to prevent disability and functional decline in later life is growing as the population ages, multi-morbidity increases and healthcare resources are placed under ever-greater strain.

1 citations

Journal Article
Henry Yu-Hin Siu1
TL;DR: Notre population vieillit, les personnes de plus de 65 ans aura double d’ici a 2036, pour atteindre 10,4 millions environnementalment.
Abstract: Notre population vieillit. Selon de recentes previsions tirees du recensement, la population d’aines de plus de 65 ans aura double d’ici a 2036, pour atteindre 10,4 millions[1][1]. Consequemment, la population d’aines fragiles, definie comme les personnes de plus de 65 ans qui de
References
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Journal ArticleDOI
TL;DR: The Nature of Qualitative Inquiry Theoretical Orientations Particularly Appropriate Qualitative Applications as mentioned in this paper, and Qualitative Interviewing: Qualitative Analysis and Interpretation Enhancing the quality and credibility of qualitative analysis and interpretation.
Abstract: PART ONE: CONCEPTUAL ISSUES IN THE USE OF QUALITATIVE METHODS The Nature of Qualitative Inquiry Strategic Themes in Qualitative Methods Variety in Qualitative Inquiry Theoretical Orientations Particularly Appropriate Qualitative Applications PART TWO: QUALITATIVE DESIGNS AND DATA COLLECTION Designing Qualitative Studies Fieldwork Strategies and Observation Methods Qualitative Interviewing PART THREE: ANALYSIS, INTERPRETATION, AND REPORTING Qualitative Analysis and Interpretation Enhancing the Quality and Credibility of Qualitative Analysis

31,305 citations

Journal ArticleDOI
TL;DR: In this article, the authors discuss the uses of literature and open coding techniques for enhancing theoretical sensitivity of theoretical studies, and give guidelines for judging a grounded theory study.
Abstract: Introduction Getting Started Theoretical Sensitivity The Uses of Literature Open Coding Techniques for Enhancing Theoretical Sensitivity Axial Coding Selective Coding Process The Conditional Matrix Theoretical Sampling Memos and Diagrams Writing Theses and Monographs, and Giving Talks about Your Research Criteria for Judging a Grounded Theory Study

28,999 citations

Journal Article
TL;DR: The Nature of Qualitative Inquiry Theoretical Orientations Particularly Appropriate Qualitative Applications as mentioned in this paper, and Qualitative Interviewing: Qualitative Analysis and Interpretation Enhancing the quality and credibility of qualitative analysis and interpretation.

22,714 citations

Journal ArticleDOI
TL;DR: The challenge is to organize these components into an integrated system of chronic illness care, which can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care.
Abstract: Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.

2,805 citations


"Primary Care for Elderly People Why..." refers background in this paper

  • ...In the area of practice organization, a number of interventions to facilitate primary care of chronically ill elders have been proposed and a few have been studied (Boult, Boult, Morishita, Smith, & Kane, 1998; Leveille et al., 1998; Schraeder, Shelton, & Sager, 2001; Netting & Williams, 2000; Wagner et al., 1996)....

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