Definition of Treatment Delay
Treatment delay is defined as the time that elapses from when a person first notices or recognizes a symptom or potential health problem until the time she or he receives definitive treatment by a health care provider. Treatment delay is an important phenomenon in health care because it affects the ability of clinicians to deliver appropriate treatment in a timely manner. Delay in treatment can result in increased morbidity and mortality. For example, if a person is experiencing symptoms of a heart attack, delay in seeking care prevents the application of proven treatments such as thrombolysis or angioplasty that minimize or prevent the heart attack. Delay results in greater destruction of heart muscle, leading to a poorer prognosis and reduced quality of life.
From a temporal standpoint, delay time is divided into patient delay and system or structural delay (e.g., transport, diagnostic, appointment, treatment, and hospital delays). System delays are relatively controllable, that is, amenable to structural changes in the health care system The result is improved efficiency in diagnosis and treatment. However, reduction of patient delay has proven much more challenging. Persons experiencing symptoms for diseases such as heart attacks, breast cancer, asthma, and others continue to delay unacceptably long periods of time despite massive patient education and early detection efforts.
One of the more notable examples of public education efforts has been in the area of patients experiencing heart attacks. Efforts to reduce delay in patients experiencing symptoms of a heart attack originally concentrated on reducing transport and hospital delay. These efforts were relatively successful, and it is generally felt that these times have been reduced as much as logistically possible. In the largest study to date, the Rapid Early Action for Coronary Treatment investigators reported that transport and hospital delay accounted for 3% to 8% and 22% to 33% of the total delay time, respectively. However, patient delay accounts for 50% to 75% of delay time. This time has not been reduced over the last two decades despite major efforts to educate the public.
Patient delay also comprises a substantial proportion of total delay time for women who experience symptoms of breast cancer. These times also have not been reduced despite aggressive education campaigns. Finally, asthma patients (adults and children) delay despite experiencing severe symptoms and patient education efforts.
Stages of Treatment Delay
Patient delay is a complex, multifaceted problem, and the time between symptom onset and seeking definitive treatment is often divided into phases to gain a better understanding of the issue. The process of evaluating an illness may be different based on a number of factors, including timing of the symptoms (i.e., early or late in the process), their potential seriousness, and the amount of discomfort experienced. Researchers have labeled the stages of patient delay slightly differently; however, there is general agreement that it is helpful to divide them into the following three stages.
- Appraisal delay is the period of time in which the person first notices that something is different or wrong and performs an appraisal of the situation. In other words, the person must decide if what she or he is experiencing is an illness or something out of the ordinary. If the answer to the question is “No,” the result is appraisal delay. If the answer is “Yes, there is something wrong,” she or he proceeds to the next stage, that of illness delay. Appraisal delay involves a mental representation of the health threat and is affected by the patient’s subjective experience, the sense of vulnerability to illness, and general knowledge about that illness.
- Illness delay is the period of time in which the person decides whether the symptoms are serious enough to require attention by a health care professional. If the individual judges the symptoms important enough to require action, then various alternatives are considered. Recently, illness delay has been categorized as the time taken to determine the coping or action plan. These coping and action plans operate on both emotional and cognitive levels.
- Utilization delay is the period of time where the person assesses the costs and benefits of seeking care as well as the barriers to seeking care. If patients do not perceive that seeking care is worth the effort or that the barriers are too great, they continue to delay.
- Total patient delay time is the sum of appraisal, illness, and utilization delay time.
Influence of Psychosocial Factors on Treatment-Seeking Behavior
There are a number of psychosocial factors that influence treatment-seeking behavior. These factors may change somewhat depending on different disease states. People vary greatly in how they experience or perceive symptoms. Delay may increase if symptoms do not match a patient’s expectation or are different than what she or he experienced previously in the same illness. Delay time can be increased if symptoms are vague, confusing, intermittent, or come on gradually. In the case of heart attack symptoms, patients often delay if they believe that the symptoms are not cardiac related. Severity of pain or other symptoms has not been shown to consistently affect delay time.
Patients delay longer when they hope that the symptoms will subside on their own, or if they try self-medication before seeking help. Delay is also increased if patients fail to recognize or understand the importance of symptoms. Patients are often worried about being embarrassed if their symptoms turn out to be nothing, and therefore delay longer. Interestingly, the presence of a family member or spouse increases delay in cardiac patients, but the presence of friends or coworkers decreases delay, presumably because they can evaluate the situation objectively and make more accurate assessments of appropriate courses of action than family members. On the other hand, telling a family member or friend decreases delay time in breast cancer patients.
Often, individuals are hesitant to bother the physician, hospital staff, family, and/or friends and will delay telling anyone. Asthma patients are known to delay seeking care because of previous negative experiences with emergency departments. Some asthma patients even fear that seeking medical care will somehow worsen their condition, which leads to a desire to “tough it out alone.” Asthma patients also fear systemic corticosteriods because of side effects they experienced during prior treatments.
Some patients feel that if they enter the health care system by calling their physician or going to the hospital, they will lose control over their lives or that their lives will be disrupted. However, some research has shown that if patients believe that their condition can be treated effectively, they will seek help more quickly. This belief speaks to cost/benefit issues, with individuals more likely to seek immediate treatment if the treatment is known to have a positive impact on morbidity and mortality. A sense of fatalism, various self-care behaviors, perceived constraints, and in appropriate problem-solving style increase delay in breast cancer patients.
Sociodemographic factors also can influence patient delay. In breast cancer patients, it has been found that lower income and education levels affect delay. Older age, ethnic minority, lower income, and public payer insurance tend to be associated with delay in myocardial infarction patients. Economic considerations such as the expense of medication or hospitalization have also been shown to delay care seeking in asthma patients.
Because delay in providing care causes increased morbidity and mortality, health care providers must understand the reasons for delay so that they can intervene in an appropriate and effective manner. For example, if patients state that they delay seeking treatment for symptoms because they will be embarrassed if the symptoms are nothing, then an appropriate intervention might be for the health care provider to focus on this issue, acknowledging that embarrassment is a normal response. A cost/benefit argument might be made that given the benefit of early treatment, being wrong on occasion is less important than avoiding the potential disability and loss of personal productive capacity. Lastly, it is important to note that most factors influencing patient delay are often modifiable, and therefore and efforts to reduce patient delay have direct benefits to patients in terms of decreased morbidity and mortality.
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