Experiences of food access in hospital. A new questionnaire measure.

BACKGROUND & AIMS: People in hospital experience problems gaining access to food. We aimed to develop an experience-based measure of access to food. METHODS: The 27-item questionnaire has five domains: feeling hungry, physical barriers, organisational barriers, food choice and food quality. A survey was implemented on 29 wards in four hospitals using both self-completion and interview administration formats. RESULTS: Questionnaires were analysed for 764/1154 (66%) eligible participants. Values for Cronbach's alpha were: feeling hungry 0.886; physical barriers 0.809; organisational barriers 0.632; food choice 0.414; and food quality 0.738. The proportions of compromised patients in each domain were: hunger 30%; physical barriers 24%; organisational barriers 29%; food choice 24%; and food quality 21%. Poor self-rated health was associated with increased problems from feeling hungry (adjusted odds ratio 2.39, 95% confidence interval 1.10-5.18); older age was associated with increased difficulties with physical problems (2.67, 1.31-5.42) as were admission to a stroke ward (16.8, 5.09-55.3) or elderly care ward (3.50, 1.08-11.40). Problems with food access varied between hospitals and wards. CONCLUSIONS: We have developed a reliable and valid questionnaire measure of hospital food access. The measure reveals widespread problems of food access in hospital.

Hospital inpatients' experiences of access to food: a qualitative interview and observational study.

BACKGROUND: Hospital surveys indicate that overall patients are satisfied with hospital food. However undernutrition is common and associated with a number of negative clinical outcomes. There is little information regarding food access from the patients' perspective. PURPOSE: To examine in-patients' experiences of access to food in hospitals. METHODS: Qualitative semi-structured interviews with 48 patients from eight acute wards in two London teaching hospitals. Responses were coded and analysed thematically using NVivo. RESULTS: Most patients were satisfied with the quality of the meals, which met their expectations. Almost half of the patients reported feeling hungry during their stay and identified a variety of difficulties in accessing food. These were categorized as: organizational barriers (e.g. unsuitable serving times, menus not enabling informed decision about what food met their needs, inflexible ordering systems); physical barriers (not in a comfortable position to eat, food out of reach, utensils or packaging presenting difficulties for eating); and environmental factors (e.g. staff interrupting during mealtimes, disruptive and noisy behaviour of other patients, repetitive sounds or unpleasant smells). Surgical and elderly patients and those with physical disabilities experienced greatest difficulty accessing food, whereas younger patients were more concerned about choice, timing and the delivery of food. CONCLUSIONS: Hospital in-patients often experienced feeling hungry and having difficulty accessing food. These problems generally remain hidden because staff fail to notice and because patients are reluctant to request assistance.

Continuity of care and intermediate outcomes of type 2 diabetes mellitus.

BACKGROUND: The relevance of continuity of care in chronic illness is uncertain. OBJECTIVE: We evaluated whether experienced continuity of care for type 2 diabetes is associated with HbA1c, blood pressure or body weight. METHODS: Cohort study in 19 family practices in London, UK. Participants were 209 type 2 diabetic patients with 156 (75%) followed-up at 10 months. Main measures were experienced continuity of care (ECC) by patient questionnaire (mean score 62.1, SD 16.0), satisfaction with care, health-related quality of life [short-form 12 (SF-12)], HbA1c, blood pressure and body weight. Analyses were adjusted for baseline values, age, sex, ethnicity, duration of diabetes, diabetes treatment, education, housing tenure and whether living alone. RESULTS: Experienced continuity scores were obtained for 193 (92%) of participants at baseline and 156 (75%) at follow-up with no difference in outcome measures between those followed-up and those not. Subjects with the highest satisfaction ratings, compared with the lowest, had higher experienced continuity (difference in experienced continuity 7.87, 95% confidence interval 3.22-12.5, P = 0.001). ECC was not associated with HbA1c (adjusted difference per 10-unit increase in ECC score, -0.09%, -0.29 to 0.12%, P = 0.402), systolic blood pressure (-0.41, -2.88 to 2.06 mm Hg, P = 0.746), body mass index (-0.08, -0.34 to 0.18 kg/m(2), P = 0.562) or SF-12 physical component score (0.73, -0.88 to 2.35, P = 0.375). CONCLUSION: Experienced continuity of diabetes care is associated with greater patient satisfaction but not with improved intermediate outcomes during 10 months follow-up in this setting. Studies with more subjects will be required to determine whether continuity of care is associated with the frequency of adverse events.

Measuring continuity of care in diabetes mellitus: an experience-based measure.

PURPOSE: Continuity is an important attribute of health care, but appropriate measures are not currently available. We developed an experience-based measure of continuity of care in type 2 diabetes. METHODS: A 19-item measure of experienced continuity of care for diabetes mellitus (ECC-DM) was developed from qualitative patient interview data with 4 continuity subdomains: longitudinal, flexible, relational, and team and cross-boundary continuity. The measure was implemented in a survey of 193 patients with type 2 diabetes from 19 family practices. Associations of ECC-DM scores with clinician organizational characteristics were estimated. RESULTS: Potential ECC-DM scores ranged from 0 to 100 with an observed mean of 62.1 (SD 16.0). The average inter-item correlation was 0.343 and Cronbach's alpha was 0.908. Factor analysis found 4 factors that were generally consistent with the proposed subdomains. Patients' mean scores varied significantly between practices (P = .001), ranging from 46 to 78 at different family practices. Experienced continuity was lower for patients receiving only hospital clinic care than for those receiving some diabetes care from their family practice (difference 13.7; 95% confidence interval [CI], 8.2-19.2; P <.001). Patients had higher ECC-DM scores if their family practice had a designated lead doctor for diabetes (difference 8.2; 95% CI, 2.7-13.6; P = .003). CONCLUSIONS: The results provide evidence for the reliability, construct validity, and criterion validity of the experienced continuity-of-care measure. The measure may be used in research and monitoring to evaluate patient-centered outcomes of diabetes care. Patients' experiences of continuity of care vary between health care organizations and are influenced by the organizational arrangements for care.

What is 'continuity of care'?

Continuity of care is concerned with the quality of care over time. There are two important perspectives on this. Traditionally, continuity of care is idealized in the patient's experience of a 'continuous caring relationship' with an identified health care professional. For providers in vertically integrated systems of care, the contrasting ideal is the delivery of a 'seamless service' through integration, coordination and the sharing of information between different providers. As patients' health care needs can now only rarely be met by a single professional, multidimensional models of continuity have had to be developed to accommodate the possibility of achieving both ideals simultaneously. Continuity of care may, therefore, be viewed from the perspective of either patient or provider. Continuity in the experience of care relates conceptually to patients' satisfaction with both the interpersonal aspects of care and the coordination of that care. Experienced continuity may be valued in its own right. In contrast, continuity in the delivery of care cannot be evaluated solely through patients' experiences, and is related to important aspects of services such as 'case-management' and 'multidisciplinary team working'. From a provider perspective, the focus is on new models of service delivery and improved patient outcomes. A full consideration of continuity of care should therefore cover both of these distinct perspectives, exploring how these come together to enhance the patient-centredness of care.

Sharing specialist skills for diabetes in an inner city: a comparison of two primary care organisations over 4 years.

OBJECTIVE: To evaluate the effects of organizational change and sharing of specialist skills and information technology for diabetes in two primary care groups (PCGs) over 4 years. METHODS: In PCG-A, an intervention comprised dedicated specialist sessions in primary care, clinical guidelines, educational meetings for professionals and a shared diabetes electronic patient record (EPR). Comparison was made with the neighbouring PCG-B as control. In intervention and control PCGs, practice development work was undertaken for a new contract for family doctors. Data were collected for clinical measures, practice organizational characteristics and professional and patient views. RESULTS: Data were analysed for 26 general practices including 17 in PCG-A and nine in PCG-B. The median practice-specific proportions of patients with HbA1c recorded annually increased in both areas: PCG-A from median 65% to 77%, while PCG-B from 53% to 84%. For cholesterol recording, PCG-A increased from 50% to 76%, and PCG-B from 56% to 80%. Organizational changes in both PCGs included the establishment of recall systems, dedicated clinics and educational sessions for patients. In both PCGs, practices performing poorly at baseline showed the greatest improvements in organization and clinical practice. Primary care professionals' satisfaction with access and communication with diabetes specialist doctors and nurses increased, more so in the intervention PCG. Only 16% of primary care professional respondents used the diabetes EPR at least monthly. Patient satisfaction and knowledge did not change. CONCLUSIONS: Improvements in practices' organizational arrangements were associated with improvements in clinical care in both PCGs. Sharing specialist skills in one PCG was associated with increased professional satisfaction but no net improvement in clinical measures. A shared diabetes EPR is unlikely to be used, unless integrated with practice information systems.

Patients' perceptions and experiences of 'continuity of care' in diabetes.

BACKGROUND: 'Continuity of care' is an important aspect of quality. However, definitions are broad and existing models of continuity are not well grounded in empirical data. OBJECTIVE: To identify patients' experiences and values with respect to continuity in diabetes care. METHODS: In-depth semi-structured interviews with 25 type 2 diabetic patients from 14 general practices in two inner London boroughs. Interviews were transcribed and responses analysed thematically and grouped into dimensions of continuity of care. RESULTS: Patients' accounts identified aspects of care they valued that were consistent with four dimensions of experienced continuity of care. These were receiving regular reviews with clinical testing and provision of advice over time (longitudinal continuity); having a relationship with a usual care provider who knew and understood them, was concerned and interested, and took time to listen and explain (relational continuity); flexibility of service provision in response to changing needs or situations (flexible continuity); and consistency and co-ordination between different members of staff, and between hospital and general practice or community settings (team and cross-boundary continuity). Problems of a lack of experienced continuity mainly occurred at transitions between sites of care, between providers, or with major changes in patients' needs. CONCLUSIONS: The study develops a patient-based framework for assessing continuity of care in chronic disease management and identifies key transition points with problems of lack of continuity. It is important that service 'redesign' and developments in vertically integrated services for chronic disease management take account of impacts on patients' experience of continuity of care.