Meeting patient expectations of care: the major determinant of satisfaction with out-of-hours primary medical care?

BACKGROUND: Client or consumer expectation is considered to influence their satisfaction with the service provided, but its importance has not been quantified in health care. OBJECTIVE: The aim of this study was to determine the effect of "patient expectations of care" on satisfaction with care provided by out-of-hours services. METHODS: We surveyed 3457 patients who requested out-of-hours care from five practices, two general practice out-of-hours co-operatives and a deputizing service in an English health authority during late 1997. The independent variables were: the service providing the care (service type), where out-of-hours care was given (location of care) and whether the care met the patient's expectations. The independent variable was overall patient satisfaction with out-of-hours care. RESULTS: Patients who received the care they hoped for (their idealized expectation was met) were more satisfied than those who did not. Patients who attended centres were more satisfied with the care received than those who had had home visits. Patients were more satisfied if they received care from the co-operative which did not employ assistants than from the deputizing service. Idealized expectation (care which was hoped for) match, location of care and service type explained 34, 2 and 4% of the variance, respectively. Age, sex, ethnicity, access to a car, normative/comparative expectation (care which was expected) and whether patients expected and received telephone advice, a home visit or domiciliary care, and the delay between request for care and care provision were not independently associated with satisfaction. CONCLUSIONS: Meeting or failing to meet the care patients hoped for is an important predictor of patient satisfaction with out-of-hours care. Purchasers and providers of out-of-hours care should consider whether and how patient expectation of service can be managed. This may reduce patient dissatisfaction with the service they provide. These findings also have important implications for the design of studies which use patient satisfaction as an outcome variable.

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. I: The process of care.

OBJECTIVE: To compare the process of out of hours care provided by general practitioners from patients' own practices and by commercial deputising services. DESIGN: Randomised controlled trial. SETTING: Four urban areas in Manchester, Salford, Stockport, and Leicester. SUBJECTS: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals) who responded to those requests. MAIN OUTCOME MEASURES: Response to call, time to visit, prescribing, and hospital admissions. RESULTS: 1046 calls were dealt with by practice doctors and 1106 by deputising doctors. Practice doctors were more likely to give telephone advice (20.2% v 0.72% of calls) and to visit more quickly than deputising doctors (median delay 35 minutes v 52 minutes). Practice doctors were less likely than deputising doctors to issue a prescription (56.1% v 63.2% of patients) or to prescribe an antibiotic (43.7% v 61.3% of prescriptions issued) and more likely to prescribe genetic drugs (58.4% v 32.1% of drugs prescribed), cheaper drugs (mean cost per prescription pounds 3.28 v pounds 5.04), and drugs in a predefined out of hours formulary (49.8% v 41.1% of drugs prescribed). There was no significant difference in the number of hospital admissions. CONCLUSIONS: By contrast with practice doctors, deputising doctors providing out of hours care less readily give telephone advice, take longer to visit at home, and have patterns of prescribing that may be less discriminating.

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. II: The outcome of care.

OBJECTIVE: To compare the outcome of out of hours care given by general practitioners from patients' own practices and by commercial deputising services. DESIGN: Randomised controlled trial. SETTING: Four urban areas in Manchester, Salford, Stockport, and Leicester. SUBJECTS: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals in general practice) who responded to the requests. MAIN OUTCOME MEASURES: Health status outcome, patient satisfaction, and subsequent health service use. RESULTS: Patients seen by deputising doctors were less satisfied with the care they received. The mean overall satisfaction score for practice doctors was 70.7 (95% confidence interval 68.1 to 73.2) and for deputising doctors 61.8 (59.9 to 63.7). The greatest difference in satisfaction was with the delay in visiting. There were no differences in the change in health or overall health status measured 24 to 120 hours after the out of hours call or subsequent use of the health service in the two groups. CONCLUSIONS: Patients are more satisfied with the out of hours care provided by practice doctors than that provided by deputising doctors. Organisation of doctors into large groups may produce lower levels of patient satisfaction, especially when associated with increased delays in the time taken to visit. There seem to be no appreciable differences in health outcome between the two types of service.

Gravity-regulated formation of the peg in developing cucumber seedlings.

It has been proposed that peg formation in the vascular transition region (TR zone) between the hypocotyl and the root in Cucurbitaceae seedlings is a gravimorphogenetic phenomenon. Initiation of the peg became visible 36 h after imbibition when cucumber (Cucumis sativus L. cv. Burpee Hybrid II) seeds were germinated in a horizontal position at 24 degrees C in the dark. Simultaneously, sedimented amyloplasts (putative statoliths) were apparent in the sheath cells surrounding the vascular strands, and in the cortical cells immediately adjacent to them, in the TR zone. In contrast, the other cortical cells, some of which were destined to develop into the peg, contained amyloplasts which were not sedimented. These results suggest that the graviperception mechanism for peg formation may be like that of statoliths in shoot gravitropism. By 48 h following imbibition, the cells of the TR zone still had sedimented amyloplasts but had lost their sensitivity to gravity, possibly because of their maturation.

Intensity of hydrostimulation for the induction of root hydrotropism and its sensing by the root cap.

Roots of Pisum sativum L. and Zea mays L. were exposed to different moisture gradients established by placing both wet cheesecloth (hydrostimulant) and saturated aqueous solutions of various salts in a closed chamber. Atmospheric conditions with different relative humidity (RH) in a range between 98 and 86% RH were obtained at root level, 2 to 3mm from the water-saturated hydrostimulant. Roots of Silver Queen corn placed vertically with the tips down curved sideways toward the hydrostimulant in response to approximately 94% RH but did not respond positively to RH higher than approximately 95%. The positive hydrotropic response increased linearly as RH was lowered from 95 to 90%. A maximum response was observed at RH between 90 and 86%. However, RH required for the induction of hydrotropism as well as the responsiveness differed among plant species used; gravitropically sensitive roots appeared to require a somewhat greater moisture gradient for the induction of hydrotropism. Decapped roots of corn failed to curve hydrotropically, suggesting the root cap as a major site of hydrosensing.

Indirect discrimination and breast screening.

Uptake of screening services in inner-city communities has been low, particularly in older age groups, lower social classes, and ethnic minorities. In Leicester City, where up to 25% of the population belong to ethnic minorities, this may have important implications for breast screening. We randomly sampled 701 inner-city women aged 45 to 64 years, stratified by neighborhood and by women's "likely home language." Trained interviewers succeeded in interviewing 79% of those eligible, and we report here a preliminary analysis of 413 respondents. Knowledge of breast cancer and screening varied markedly and significantly by actual language: 60.4% of English-speaking and 12.5% of non-English-speaking women correctly answered 10 or more questions (of 14) about breast cancer and screening (chi 2(1) = 89.884; P = .000). Despite that, 80% or more women stated their intention to attend for screening and assessment if necessary, irrespective of neighborhood, language, age, or social class. We suggest that the difference in knowledge between language groups arose from indirect discrimination in the way in which health-related information is disseminated in British society. However, after providing appropriate screening information, we report similarly high intended acceptance rates in the two language groups.

Hydrotropism in pea roots in a porous-tube water delivery system.

Orientation of root growth on earth and under microgravity conditions can possibly be controlled by hydrotropism--growth toward a moisture source in the absence of or reduced gravitropism. A porous-tube water delivery system being used for plant growth studies is appropriate for testing this hypothesis since roots can be grown aeroponically in this system. When the roots of the agravitropic mutant pea ageotropum (Pisum sativum L.) were placed vertically in air of 91% relative humidity and 2 to 3 mm from the water-saturated porous tube placed horizontally, the roots responded hydrotropically and grew in a continuous arch along the circular surface of the tube. By contrast, normal gravitropic roots of Alaska' pea initially showed a slight transient curvature toward the tube and then resumed vertical downward growth due to gravitropism. Thus, in microgravity, normal gravitropic roots could respond to a moisture gradient as strongly as the agravitropic roots used in this study. Hydrotropism should be considered a significant factor responsible for orientation of root growth in microgravity.

Stimulation of root elongation and curvature by calcium.

Ca2+ has been proposed to mediate inhibition of root elongation. However, exogenous Ca2+ at 10 or 20 millimolar, applied directly to the root cap, significantly stimulated root elongation in pea (Pisum sativum L.) and corn (Zea mays L.) seedlings. Furthermore, Ca2+ at 1 to 20 millimolar, applied unilaterally to the caps of Alaska pea roots, caused root curvature away from the Ca2+ source, which was caused by an acceleration of elongation growth on the convex side (Ca2+ side) of the roots. Roots of an agravitropic pea mutant, ageotropum, responded to a greater extent. Roots of Merit and Silver Queen corn also responded to Ca2+ in similar ways but required a higher Ca2+ concentration than that of pea roots. Roots of all other cultivars tested (additional four cultivars of pea and one of corn) curved away from the unilateral Ca2+ source as well. The Ca(2+)-stimulated curvature was substantially enhanced by light. A Ca2+ ionophore, A23187, at 20 micromolar or abscisic acid at 0.1 to 100 micromolar partially substituted for the light effect and enhanced the Ca(2+)-stimulated curvature in the dark. Unilateral application of Ca2+ to the elongation zone of intact roots or to the cut end of detipped roots caused either no curvature or very slight curvature toward the Ca2+. Thus, Ca2+ action on root elongation differs depending on its site of application. The stimulatory action of Ca2+ may involve an elevation of cytoplasmic Ca2+ in root cap cells and may partipate in root tropisms.

Hydrotropism and its interaction with gravitropism in maize roots.

We have partially characterized root hydrotropism and its interaction with gravitropism in maize (Zea mays L.). Roots of Golden Cross Bantam 70, which require light for orthogravitropism, showed positive hydrotropism; bending upward when placed horizontally below a hydrostimulant (moist cheesecloth) in 85% relative humidity (RH) and in total darkness. However, the light-exposed roots of Golden Cross Bantam 70 or roots of a normal maize cultivar, Burpee Snow Cross, showed positive gravitropism under the same conditions; bending downward when placed horizontally below the hydrostimulant in 85% RH. Light-exposed roots of Golden Cross Bantam 70 placed at 70 degrees below the horizontal plane responded positively hydrotropically, but gravitropism overcame the hydrotropism when the roots were placed at 45 degrees below the horizontal. Roots placed vertically with the tip down in 85% RH bent to the side toward the hydrostimulant in both cultivars, and light conditions did not affect the response. Such vertical roots did not respond when the humidity was maintained near saturation. These results suggest that hydrotropic and gravitropic responses interact with one another depending on the intensity of one or both factors. Removal of the approximately 1.5 millimeter root tip blocked both hydrotropic and gravitropic responses in the two cultivars. However, removal of visible root tip mucilage did not affect hydrotropism or gravitropism in either cultivar.

Phytochrome-mediated swelling of etiolated leaf protoplasts and its possible biological significance.

Red light, mediated by the photoreceptor phytochrome, induces maize leaf unrolling as well as leaf expansion. Protoplasts prepared from maize leaves still in the rolled condition swell in a red-far red photoreversible manner indicating that phytochrome mediates this phenomenon. To determine if protoplast swelling is related to leaf unrolling, leaf expansion, or both, we compared red-light induced swelling of protoplasts from rolled maize leaves to protoplasts prepared from tissues that are known to grow in response to light but do not unroll. We also compared the swelling response of protoplasts from rolled vs. unrolled leaves. In all cases, we found that swelling correlated with the unrolling response and not leaf expansion.

Inhibition of Acid-Enhanced Elongation of Zea mays Root Segments by Galactose.

The effect of sugars and metabolic inhibitors on the elongation of Zea mays root segments was analyzed by a rhizometer which records the elongation of each of 32 root segments at the same time. Galactose suppressed the acid-enhanced rapid elongation after a lag period of 1.5 hours, but it did not inhibit the slow elongation at pH 7. Mannose was less inhibitory than galactose. Arabinose, xylose, glucose, sucrose, mannitol, and sorbitol caused no inhibition. When galactose was removed after a 1-hour treatment, the elongation was partially recovered. Cycloheximide and 2-deoxyglucose suppressed acid-enhanced elongation when these were applied at the same time as acid treatments, whereas cordycepin (3'-deoxyadenosine) inhibited elongation only if it was applied prior to acid treatment. Over the 9-hour period of elongation studied, the inhibition by galactose was comparable to that of cycloheximide. Since galactose has been reported to suppress the sugar metabolism necessary for the cell wall synthesis, the later phase of acid-enhanced elongation of root segments may at least partially depend on the synthesis or metabolism of cell wall components. The inhibition of root growth by galactose may be partially ascribed to a direct effect on the elongation process in roots, an effect that is enhanced by the acidification of the cell walls.

Rapid Effects of IAA on Cell Surface Proteins from Intact Carrot Suspension Culture Cells.

Suspension cultures of carrot (Daucus carrota L.) which had an absolute requirement for exogenously supplied auxin were grown in medium containing indoleacetic acid (IAA) as the sole auxin source. Putative cell surface proteins were extracted from the intact cells. Resupply of IAA to cultures partially depleted of auxin resulted in rapidly increased activities of three enzyme activities subsequently extracted. Two of the enzyme activities which increased, peroxidase and pectinesterase, have been implicated in the literature as important to cell wall development, structure, and growth. The other enzyme activity which was increased, IAA oxidase, may be involved in the degradation of IAA In vivo. Polypeptides in the extracts were found to increase equally as rapidly as the enzymes in response to IAA as determined with sodium dodecyl sulfate-polyacrylamide electrophoretic gels stained with silver. It is not known whether the changes in enzyme and polypeptide levels in the protein extracts were due to auxin effects on protein synthesis, transport, or extractability.

Proton Flux and Elongation in Primary Roots of Barley (Hordeum vulgare L.).

The elongation zone of the primary root of barley (Hordeum vulgare L.) has been reported to be markedly basic in pH, in apparent contradiction of the acid-growth theory. We determined simultaneously the location of the elongation zone and the basic zone in these roots and found them indeed to be the same. However, sections of barley root elongation zones were found to respond to acidic, basic, and neutral solutions as predicted by the acid-growth theory.

Transfer ribonucleic Acid modification and its relationship to tumorous and nontumorous plant growth.

Detailed analyses of tRNA hydrolysates from four tissue types of Nicotiana tabacum, pith from intact plants, pith growing in culture, habituated tissue in culture, and crown gall tumor tissue in culture, revealed significant qualitative and quantitative differences in the pattern of methylation. Although pith from intact plants and pith growing in culture possessed seven different methylated nucleosides, only two were found in habituated and tumorous tissues in culture. Four of the five compounds accounting for the difference were tentatively identified as methylated guanosines. Evaluation of results in terms of several parameters, including growth rate, the tumorous state, habituation, tissue culture, and potential for differentiation, indicate that the extent of tRNA methylation may be correlated with the potential for differentiation of a particular tissue.

Rapid-growth responses of corn root segments: Effect of auxin on elongation.

The effect of indole-3-acetic acid (IAA) on the elongation rates of 2 mm corn (Zea mays L.) root segments induced by citrate-phosphate buffer (or unbuffered) solutions of pH 4.0 and 7.0 was studied. At pH 7.0, auxin initially reduced the elongation rate in both buffered and unbuffered solutions. Only in buffer at pH 7.0 was auxin at a concentration of 0.1 µM found to promote the elongation rate though briefly. THis promoted rate represented only ca. 20% of the rate achieved with only buffer at pH 4.0. Auxin in pH 4.0 buffered and unbuffered solutions only served to reduce the elongation rates of root segments. Some comparative experiments were done using 2 mm corn coleoptile segments. Auxin (pH 6.8) promoted the elongation rate of coleoptile segments to a level equal or greater than the maximal H ion-induced rate. The two responses of root segments to auxin are compared to auxin action in coleoptile growth.

Cellulosic microfibrils: nascent stages of synthesis in a higher plant cell.

Freeze-fracturing of untreated plasma membrane and inner wall surfaces of stelar tissue in corn roots demonstrated the association of globular complexes with the ends of nascent microfibrils. It is proposed that the granule complexes associated with the outer leaflet of the plasma membrane coordinate the assembly of the cellulosic microfibrils.

Rapid-growth responses of corn root segments: Effect of citrate-phosphate buffer on elongation.

The effects of citrate-phosphate buffer on the elongation rate of 2 mm root segments of Zea mays L. was investigated under O2 and N2 conditions by comparing with the effects in non-buffered solution. The buffer at pH 7.0 has an inhibiting effect on the elongation rate of root segments. At pH 4.0 the buffer has a promoting effect on the elongation rate twice that of the H-ion concentration. Nitrogen experiments indicate that growth in neutral buffer is O2 dependent. On the other hand the acid-growth response of root segments in citrate-phosphate buffer appears to have two components, 1) a H-ion component which is partially inhibited by N2 and fluoride and 2) a citrate component which is inhibited in part by N2 but not by fluoride.

Rapid growth responses of corn root segments: Effect of pH on elongation.

The effect of pH on the elongation rate of 2-mm-long subapical segments from corn roots (Zea mays L.) was investigated under aerobic (O2) and anaerobic (N2) conditions using a specially designed apparatus. The maximum elongation rate was obtained with a citrate-phosphate buffered solution of pH 3.4 or a non-buffered solution of pH 3.2. Acid stimulation of the elongation rate occurred in the zone of maximum elongation in the root, the 3 mm region 1 mm behind the apex. The acid response can be rapidly and repeatedly reinitiated by alternating between pH 4.0 and 7.0 media. Low pH can increase the elongation rate under N2 conditions, but the response is only ca. 50% that of the increase observed under O2 conditions. Reinitiation of the acid response does not occur when solutions are gassed with N2. The data suggest that the response of root segments to H ions is similar to that reported in the literature for shoot tissue. However, the magnitude of the root response is much higher than that of shoot tissue. Also, there is evidence that some aspects of the mode of action of H ions on wall loosening in root tissue may differ from that in shoot tissue. Corn root segments, though lacking a cuticle, do not respond to low pH in the manner reported for peeled stem tissue, the cuticle and epidermis of which have been removed. For these reasons rapid-growth responses of roots and shoots may not be strictly comparable.