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2015. Volume 4. Issue 1. Article CID e0101 DOI: 10.15275/rusomj.2015.0101_
Health Service Organization
Original article Reprint
Quality of medical care for the elderly in out-patient conditions according to the sociological survey
Irina G. Novokreshchenova, Inga K. Senchenco
Saratov State Medical University n.a. V.I. Razumovsky, Saratov, Russia
Accepted 25 December 2014
Original Text © Novokreshchenova I.G., Senchenco I.K., 2014, published in Saratov Journal of Medical Scientific Research 2014; 10(1): 21-26.
Abstract: The process of aging is caused by the early development of chronic complications and diversity of morphological and functional changes of organs and systems. Therefore the provision of preventive and curative care of this category of citizens has significant clinical and organizational features. Aim — To identify the main problems of medical care for the elderly and to examine the medical care. Material and Methods — 250 physicians of various specialties of medical institutions of the Saratov region on health care of the elderly in out-patient clinics have been surveyed by specially designed questionnaires. The state of receiving care in out-patient clinics has been studied among the elderly and the senile patients (n=568) by questioning.
Results — The majority of physicians recognize the importance of the problem of increasing the quality of care for the elderly. The development of assistance of gerontological profile and the need for optimization of rendering out-patient care for this category of population in the central clinics and regional medical institutions.
Conclusion — The level of satisfaction of elderly patients depends on the age characteristics, gender, health and social status and the place of residence of the study group.
Keywords: elderly patients, senile patients, out-patient clinics, quality of medical care
Cite as Novokreshchenova IG, Senchenco IK. Quality of medical care for the elderly in out-patient conditions according to the sociological survey. Russian Open Medical Journal 2015; 4: e0101.
Correspondence to Inga K. Senchenco. Phone: +79376326306. E-mail: oob123@rambler.ru
Introduction
Worsening of health and reducing of a self-care capability at persons of elderly and old age cause certain problems of economical, medical, social character, solving of which involves considerable government investments, as well as physical, organizational and technical resources [1].
In the Policy of healthcare and medical science development in the Russian Federation there the major directions are determined. The chief goal: maintenance and improving of health by reducing the morbidity and mortality of the population. One of the problems of healthcare is a refinement and increase of the ability of medical care for persons of elderly and old age [2].
The development of the primary medical care of persons of elderly and old age is getting to be a significant question, as outpatient care should perform a heavy-duty service in medical care and rehabilitation of this category of the population [3]. Morbidity features and a high percent of medical aid appealability, caused by different medical and social needs of persons of elderly and old age, show the necessity of rational planning and effective system of medical service organization in order to increase the satisfaction of major needs of the socially significant category of citizens [4].
The study aimed to reveal the major problems of medical care for elderly people, and to study the satisfaction of persons of elderly and old age by medical service.
Material and Methods
By the use of a specially managed survey there were questioned 250 doctors of various medical and preventive treatment facilities of Saratov region (regional center - 56.8%, district centers - 43.2%) working in clinical outpatient departments (62.4%) and medical hospital organizations (37.6%). The questionnaire for doctors included 26 questions about problems of medical service for persons of elderly and old age, and as well, developing medical service in the current context.
The most part of the respondents were experienced specialists with long record of serving: more than 20 years (35.6%) and from 10 to 20 years (34.4%). 19.2% have been working for 5-10 years and less than 5 years have been serving 10.8% of the respondents. Most of them are women (86.3%) at the age of 41-50 years and 51-60 years - 33.7% and 24.6% respectively (Figure 1).
12.2 10.8 23-30 years
=31-40 years
18.7
41-50 years ■ 51-60 years «61 years and older
Figure 1. Classification of the doctors according to age categories
2015. Volume 4. Issue 1. Article CID e0101 DOI: 10.15275/rusomj.2015.0101_
Table 1. Estimation of the respondents' opinion about the significance degree of variously specialized doctors for the persons of elderly age
Specialists Total rank Medium rank (M±m) Final positions
Therapists 876 1.1±0.02 I
Cardiologists 978 1.7±0.08 II
Neurologists 1100 3.2±0.06 III
Ophthalmologists 1045 3.3±0.09 IV
Gerontologist 1374 4.1±0.09 V
Psychiatrist 1652 5.9±0.03 VI
Surgeons 1972 6.2±0.03 VII
Gastroenterologists 2036 6.6±0.08 VIII
Osteoporologists 2156 7.9±0.14 IX
The significant part of the specialists are highly-skilled professionals, they have the highest (38.8%), the I (35.6%), the II (17.2%) professional categories.
The survey of elderly persons was performed as a face-to-face poll using a specially managed standardized questionnaire including questions about medical service problems at elderly persons and their satisfaction by medical care. There had been questioned persons of elderly and old age (n=568) who had been getting outpatient medical care in regional (n=343) and district (n=225) centers. During the analyzing of the result the respondents were divided into 4 age categories: from 55 to 59 years (n=93), from 60 to 69 years (n=185), from 70 to 79 years (n=182), above 80 years (n=108), 62% of them were men, 38% -women. Determination of these categories was grounded on the fact of retirement of men and women at the age of 55 and 60 years, and as well, WHO classification of the age was the base: 6075 years - elderly age, 75-90 years - old age, over 90 years - long-living persons.
Results
Analysis of the specialists' opinion working in medical organizations for elderly and old age persons revealed major medico-social problems of qualified medical care for this category of people.
The persons older than a working age are in the main part of all patients: 41-60% (47.3%) and more than 60% (24.5%) of all appliances in outpatient organizations. According to the specialists' data this group of the population features a high frequency of appliances into outpatient facilities: 40.1% - monthly, 31.2% more than once per month, and 28.7% of the doctors pointed at 28.7% of the patients attended specialists every three months.
In the most of the cases (81.6%), in polyclinics as well in inpatient hospitals, independently on the location of the facility (in regional or district centers), there was a problem of the lack of the medical staff for the persons of elderly age. In only one medical facility - regional hospital of war veterans - due to an especial type of hospitalized people, there is a medical staff who are responsible for the medical service for the studied category of citizens.
The most part of the respondents (59.6%) mark the absence of continuity of special gerontological facilities in the service of elderly people. Only 4.8% of the doctors (all of them work in medical organizations of the regional center) are sure that there is no necessity to consult this category of people as a qualified medical care is performed. Other think that there is a necessity in professional medical advice - 34.4% (regional center 42.9%, district centers 23.1%), and there is no contact with these
organizations 20.4% (regional center 13.3%, district centers 29.6%). Although in 21.6% of cases respondents answered that specialists of gerontological center do consult patients and recommend hospitalization (regional center 32.3%, district centers 7.4%), and 19.2% of the doctors (regional center 29.6%, district centers 5.6%) keep contact with the patients and send the cases to gerontological medical and preventive facilities every month.
The necessity of an enhanced training and skills at communication with persons who elder than a working age was marked by 62.4% of the doctors and 36.1% of the respondents did not need an enhanced training. One of the most important reasons of the further training was the need of improving medical skills, as this category of the patients is characterized by high morbidity and mortality (37.3%), although there were psychological features of the given group of the population (25.4%). The answers for the question "Where persons of elderly ages should be followed up?" were different: 91.4% asked that they should attend polyclinics according to a residence, and only 8.6% of the respondents (all of them work in regional center facilities) chose specialized centers.
In the doctor's opinion, for the serving of persons of elderly age the higher need is in therapists (the I position), cardiologists (the II position) and neurologists (the III position). The role of gerontologists was on the V position in order of importance (Table 1).
The significant part of medical specialists consider that it is necessary to take part in medical serving of the given contingent (79.2%) (regional 85,2 % and district centers 71.3%, Student's t-test t=3.58). There are the following reasons of the necessity of gerontologist: elderly age claims a special attention (22.4%), there is a specific therapy and appropriate skills (21.4%), the major part of the patients need a psychological help and attendance (18.6%), there are many comorbidities which call for general knowledge (16.8%).
The major part of medical staff (70.8%) think that a psychologist is necessary at outpatient facilities, and there are different reasons for that: "this will help to establish a contact "doctor-patient" - 22.6%, "it is easier to reveal basic problems of the patients and preventive services will be developed" - 21.8%, "it will reduce the load of the specialists as many of the patients need just a psychological help" - 15.6%, "this will help in medico-social adaptation" - 10.8%. 29.2% of the respondents are sure that there is no need in psychologists (most of them are specialists at the age of 20-30 years and less than 5 years of serving) and specialists from hospitals (65.8%). There are the following reasons: "this is a relevant waste of money from budget in a healthcare system" - 21.5%, "there are special centers where psychologists consult people" - 7.7%.
The most part of the specialists are sure that persons of elderly age are partially (57.2% of the respondents) and totally (29.6%) satisfied with the quality of medical care. Only 13.2% of the respondents think that elderly patients are not satisfied with the quality of medical care, and these are doctors at the age of 51-60 years and with more than 20 years of serving.
The major factors determining the satisfaction with medical care of persons of elderly and old age, as the doctors say, are: quality of diagnostic research at a hospital and polyclinic (88.4%), preferential provision of medicines (64.8%), the results of appliance for medical care at polyclinic department (50.4%) (Figure 2).
2015. Volume 4. Issue 1. Article CID e0101 DOI: 10.15275/rusomj.2015.0101_
Table 2. The respondents' opinion about the importance of major medico-social measures for elderly patients
Basic medico-social measures for elderly patients Total rank Medium rank (M±SD) Final positions
Increasing of the quality of medical care 1026 1.6±0.4 I
Increase of the sums of money for retirement benefits 1350 2.4±0.6 II
Psychological help 1486 3.1±0.7 III
Increasing of preferential provision of medicines list 1564 4.7±1.1 IV
Establishing of medico-social services for elderly patients care 1650 4.9±1.2 V
Providing with prosthetic and orthopaedic appliances 1844 5.5±1.3 VI
Developing of medical care departments for elderly people 1976 5.7±1.4 VII
Table 3. The frequency of appliances for medical care at outpatient facilities according to the age_
Index of appliances frequency The frequency of appliances of the persons of elderly age depending on age group, %
55-59 years 60-69 years 70-79 years >80 years Total
Do not attend 38.2 11.3 4.4 3.6 10.8
Once a year 32.6 36.6 13.6 11.2 20.8
Once a half of a year 20.4 28.4 19.6 22.2 19.7
Once-twice per 3 months 2.6 6.1 23.8 29.4 26.1
Once or more per a month 6.2 17.6 38.6 33.6 22.6
Total 100 100 100 100 100
0 20 40 60 so 100
Figure 2. The doctors' opinion about the major factors influencing the satisfactory of elderly persons with the quality of medical service
Figure 3. Main pretensions of elderly persons to organization of medical care at preventive facilities
The number of common problems which specialists face at work, according to the respondents' opinion: lack of time to examine patients - 34.8% of the respondents, lack of money at patients to buy the prescribed effective drugs - 22.4%, necessity of filling many medical blanks and documents - 19.4%, noncompliance of the therapy - 13.4%, difficulties of the administration caused by poor material and technical basis and equipment deficiency of an outpatient facility - 5.2%.
Improving of the medical care for persons of elderly and old age, according to specialists' points of view, is the most important measure of medico-social service (Table 2).
As doctors-respondents consider, the facility medical administration should control medical care service for persons of elderly and old age (42.9%), a specially reserved specialist for a medical and preventive treatment facility (28.6%), social services (26.1%) and insurance companies (1.8%).
The patients of elderly and old age estimated medical service depending on age group and their medico-social status. Medico-social needs and attitude towards the medical service system are determined by the following factors: activity limitation caused by a functional loss or reduced working capacity, retirement, loneliness syndrome, social isolation.
The most part of the respondents (63.4%) live with their children, they are: persons above 70-79 years old (25.8%) and over 80 years (23.9%). It is need to be said that 21.7% of the respondents live with a husband or a wife or alone (in 14.9% of the cases), which is, probably, causes social vulnerability and medico-psychological problems connected with the feeling of isolation. There was the main part of nonworkers (73.3%) among the respondents, 55.6% - women and 17.7% - men. There were 3.3 times more of nonworking retired women then men. At self-estimation of income the most of the respondents said that they had a minimum wage (59.2%) or below subsistence line (30.5%), relatives help a half of them (52.1%). The smallest part of the respondents mark that their income is above subsistence line (10.3%).
Persons of elderly and old age, according to self-estimation, apply for medical care at outpatient facilities with the following frequency: once or twice per three months - 26.1%, once or more per a month - 22.6%, once a year - 20.8%, once a half of a year -19.7%, 10.7% do not attend medical facilities.
The frequency of the appliance for medical help of persons of elderly and old age changes with age. Persons at the age of 70-79 (38.6%) years apply for medical help once or more times per month, and respondents at the age of 55-59 years (38.2%) and 6069 years (11.3%) say that they do not attend outpatient facilities. The decrease of the appliance frequency at persons elder than 80 years old is connected with the prevalence of various types of medical services for the given category of citizens (Table 3).
2015. Volume 4. Issue 1. Article CID e0101 DOI: 10.15275/rusomj.2015.0101_
The main reasons because of which people of this age category apply for medical facilities are: the need in medical help resulting from acute exacerbation of a chronic disease - 47.2% (regional center 41.3%, district centers 52.8%); in order to treatment correcting and acute period prevention - 24.4% (29.9% regional center, 20.2% district centers); preferential provision of medicines - 16.2% (13.8% regional center, 19.4% district centers), planned dispensary observation - 7.6% (11.2% regional center, 9.6% district centers), 4.2% of the respondents confessed that they can discuss all essential health questions in polyclinics (100% regional center).
Common pretensions of persons of elderly and old age are about the organization of medical service (Figure 3): it is difficult to get an appointment to a specialized doctor (62.2%), a long time of waiting for seeing a doctor at polyclinics (44.2%), poor workmanship of registration and reception (32.6%).
The satisfaction in medical service of persons older than a working age is determined as low: according to a five-point grading scale, "fair" and "low grade" marks gave 43.6% and 9.8% of the patients respectively. Only 38.4% of the respondents gave "good" and "excellent" 8.2% marks.
52.5% those persons who gave an "excellent" mark were over 80 years. So, the high estimate is connected with reducing of medico-social pretensions and approval of their relatives living with the respondents. It had been revealed that the satisfaction level of the population of regional center was higher than in district centers: medical services estimations as "excellent" and "good" are in sum 29.0±2.7% and 17.2±2.5% respectively (Student's t-test t=2.29).
The most of the persons of elderly and old age need gerontologist's consultations which are confirmed by the analysis of the survey: 68.6% of the respondents realize the need in gerontologist at outpatient facilities (regional center 93.6%).
Persons of elderly and old age consider that a psychologist is also necessary (66.8% of the respondents, 79.6% in regional center and 45.7% — district centers), although the major part of the patients had not applied for medical help (98.4%), 1.6% of the patients applied for psychologist's help lived in regional center.
Establishing of specialized centers of medical service for elderly people is necessary, as 88.6% of the respondents consider, 60.2% among which are regional center residents. Basic reasons of establishing specialized centers of medical service for elderly people according to the respondents' points of view are: people can receive treatment in hospital (46.8%), getting attendance, medications and nutrition which elderly people need (37.4%), and staying under the care of specialists (13.2%). Only 2.6% of the respondents are sure that they can ask any specialists for medical care according to a residence, and there was no need to establish specialized medical centers for elderly people.
Persons of elderly age say that the following items of medical care should be improved: availability 49.6% (39.9% regional center, 64.0% district centers), effectiveness 18.6% (19.2% regional center, 17.7% district centers), competence and ethics of medical staff 13.8% (11.9% regional center, district centers 16.4%) and 13.6% (9.0% regional center, district centers 20.4%) respectively. And only 4.4% of the respondents emphasize that safety should be improved (6.4% regional center, 3.5% district centers).
As persons of elderly age consider, main factors influencing the quality of medical care are: the quality of diagnostic research
in outpatient department and polyclinic (68.8%), preferential provision of medicines (56.4%), results of appliance for medical help at polyclinic department (52.2%), loss of medical documentation (48.6%), lack of attention from medical staff (42.6%), qualification of doctors and nursing staff (36.8%).
Improving of his quality of medical care, according to the opinion of 41.4% of the patients, may be achieved by developing of availability and organizing of medical care (reducing of queues, paperwork, etc.). There had been often suggested (32.6%) to appropriate money for equipment and providing medical facilities with medications, and control strictly the responsibility for medical care performance. The respondents also think that training of qualified specialists in regions and towns and increasing their wages are not so effective (7.4% and 6.3% of the patients respectively).
There had not been revealed a statistical difference between the groups of the respondents of various ages and residences.
Discussion
The major part of the patients (more than 41%) is the persons of elderly age. According to specialists' opinion, persons of elderly and old age ask for medical care every month or more often then once per a month (70.3% in the sum). Although the elderly patients themselves mark significantly lower percent of appliance to medical facilities: only 22.6% of the patients confirm that they do apply to outpatient departments once or more per month.
The most part of the doctors and the patients realize the importance and necessity of gerontologist and psychologist taking part in medical care. At the most part of outpatient facilities, according to the doctors' questioning (59.6%), specialists mark the absence of continuity of special gerontological facilities independently on the location (regional, district centers), and the absence of gerontologist and specialists (81.6%) performing medico-social care for elderly persons. At that, according to self-estimation data, the most of elderly persons need medial care at specialized centers (88.6%) and gerontologist (79.2%) and psychologist (70.8%) consultation.
Satisfaction level of elderly patients depends on age, sex, medico-social status and residence of the studied group. Satisfaction with medical service for the persons elder than a working age is totally determined as low: "fair" and "low grade" marks gave 43.6% and 9.8% of the patients respectively. At that, 13.2% of the specialists realize a low satisfaction level of elderly people.
There had been revealed the unity of the doctors' opinions and of the elderly persons about factors influencing the satisfaction of the persons of elderly and old age with the quality of medical care. According to arranging the first three positions are for the quality of diagnostic research, preferential provision of medicines and effectiveness of the appliance for medical help. As elderly persons say, the basic measure for improving the quality of medical care is developing the availability and medical service performance. The doctors also consider that increase of medical care quality is the most important among all medico-social measures for the persons of elderly and old age.
Conclusion
Developing of the basic principles of optimization medical care for persons of elderly and old age in outpatient departments let us
2015. Volume 4. Issue 1. Article CID e0101 DOI: 10.15275/rusomj.2015.0101_
Health Service Organization
objectively estimate the level of availability and satisfaction with medical care, and provide continuity of medical care performing at all levels and improve the quality of preventive, diagnostic and rehabilitative care for the persons of elderly age.
Conflict of interests: none declared.
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Irina G. Novokreshchenova — MD, DSc, Professor, Head of Department of Economics and Management of Health Service and Pharmacy, Saratov State Medical University n.a. V.I. Razumovsky, Saratov, Russia. Inga K. Senchenko — MD, Post-graduate, Department of Economics and Management of Health Service and Pharmacy, Saratov State Medical University n.a. V.I. Razumovsky, Saratov, Russia.
Authors:
