Academic journal article Health Sociology Review

Patients Receiving Ambulatory Care: A Problematic Autonomy Situation

Academic journal article Health Sociology Review

Patients Receiving Ambulatory Care: A Problematic Autonomy Situation

Article excerpt

The number of patients treated as part of a hospital-in-the-home programme designed to deliver hospital care, such as pal- liative care or treatment for neurodegenera- tive diseases, increased by nearly 80% between 2005 and 2008 in France (National Association of French Home Hospitalisation Institutions [FNEHAD], 2009). Concurrently, the avail- ability of outpatient options and the develop- ment of different forms of oral chemotherapy have resulted in no more than 9% of cancer patients requiring full hospitalisation (French National Cancer Institute [INCa], 2010). Not only has the average length of hospital stay fallen but classic hospitalisation patterns, where care is delivered in a hospital setting, are being replaced by other, more cost-effective ways of providing medical treatment, such as home hospitalisation (HH) or outpatient care for a growing number of pathologies including the most severe kinds (cancer, AIDS, cardiovascu- lar diseases) (Carricaburu & Ménoret, 2005). According to Schweyer, hospitals, whose ini- tial purpose was to admit patients, now tend to reduce as much as possible their activity as places of care, a structural conversion he describes as shifting 'from a stay without care to care without a stay' (Schweyer, 2003, p. 241).

Due to the emphasis on the cost of health care, the impact of the new care delivery models on the health system has become the focus of economic research projects. As a consequence, economic literature reviews were conducted as early as the 1980s on this topic (for example, see Berk & Chalmers, 1981). As for other areas of social sciences, the main studies on care delivery models are more recent and have dealt with the consequences of the 'outpatient shift' and the development of Hospital-in-the-Home (HH) on medical staff and care organisation (Bonneville, 2006; Diaz, 2000; Pérodeau & Côté, 2002). But as indicated in a 2003 review of scientific lit- erature (Duke & Street, 2003), few studies have addressed the consequences of these types of sys- tems from the patients' point of view.

A priori the evolution of health care deliv- ery models made possible by technological and medical advances should prove to be a positive factor and an opportunity for users to avoid lengthy stays: Hospitals often being described in sociological literature as places of confine- ment and institutional isolation where patients, faced with the prospect of increased depen- dency, lose their former 'external' status (Arras & Neveloff Dubler, 1994; Goffman, 1961). The HH or outpatient models reflects the will to reduce the average length of hospital stays. A 2009 report based on a study by the National Association of HH Institutions on information systems and health technologies, states that HH is 'primarily a patient's choice. It is the response to the wish expressed by a given patient to regain con- trol of his or her illness and treatment and to receive appropriate medical care in a familiar environment' (FNEHAD, 2009, p. 32). Caplan and other academic researchers with an interest in patient care delivery share this point of view. Caplan stated in a comparative home/hospital study that it is preferable for patients to be spared the need to adapt to the hospital culture, remaining in a familiar environment and keeping some form of routine instead (Caplan et al., 1999). However new hospitalisation models are not unanimously acclaimed and some authors note that the urgent need to reduce health costs is taking precedence over any social, ethic or sanitary considerations (Duke & Street, 2003; Pousada, 1995). Since the existing literature has not dealt extensively with the transformations induced by the new health care delivery models, we decided to focus our attention on the status of patients not confined to a medical institution: Does leaving the hospi- tal premises actually mean reducing their depen- dency on the institution? Can patients limit their reliance on the hospital by using other available external resources such as family, physicians and the media? …

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