Sample records for ambulatory primary care
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Clinical productivity of primary care nurse practitioners in ambulatory settings.
Xue, Ying; Tuttle, Jane
Nurse practitioners are increasingly being integrated into primary care delivery to help meet the growing demand for primary care. It is therefore important to understand nurse practitioners' productivity in primary care practice. We examined nurse practitioners' clinical productivity in regard to number of patients seen per week, whether they had a patient panel, and patient panel size. We further investigated practice characteristics associated with their clinical productivity. We conducted cross-sectional analysis of the 2012 National Sample Survey of Nurse Practitioners. The sample included full-time primary care nurse practitioners in ambulatory settings. Multivariable survey regression analyses were performed to examine the relationship between practice characteristics and nurse practitioners' clinical productivity. Primary care nurse practitioners in ambulatory settings saw an average of 80 patients per week (95% confidence interval [CI]: 79-82), and 64% of them had their own patient panel. The average patient panel size was 567 (95% CI: 522-612). Nurse practitioners who had their own patient panel spent a similar percent of time on patient care and documentation as those who did not. However, those with a patient panel were more likely to provide a range of clinical services to most patients. Nurse practitioners' clinical productivity was associated with several modifiable practice characteristics such as practice autonomy and billing and payment policies. The estimated number of patients seen in a typical week by nurse practitioners is comparable to that by primary care physicians reported in the literature. However, they had a significantly smaller patient panel. Nurse practitioners' clinical productivity can be further improved. Copyright © 2016 Elsevier Inc. All rights reserved.
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Preparing for the primary care clinic: an ambulatory boot camp for internal medicine interns
Esch, Lindsay M.; Bird, Amber-Nicole; Oyler, Julie L.; Lee, Wei Wei; Shah, Sachin D.; Pincavage, Amber T.
2015-01-01
Introduction Internal medicine (IM) interns start continuity clinic with variable ambulatory training. Multiple other specialties have utilized a boot camp style curriculum to improve surgical and procedural skills, but boot camps have not been used to improve interns’ ambulatory knowledge and confidence. The authors implemented and assessed the impact of an intern ambulatory boot camp pilot on primary care knowledge, confidence, and curricular satisfaction. Methods During July 2014, IM interns attended ambulatory boot camp. It included clinically focused case-based didactic sessions on common ambulatory topics as well as orientation to the clinic and electronic medical records. Interns anonymously completed a 15-question pre-test on topics covered in the boot camp as well as an identical post-test after the boot camp. The interns were surveyed regarding their confidence and satisfaction. Results Thirty-eight interns participated in the boot camp. Prior to the boot camp, few interns reported confidence managing common outpatient conditions. The average pre-test knowledge score was 46.3%. The average post-test knowledge score significantly improved to 76.1% (pinterns reported that the boot camp was good preparation for clinics and 97% felt that the boot camp boosted their confidence. Conclusions The ambulatory boot camp pilot improved primary care knowledge, and interns thought it was good preparation for clinic. The ambulatory boot camp was well received and may be an effective way to improve the preparation of interns for primary care clinic. Further assessment of clinical performance and expansion to other programs and specialties should be considered. PMID:26609962
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Beyond the clinic: redefining hospital ambulatory care.
Rogut, L
1997-07-01
Responding to changes in health care financing, government policy, technology, and clinical judgment, and the rise of managed care, hospitals are shifting services from inpatient to outpatient settings and moving them into the community. Institutions are evolving into integrated delivery systems, developing the capacity to provide a continuum of coordinated services in an array of settings and to share financial risk with physicians and managed care organizations. Over the past several years, hospitals in New York City have shifted considerable resources into ambulatory care. In their drive to expand and enhance services, however, they face serious challenges, including a well-established focus on hospitals as inpatient centers of tertiary care and medical education, a heavy reliance upon residents as providers of medical care, limited access to capital, and often inadequate physical plants. In 1995, the United Hospital Fund awarded $600,000 through its Ambulatory Care Services Initiative to support hospitals' efforts to meet the challenges of reorganizing services, compete in a managed care environment, and provide high-quality ambulatory care in more efficient ways. Through the initiative, 12 New York City hospitals started projects to reorganize service delivery and build an infrastructure of systems, technology, and personnel. Among the projects undertaken by the hospitals were:--broad-based reorganization efforts employing primary care models to improve and expand existing ambulatory care services, integrate services, and better coordinate care;--projects to improve information management, planning and testing new systems for scheduling appointments, registering patients, and tracking ambulatory care and its outcomes;--training programs to increase the supply of primary care providers (both nurse practitioners and primary care physicians), train clinical and support staff in the skills needed to deliver more efficient and better ambulatory care, prepare staff
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Achieving the AAAs of Ambulatory Care: Aptitude, Appeal, and Appreciation
Rybolt, Ann H.; Staton, Lisa J.; Panda, Mukta; Jones, Roger C.
2009-01-01
Background In the current health care environment more patient care has moved from in-hospital care to the ambulatory primary care settings; however, fewer internal medicine residents are pursuing primary care careers. Barriers to residents developing a sense of competency and enjoyment in ambulatory medicine include the complexity of practice-based systems, patients with multiple chronic diseases, and the limited time that residents spend in the outpatient setting. Objective In an effort to accelerate residents' ambulatory care competence and enhance their satisfaction with ambulatory practice, we sought to change the learning environment. Interns were provided a series of intensive, focused, ambulatory training sessions prior to beginning their own continuity clinic sessions. The sessions were designed to enable them to work confidently and effectively in their continuity clinic from the beginning of the internship year, and it was hoped this would have a positive impact on their perception of the desirability of ambulatory practice. Methods Improvement needs assessment after a performance, so we developed a structured, competency-based, multidisciplinary curriculum for initiation into ambulatory practice. The curriculum focused on systems-based practice, patient safety, quality improvement, and collaborative work while emphasizing the importance of continuity of care and long-term doctor-patient relationships. Direct observation of patient encounters was done by an attending physician to evaluate communication and physical examination skills. Systems of care commonly used in the clinic were demonstrated. Resources for practice-based learning were used. Conclusion The immersion of interns in an intensive, hands-on experience using a structured ambulatory care orientation curriculum early in training may prepare the intern to be a successful provider and learner in the primary care ambulatory setting. PMID:21975724
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Tu, Jack V; Maclagan, Laura C; Ko, Dennis T; Atzema, Clare L; Booth, Gillian L; Johnston, Sharon; Tu, Karen; Lee, Douglas S; Bierman, Arlene; Hall, Ruth; Bhatia, R Sacha; Gershon, Andrea S; Tobe, Sheldon W; Sanmartin, Claudia; Liu, Peter; Chu, Anna
2017-04-25
High-quality ambulatory care can reduce cardiovascular disease risk, but important gaps exist in the provision of cardiovascular preventive care. We sought to develop a set of key performance indicators that can be used to measure and improve cardiovascular care in the primary care setting. As part of the Cardiovascular Health in Ambulatory Care Research Team initiative, we established a 14-member multidisciplinary expert panel to develop a set of indicators for measuring primary prevention performance in ambulatory cardiovascular care. We used a 2-stage modified Delphi panel process to rate potential indicators, which were identified from the literature and national cardiovascular organizations. The top-rated indicators were pilot tested to determine their measurement feasibility with the use of data routinely collected in the Canadian health care system. A set of 28 indicators of primary prevention performance were identified, which were grouped into 5 domains: risk factor prevalence, screening, management, intermediate outcomes and long-term outcomes. The indicators reflect the major cardiovascular risk factors including smoking, obesity, hypertension, diabetes, dyslipidemia and atrial fibrillation. All indicators were determined to be amenable to measurement with the use of population-based administrative (physician claims, hospital admission, laboratory, medication), survey or electronic medical record databases. The Cardiovascular Health in Ambulatory Care Research Team indicators of primary prevention performance provide a framework for the measurement of cardiovascular primary prevention efforts in Canada. The indicators may be used by clinicians, researchers and policy-makers interested in measuring and improving the prevention of cardiovascular disease in ambulatory care settings. Copyright 2017, Joule Inc. or its licensors.
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Redesigning the regulatory framework for ambulatory care services in New York.
Chokshi, Dave A; Rugge, John; Shah, Nirav R
2014-12-01
Policy Points: The landscape of ambulatory care services in the United States is rapidly changing on account of payment reform, primary care transformation, and the rise of convenient care options such as retail clinics. New York State has undertaken a redesign of regulatory policy for ambulatory care rooted in the Triple Aim (better health, higher-quality care, lower costs)-with a particular emphasis on continuity of care for patients. Key tenets of the regulatory approach include defining and tracking the taxonomy of ambulatory care services as well as ensuring that convenient care options do not erode continuity of care for patients. While hospitals remain important centers of gravity in the health system, services are increasingly being delivered through ambulatory care. This shift to ambulatory care is giving rise to new delivery structures, such as retail clinics and urgent care centers, as well as reinventing existing ambulatory care capacity, as seen with the patient-centered medical home model and the movement toward team-based care. To protect the public's interests, oversight of ambulatory care services must keep pace with these rapid changes. With this purpose, in January 2013 the New York Public Health and Health Planning Council undertook a redesign of the regulatory framework for the state's ambulatory care services. This article describes the principles undergirding the framework as well as the regulatory recommendations themselves. We explored and analyzed the regulation of ambulatory care services in New York in accordance with the available gray and peer-reviewed literature and legislative documents. The deliberations of the Public Health and Health Planning Council informed our review. The vision of high-performing ambulatory care should be rooted in the Triple Aim (better health, higher-quality care, lower costs), with a particular emphasis on continuity of care for patients. There is a pressing need to better define the taxonomy of ambulatory
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Gonçalves, Marcelo Rodrigues; Hauser, Lisiane; Prestes, Isaías Valente; Schmidt, Maria Inês; Duncan, Bruce Bartholow; Harzheim, Erno
2016-06-01
To investigate the relation of hospitalization for ambulatory care sensitive conditions (ACSC) with the quality of public primary care health services in Porto Alegre, Brazil. Cohort study constructed by probabilistic record linkage performed from August 2006 to December 2011 in a population ≥18 years of age that attended public primary care health services. The Primary Care Assessment Tool (PCATool-Brazil) was used for evaluation of primary care services. Of 1200 subjects followed, 84 were hospitalized for primary care sensitive conditions. The main causes of ACSC hospital admissions were cardiovascular (40.5%) and respiratory (16.2%) diseases. The PCATool average score was 5.3, a level considerably below that considered to represent quality care. After adjustment through Cox proportional hazard modelling for covariates, >60 years of age [hazard ratio (HR): 1.13; P = 0.001), lesser education (HR: 0.66; P = 0.02), ethnicity other than white (HR: 1.77; P = 0.01) and physical inactivity (HR: 1.65; P = 0.04) predicted hospitalization, but higher quality of primary health care did not. Better quality of health care services, in a setting of overwhelmingly low quality services not adapted to the care of chronic conditions, did not influence the rate of avoidable hospitalizations, while social and demographic characteristics, especially non-white ethnicity and lesser schooling, indicate that social inequities play a predominant role in health outcomes. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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O'Malley, Ann S; Reschovsky, James D; Saiontz-Martinez, Cynthia
2015-01-01
Practice tools such as health information technology (HIT) have the potential to support care processes, such as communication between health care providers, and influence care for "ambulatory care-sensitive conditions" (ACSCs). ACSCs are conditions for which good outpatient care can potentially prevent the need for hospitalization. To date, associations between such primary care practice capabilities and hospitalizations for ambulatory care-sensitive conditions have been primarily limited to smaller, local studies or unique delivery systems rather than nationally representative studies of primary care physicians in the United States. We analyzed a nationally representative sample of 1,819 primary care physicians who responded to the Center for Studying Health System Change's Physician Survey. We linked 3 years of Medicare claims (2007 to 2009) with these primary care physician survey respondents. This linkage resulted in the identification of 123,760 beneficiaries with one or more of 4 ambulatory care-sensitive chronic conditions (diabetes, chronic obstructive pulmonary disease, asthma, and congestive heart failure) for whom these physicians served as the usual provider. Key independent variables of interest were physicians' practice capabilities, including communication with specialists, use of care managers, participation in quality and performance measurement, use of patient registries, and HIT use. The dependent variable was a summary measure of ambulatory care-sensitive hospitalizations for one or more of these 4 conditions. Higher provider-reported levels of communication between primary care and specialist physicians were associated with lower rates of potentially avoidable hospitalizations. While there was no significant main effect between HIT use and ACSC hospitalizations, the associations between interspecialty communication and ACSC hospitalizations were magnified in the presence of higher HIT use. For example, patients in practices with both the
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National Hospital Ambulatory Medical Care Survey
U.S. Department of Health & Human Services — The National Hospital Ambulatory Medical Care Survey (NHAMCS) is designed to collect data on the utilization and provision of ambulatory care services in hospital...
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Ambulatory care registered nurse performance measurement.
Swan, Beth Ann; Haas, Sheila A; Chow, Marilyn
2010-01-01
On March 1-2, 2010, a state-of-the-science invitational conference titled "Ambulatory Care Registered Nurse Performance Measurement" was held to focus on measuring quality at the RN provider level in ambulatory care. The conference was devoted to ambulatory care RN performance measurement and quality of health care. The specific emphasis was on formulating a research agenda and developing a strategy to study the testable components of the RN role related to care coordination and care transitions, improving patient outcomes, decreasing health care costs, and promoting sustainable system change. The objectives were achieved through presentations and discussion among expert inter-professional participants from nursing, public health, managed care, research, practice, and policy. Conference speakers identified priority areas for a unified practice, policy, and research agenda. Crucial elements of the strategic dialogue focused on issues and implications for nursing and inter-professional practice, quality, and pay-for-performance.
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Pessanha, Paulo; Viana, Manuel; Ferreira, Paula; Bertoquini, Susana; Pol?nia, Jorge
2013-01-01
Background Hypertensive patients (HTs) are usually attended in primary care (PC). We aimed to assess the diagnostic accuracy and cost-benefit ratio of 24-hour ambulatory blood pressure monitoring (ABPM) in all newly diagnosed hypertensive patients (HTs) attended in PC. Methods In a cross-sectional study ABPM was recorded in all 336 never treated HTs (Office BP ?140 and/or???90?mm Hg) that were admitted during 16?months. Since benefits from drug treatment in white-coat hypertension (WCH) remai...
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Redesigning ambulatory care business processes supporting clinical care delivery.
Patterson, C; Sinkewich, M; Short, J; Callas, E
1997-04-01
The first step in redesigning the health care delivery process for ambulatory care begins with the patient and the business processes that support the patient. Patient-related business processes include patient access, service documentation, billing, follow-up, collection, and payment. Access is the portal to the clinical delivery and care management process. Service documentation, charge capture, and payment and collection are supporting processes to care delivery. Realigned provider networks now demand realigned patient business services to provide their members/customers/patients with improved service delivery at less cost. Purchaser mandates for cost containment, health maintenance, and enhanced quality of care have created an environment where every aspect of the delivery system, especially ambulatory care, is being judged. Business processes supporting the outpatient are therefore being reexamined for better efficiency and customer satisfaction. Many health care systems have made major investments in their ambulatory care environment, but have pursued traditional supporting business practices--such as multiple access points, lack of integrated patient appointment scheduling and registration, and multiple patient bills. These are areas that are appropriate for redesign efforts--all with the customer's needs and convenience in mind. Similarly, setting unrealistic expectations, underestimating the effort required, and ignoring the human elements of a patient-focused business service redesign effort can sabotage the very sound reasons for executing such an endeavor. Pitfalls can be avoided if a structured methodology, coupled with a change management process, are employed. Deloitte & Touche Consulting Group has been involved in several major efforts, all with ambulatory care settings to assist with the redesign of their business practices to consider the patient as the driver, instead of the institution providing the care.
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An overview of anesthetic procedures, tools, and techniques in ambulatory care
Directory of Open Access Journals (Sweden)
Messieha Z
2015-01-01
Full Text Available Zakaria Messieha Department of Anesthesiology, University of Illinois at Chicago, Chicago, IL, USA Abstract: Ambulatory surgical and anesthesia care (ASAC, also known as Same Day Surgery or Day Care in some countries, is the fastest growing segment of ambulatory surgical and anesthesia care. Over 50 million ambulatory surgical procedures are conducted annually comprising over 60% of all anesthesia care with an impressive track record of safety and efficiency. Advances in ambulatory anesthesia care have been due to newer generation of inhalation and intravenous anesthetics as well as airway management technology and techniques. Successful ambulatory anesthesia care relies on patient selection, adequate facilities, highly trained personnel and quality improvement policies and procedures. Favoring one anesthetic technique over the other should be patient and procedure-specific. Effective management of post-operative pain as well as nausea and vomiting are the final pieces in assuring success in ambulatory anesthesia care. Keywords: ambulatory anesthesia, out-patient anesthesia, Day-Care anesthesia
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Magán, Purificación; Alberquilla, Angel; Otero, Angel; Ribera, José Manuel
2011-01-01
Hospitalizations for ambulatory care sensitive conditions (ACSH) have been proposed as an indirect indicator of the effectiveness and quality of care provided by primary health care. To investigate the association of ACSH rates with population socioeconomic factors and with characteristics of primary health care. Cross-sectional, ecologic study. Using hospital discharge data, ACSH were selected from the list of conditions validated for Spain. All 34 health districts in the Region of Madrid, Spain. Individuals aged 65 years or older residing in the region of Madrid between 2001 and 2003, inclusive. Age- and gender-adjusted ACSH rates in each health district. The adjusted ACSH rate per 1000 population was 35.37 in men and 20.45 in women. In the Poisson regression analysis, an inverse relation was seen between ACSH rates and the socioeconomic variables. Physician workload was the only health care variable with a statistically significant relation (rate ratio of 1.066 [95% CI; 1.041-1.091]). These results were similar in the analyses disaggregated by gender. In the multivariate analyses that included health care variables, none of the health care variables were statistically significant. ACSH may be more closely related with socioeconomic variables than with characteristics of primary care activity. Therefore, other factors outside the health system must be considered to improve health outcomes in the population.
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Primary care training and the evolving healthcare system.
Peccoralo, Lauren A; Callahan, Kathryn; Stark, Rachel; DeCherrie, Linda V
2012-01-01
With growing numbers of patient-centered medical homes and accountable care organizations, and the potential implementation of the Patient Protection and Affordable Care Act, the provision of primary care in the United States is expanding and changing. Therefore, there is an urgent need to create more primary-care physicians and to train physicians to practice in this environment. In this article, we review the impact that the changing US healthcare system has on trainees, strategies to recruit and retain medical students and residents into primary-care internal medicine, and the preparation of trainees to work in the changing healthcare system. Recruitment methods for medical students include early preclinical exposure to patients in the primary-care setting, enhanced longitudinal patient experiences in clinical clerkships, and primary-care tracks. Recruitment methods for residents include enhanced ambulatory-care training and primary-care programs. Financial-incentive programs such as loan forgiveness may encourage trainees to enter primary care. Retaining residents in primary-care careers may be encouraged via focused postgraduate fellowships or continuing medical education to prepare primary-care physicians as both teachers and practitioners in the changing environment. Finally, to prepare primary-care trainees to effectively and efficiently practice within the changing system, educators should consider shifting ambulatory training to community-based practices, encouraging resident participation in team-based care, providing interprofessional educational experiences, and involving trainees in quality-improvement initiatives. Medical educators in primary care must think innovatively and collaboratively to effectively recruit and train the future generation of primary-care physicians. © 2012 Mount Sinai School of Medicine.
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Performance measurement for ambulatory care: moving towards a new agenda.
Roski, J; Gregory, R
2001-12-01
Despite a shift in care delivery from inpatient to ambulatory care, performance measurement efforts for the different levels in ambulatory care settings such as individual physicians, individual clinics and physician organizations have not been widely instituted in the United States (U.S.). The Health Plan Employer Data and Information Set (HEDIS), the most widely used performance measurement set in the U.S., includes a number of measures that evaluate preventive and chronic care provided in ambulatory care facilities. While HEDIS has made important contributions to the tracking of ambulatory care quality, it is becoming increasingly apparent that the measurement set could be improved by providing quality of care information at the levels of greatest interest to consumers and purchasers of care, namely for individual physicians, clinics and physician organizations. This article focuses on the improvement opportunities for quality performance measurement systems in ambulatory care. Specific challenges to creating a sustainable performance measurement system at the level of physician organizations, such as defining the purpose of the system, the accountability logic, information and reporting needs and mechanisms for sustainable implementation, are discussed.
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Directory of Open Access Journals (Sweden)
Ansari Zahid
2012-12-01
Full Text Available Abstract Background Ambulatory Care Sensitive Conditions (ACSCs are those for which hospitalisation is thought to be avoidable with the application of preventive care and early disease management, usually delivered in a primary care setting. ACSCs are used extensively as indicators of accessibility and effectiveness of primary health care. We examined the association between patient characteristics and hospitalisation for ACSCs in the adult and paediatric population in Victoria, Australia, 2003/04. Methods Hospital admissions data were merged with two area-level socioeconomic indexes: Index of Socio-Economic Disadvantage (IRSED and Accessibility/Remoteness Index of Australia (ARIA. Univariate and multiple logistic regressions were performed for both adult (age 18+ years and paediatric (age Results Predictors were much more strongly associated with ACSCs admissions compared to non-ACSCs admissions in the adult group than for the paediatric group with the exception of rurality. Significant adjusted ORs in the adult group were 1.06, 1.15, 1.13, 1.06 and 1.11 for sex, rurality, age, IRSED and ARIA variables, and 1.34, 1.04 and 1.09 in the paediatric group for rurality, IRSED and ARIA, respectively. Conclusions Disadvantaged paediatric and adult population experience more need of hospital care for ACSCs. Access barriers to primary care are plausible causes for the observed disparities. Understanding the characteristics of individuals experiencing access barriers to primary care will be useful for developing targeted interventions meeting the unique ambulatory needs of the population.
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Ambulatory Care Skills: Do Residents Feel Prepared?
Directory of Open Access Journals (Sweden)
Denise Bonds
2002-10-01
Full Text Available Objective: To determine resident comfort and skill in performing ambulatory care skills. Methods: Descriptive survey of common ambulatory care skills administered to internal medicine faculty and residents at one academic medical center. Respondents were asked to rate their ability to perform 12 physical exam skills and 6 procedures, and their comfort in performing 7 types of counseling, and obtaining 6 types of patient history (4 point Likert scale for each. Self-rated ability or comfort was compared by gender, status (year of residency, faculty, and future predicted frequency of use of the skill. Results: Residents reported high ability levels for physical exam skills common to both the ambulatory and hospital setting. Fewer felt able to perform musculoskeletal, neurologic or eye exams easily alone. Procedures generally received low ability ratings. Similarly, residents comfort in performing common outpatient counseling was also low. More residents reported feeling very comfortable in obtaining history from patients. We found little variation by gender, year of training, or predicted frequency of use. Conclusion: Self-reported ability and comfort for many common ambulatory care skills is low. Further evaluation of this finding in other training programs is warranted.
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International Nuclear Information System (INIS)
Mann, F.A.; Stewart, N.R.; Terrell, C.B.
1990-01-01
This paper determines the characteristics of misinterpretations of musculoskeletal radiographs by internal medicine residents (IMRs) in an ambulatory care setting. Discordances between IMRs and staff radiologists were prospectively identified and retrospectively reviewed to assess type of error and patient outcome. The setting was an acute ambulatory care clinic at a large university hospital staffed by board-certified emergency medicine faculty and IMRs. Of 541 patients radiographed, 321 (59%) had adequate follow-up to establish outcome. Error characteristics examined included nature and site, type (false negative ([F-] or false positive [F+]), clinical significance, interpreter responsible, and level of interpreter training
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Curricula and Organization of Primary Care Residencies in Internal Medicine.
Eisenberg, John M.
1980-01-01
The organization and curricula of internal medicine residencies programs that emphasize primary care are described and compared with traditional residencies in internal medicine. It is noted that primary care residents spend more time in ambulatory care and are allowed more electives in specialties outside of internal medicine. Out-of-hospital…
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Disease Management Plus Recommended Care versus Recommended Care Alone for Ambulatory COPD Patients.
Kalter-Leibovici, Ofra; Benderly, Michal; Freedman, Laurence S; Kaufman, Galit; Molcho Falkenberg Luft, Tchiya; Murad, Havi; Olmer, Liraz; Gluch, Meri; Segev, David; Gilad, Avi; Elkrinawi, Said; Cukierman-Yaffe, Tali; Chen, Baruch; Jacobson, Orit; Key, Calanit; Shani, Mordechai; Fink, Gershon
2018-03-01
The efficacy of disease management programs in the treatment of patients with chronic obstructive pulmonary disease (COPD) remains uncertain. To study the effect of disease management (DM) added to recommended care (RC) in ambulatory COPD patients. In this trial, 1,202 COPD patients (age >40 years), with moderate to very severe airflow limitation were randomly assigned either to DM plus RC (study intervention) or to RC alone (control intervention). RC included follow-up by pulmonologists; inhaled long-acting bronchodilators and corticosteroids; smoking cessation intervention; nutritional advice and psychosocial support when indicated, and supervised physical activity sessions. DM, delivered by trained nurses during patients' visits to the designated COPD centers and remote contacts with the patients between these visits, included patient self-care education; monitoring patients' symptoms and adherence to treatment; provision of advice in case of acute disease exacerbation, and coordination of care vis-à-vis other healthcare providers. The primary composite endpoint was first hospital admission for respiratory symptoms or death from any cause. During 3,537 patient-years, 284 (47.2%) patients in the control group and 264 (44.0%) in the study intervention group had a primary endpoint event. The median (range) time elapsed until a primary endpoint event was 1.0 (0-4.0) years among patients assigned to the study intervention and 1.1 (0-4.1) years among patients assigned to the control intervention; adjusted hazard ratio, 0.92 (95%CI: 0.77 to 1.08). DM added to RC was not superior to RC alone in delaying first hospital admission or death among ambulatory COPD patients. Clinical trial registration available at www.clinicaltrials.gov, ID NCT00982384.
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Gotlib, Dorothy; Bostwick, Jolene R.; Calip, Seema; Perelstein, Elizabeth; Kurlander, Jacob E.; Fluent, Thomas
2017-01-01
Objectives To determine the volume and nature (or topic) of consultations submitted to a psychiatric pharmacist embedded in an ambulatory psychiatry clinic, within a tertiary care academic medical center and to increase our understanding about the ways in which providers consult with an available psychiatric pharmacist. Experimental Design Authors analyze and describe the ambulatory psychiatric pharmacist consultation log at an academic ambulatory clinic. All consultation questions were submitted between July 2012 and October 2014. Principal Observations Psychiatry residents, attending physicians, and advanced practice nurse practitioners submitted 280 primary questions. The most common consultation questions from providers consulted were related to drug-drug interactions (n =70), drug formulations/dosing (n =48), adverse effects (n =43), and pharmacokinetics/lab monitoring/cross-tapering (n =36). Conclusions This is a preliminary analysis that provides information about how psychiatry residents, attending physicians, and advanced practice nurse practitioners at our health system utilize a psychiatric pharmacist. This collaborative relationship may have implications for the future of psychiatric care delivery. PMID:28936009
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Gotlib, Dorothy; Bostwick, Jolene R; Calip, Seema; Perelstein, Elizabeth; Kurlander, Jacob E; Fluent, Thomas
2017-09-15
To determine the volume and nature (or topic) of consultations submitted to a psychiatric pharmacist embedded in an ambulatory psychiatry clinic, within a tertiary care academic medical center and to increase our understanding about the ways in which providers consult with an available psychiatric pharmacist. Authors analyze and describe the ambulatory psychiatric pharmacist consultation log at an academic ambulatory clinic. All consultation questions were submitted between July 2012 and October 2014. Psychiatry residents, attending physicians, and advanced practice nurse practitioners submitted 280 primary questions. The most common consultation questions from providers consulted were related to drug-drug interactions (n =70), drug formulations/dosing (n =48), adverse effects (n =43), and pharmacokinetics/lab monitoring/cross-tapering (n =36). This is a preliminary analysis that provides information about how psychiatry residents, attending physicians, and advanced practice nurse practitioners at our health system utilize a psychiatric pharmacist. This collaborative relationship may have implications for the future of psychiatric care delivery.
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The ten successful elements of an ambulatory care center.
Watkins, G
1997-01-01
Experts in healthcare predict that in the future, over 80% of all care will be provided either in the home or ambulatory care centers. How radiology facilities position themselves for this shifting market is critical to their long-term success, even though it appears there are endless opportunities for providing care in this atmosphere. The ten most critical elements that healthcare providers must address to ensure their preparedness are discussed. Location is critical, particularly since patients no longer want to travel to regional medical centers. The most aggressive providers are building local care centers to serve specific populations. Ambulatory care centers should project a high tech, high touch atmosphere. Patient comfort and the appeal of the overall environment must be considered. Centers need to focus on their customers' needs in multiple areas of care. A quick and easy registration process, providing dressing gowns in patient areas, clear billing functions--these are all important areas that centers should develop. Physicians practicing in the ambulatory care center are key to its overall success and can set the tone for all staff members. Staff members must be friendly and professional in their work with patients. The hours offered by the center must meet the needs of its client base, perhaps by offering evening and weekend appointments. Keeping appointments on schedule is critical if a center wants satisfied customers. It's important to identify the target before developing your marketing plan. Where do your referrals come from? Look to such sources as referring physicians, managed care plans and patients themselves. Careful billing is critical for survival in the ambulatory care world. Costs are important and systems that can track cost per exam are useful. Know your bottom line. Service remains the central focus of all successful ambulatory care center functions.
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The value of registered nurses in ambulatory care settings: a survey.
Mastal, Margaret; Levine, June
2012-01-01
Ambulatory care settings employ 25% of the three million registered nurses in the United States. The American Academy of Ambulatory Care Nursing (AAACN) is committed to improving the quality of health care in ambulatory settings, enhancing patient outcomes, and realizing greater health care efficiencies. A survey of ambulatory care registered nurses indicates they are well positioned to lead and facilitate health care reform activities with organizational colleagues. They are well schooled in critical thinking, triage, advocating for patients, educating patients and families, collaborating with medical staff and other professionals, and care coordination. The evolving medical home concept and other health care delivery models reinforces the critical need for registered nurses to provide chronic disease management, care coordination, health risk appraisal, care transitions, health promotion, and disease prevention services. Recommendations are offered for organizational leaders, registered nurses, and AAACN to utilize nursing knowledge and skills in the pursuit of leading change and advancing health.
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Rehem, Tania Cristina Morais Santa Barbara; de Oliveira, Maria Regina Fernandes; Ciosak, Suely Itsuko; Egry, Emiko Yoshikawa
2013-01-01
To estimate the sensitivity, specificity and positive and negative predictive values of the Unified Health System's Hospital Information System for the appropriate recording of hospitalizations for ambulatory care-sensitive conditions. The hospital information system records for conditions which are sensitive to ambulatory care, and for those which are not, were considered for analysis, taking the medical records as the gold standard. Through simple random sampling, a sample of 816 medical records was defined and selected by means of a list of random numbers using the Statistical Package for Social Sciences. The sensitivity was 81.89%, specificity was 95.19%, the positive predictive value was 77.61% and the negative predictive value was 96.27%. In the study setting, the Hospital Information System (SIH) was more specific than sensitive, with nearly 20% of care sensitive conditions not detected. There are no validation studies in Brazil of the Hospital Information System records for the hospitalizations which are sensitive to primary health care. These results are relevant when one considers that this system is one of the bases for assessment of the effectiveness of primary health care.
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Directory of Open Access Journals (Sweden)
Tania Cristina Morais Santa Barbara Rehem
2013-09-01
Full Text Available OBJECTIVE: to estimate the sensitivity, specificity and positive and negative predictive values of the Unified Health System's Hospital Information System for the appropriate recording of hospitalizations for ambulatory care-sensitive conditions. METHOD: the hospital information system records for conditions which are sensitive to ambulatory care, and for those which are not, were considered for analysis, taking the medical records as the gold standard. Through simple random sampling, a sample of 816 medical records was defined and selected by means of a list of random numbers using the Statistical Package for Social Sciences. RESULT: the sensitivity was 81.89%, specificity was 95.19%, the positive predictive value was 77.61% and the negative predictive value was 96.27%. In the study setting, the Hospital Information System (SIH was more specific than sensitive, with nearly 20% of care sensitive conditions not detected. CONCLUSION: there are no validation studies in Brazil of the Hospital Information System records for the hospitalizations which are sensitive to primary health care. These results are relevant when one considers that this system is one of the bases for assessment of the effectiveness of primary health care.
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Speak Up: Help Prevent Errors in Your Care: Ambulatory Care
... Your Care Ambulatory Care To prevent health care errors, patients are urged to... SpeakUP TM Everyone has a ... he or she has confused you with another patient. P ay attention to the ... for their identification (ID) badges. • Notice whether your caregivers have washed ...
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The financial and health burden of diabetic ambulatory care sensitive hospitalisations in Mexico
Lugo-Palacios, David G; Cairns, John
2016-01-01
Objective. To estimate the financial and health burden of diabetic ambulatory care sensitive hospitalisations (ACSH) in Mexico during 2001-2011. Materials and methods. We identified ACSH due to diabetic complications in general hospitals run by local health ministries and estimated their financial cost using diagnostic related groups. The health burden estimation assumes that patients would not have experienced complications if they had received appropriate primary care and computes the assoc...
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An elective course on current concepts in adult ambulatory care.
Vincent, Ashley H; Weber, Zachary A
2014-12-15
To design and evaluate a doctor of pharmacy course exploring disease states commonly encountered in ambulatory care, while applying literature to clinical practice and promoting a continual learning mindset. This elective incorporated a learner-centered teaching approach. Each week, 2 groups of students were assigned a clinical trial to present to their peers. The focus was on clinical application and impact, rather than literature evaluation. A social networking group on Facebook was used to expose students to pharmacy information outside the classroom. Student grades were determined by multiple activities: presentations, participation and moderation of the Facebook group, class participation, quiz scores, and quiz question development. Course evaluations served as a qualitative assessment of student learning and perceptions, quizzes were the most objective assessment of student learning, and presentation evaluations were the most directed assessment of course goals. This elective was an innovative approach to teaching ambulatory care that effectively filled a curricular void. Successful attainment of the primary course goals and objectives was demonstrated through course evaluations, surveys, and quiz and presentation scores.
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National Ambulatory Medical Care Survey (NAMCS)
U.S. Department of Health & Human Services — The National Ambulatory Medical Care Survey (NAMCS) is a national survey designed to meet the need for objective, reliable information about the provision and use of...
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Hensel, Jennifer M; Taylor, Valerie H; Fung, Kinwah; Yang, Rebecca; Vigod, Simone N
2018-01-01
The role of mental illness and addiction in acute care use for chronic medical conditions that are sensitive to ambulatory care management requires focussed attention. This study examines how mental illness or addiction affects risk for repeat hospitalization and/or emergency department use for ambulatory care-sensitive conditions (ACSCs) among high-cost users of medical care. A retrospective, population-based cohort study using data from Ontario, Canada. Among the top 10% of medical care users ranked by cost, we determined rates of any and repeat care use (hospitalizations and emergency department [ED] visits) between April 1, 2011, and March 31, 2012, for 14 consensus established ACSCs and compared them between those with and without diagnosed mental illness or addiction during the 2 years prior. Risk ratios were adjusted (aRR) for age, sex, residence, and income quintile. Among 314,936 high-cost users, 35.9% had a mental illness or addiction. Compared to those without, individuals with mental illness or addiction were more likely to have an ED visit or hospitalization for any ACSC (22.8% vs. 19.6%; aRR, 1.21; 95% confidence interval [CI], 1.20-1.23). They were also more likely to have repeat ED visits or hospitalizations for the same ACSC (6.2% vs. 4.4% of those without; aRR, 1.48; 95% CI, 1.44-1.53). These associations were stronger in stratifications by mental illness diagnostic subgroup, particularly for those with a major mental illness. The presence of mental illness and addiction among high-cost users of medical services may represent an unmet need for quality ambulatory and primary care.
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[Mental disorders in primary care].
Herzig, Lilli; Mühlemann, Nicole; Bischoff, Thomas
2010-05-19
Mental disorders (depression, anxiety and somatization) are frequent in Primary care and are often associated to physical complaints and to psychosocial stressors. Mental disorders have in this way a specific presentation and in addition patients may present different associations of them. Sometimes it is difficult to recognize them, but it is important to do so and to take rapidly care of these patients. Specific screening questions exist and have been used in a research of the Institute of General Medicine and the Department of Ambulatory Care and Community Medicine (PMU), University of Lausanne, Switzerland.
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Restructuring primary care for performance improvement.
Fawcett, Kenneth J; Brummel, Stacy; Byrnes, John J
2009-01-01
Primary care practices can no longer consider ongoing quality assessment and management processes to be optional. There are ever-increasing demands from any number of interested parties for objectively measured proof of outcomes and quality of care. Primary Care Partners (PCP), a 16-site ambulatory affiliate of the Spectrum Health system in Grand Rapids, Michigan, began such a continuous quality improvement (CQI) effort in 2005. The intent was to develop an ongoing systematic process that would raise its performance potential and improve patient outcomes in the areas of chronic disease management and preventive services. This article describes the partnerships PCP established, specific benchmarks and measurements used, processes utilized, and results to date. This could be used as a roadmap for other primary care systems that are working to establish CQI in their daily operations.
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Sachdev, Gloria
2014-08-15
This article discusses considerations for making ambulatory care pharmacist services at least cost neutral and, ideally, generate a margin that allows for service expansion. The four pillars of business sustainability are leadership, staffing, information technology, and compensation. A key facet of leadership in ambulatory care pharmacy practice is creating and expressing a clear vision for pharmacists' services. Staffing considerations include establishing training needs, maximizing efficiencies, and minimizing costs. Information technology is essential for efficiency in patient care delivery and outcomes assessment. The three domains of compensation are cost savings, pay for performance, and revenue generation. The following eight steps for designing and implementing an ambulatory care pharmacist service are discussed: (1) prepare a needs assessment, (2) analyze existing strengths, weaknesses, opportunities, and threats, (3) analyze service gaps and feasibility, (4) consider financial opportunities, (5) consider stakeholders' interests, (6) develop a business plan, (7) implement the service, and (8) measure outcomes. Potential future changes in national healthcare policy (such as pharmacist provider status and expanded pay for performance) could enhance the opportunities for sustainable ambulatory care pharmacy practice. The key challenges facing ambulatory care pharmacists are developing sustainable business models, determining which services yield a positive return on investment, and demanding payment for value-added services. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
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Ambulatory care visits by Taiwanese dentists
Directory of Open Access Journals (Sweden)
Ying-Hwa Su
2013-06-01
Conclusion: There were inequalities in risks of ambulatory care use among Taiwan's dentists. Further studies should be conducted to investigate the causes responsible for the observed geographic and institutional variations in the risk of morbidity among dentists in Taiwan.
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Primary care closed claims experience of Massachusetts malpractice insurers.
Schiff, Gordon D; Puopolo, Ann Louise; Huben-Kearney, Anne; Yu, Winnie; Keohane, Carol; McDonough, Peggy; Ellis, Bonnie R; Bates, David W; Biondolillo, Madeleine
Despite prior focus on high-impact inpatient cases, there are increasing data and awareness that malpractice in the outpatient setting, particularly in primary care, is a leading contributor to malpractice risk and claims. To study patterns of primary care malpractice types, causes, and outcomes as part of a Massachusetts ambulatory malpractice risk and safety improvement project. Retrospective review of pooled closed claims data of 2 malpractice carriers covering most Massachusetts physicians during a 5-year period (January 1, 2005, through December 31, 2009). Data were harmonized between the 2 insurers using a standardized taxonomy. Primary care practices in Massachusetts. All malpractice claims that involved primary care practices insured by the 2 largest insurers in the state were screened. A total of 551 claims from primary care practices were identified for the analysis. Numbers and types of claims, including whether claims involved primary care physicians or practices; classification of alleged malpractice (eg, misdiagnosis or medication error); patient diagnosis; breakdown in care process; and claim outcome (dismissed, settled, verdict for plaintiff, or verdict for defendant). During a 5-year period there were 7224 malpractice claims of which 551 (7.7%) were from primary care practices. Allegations were related to diagnosis in 397 (72.1%), medications in 68 (12.3%), other medical treatment in 41 (7.4%), communication in 15 (2.7%), patient rights in 11 (2.0%), and patient safety or security in 8 (1.5%). Leading diagnoses were cancer (n = 190), heart diseases (n = 43), blood vessel diseases (n = 27), infections (n = 22), and stroke (n = 16). Primary care cases were significantly more likely to be settled (35.2% vs 20.5%) or result in a verdict for the plaintiff (1.6% vs 0.9%) compared with non-general medical malpractice claims (P < .001). In Massachusetts, most primary care claims filed are related to alleged misdiagnosis. Compared with malpractice
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Epplen, Kelly T
2014-08-15
This article discusses how to plan and implement an ambulatory care pharmacist service, how to integrate a hospital- or health-system-based service with the mission and operations of the institution, and how to help the institution meet its challenges related to quality improvement, continuity of care, and financial sustainability. The steps in implementing an ambulatory care pharmacist service include (1) conducting a needs assessment, (2) aligning plans for the service with the mission and goals of the parent institution, (3) collaborating with patients and physicians, (4) standardizing the patient care process, (5) proposing the service, (6) attaining the necessary resources, (7) identifying stakeholders, (8) identifying applicable quality standards, (9) defining competency standards, (10) planning for service payment, and (11) monitoring outcomes. Ambulatory care pharmacists have current opportunities to become engaged with patient-centered medical homes, accountable care organizations, preventive and wellness programs, and continuity of care initiatives. Common barriers to the advancement of ambulatory care pharmacist services include lack of complete access to patient information, inadequate information technology, and lack of payment. Ambulatory care pharmacy practitioners must assertively promote appropriate medication use, provide patient-centered care, pursue integration with the patient care team, and seek appropriate recognition and compensation for the services they provide. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
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Kiselev, Anton R; Gridnev, Vladimir I; Shvartz, Vladimir A; Posnenkova, Olga M; Dovgalevsky, Pavel Ya
2012-01-01
The use of short message services and mobile phone technology for ambulatory care management is the most accessible and most inexpensive way to transition from traditional ambulatory care management to active ambulatory care management in patients with arterial hypertension (AH). The aim of this study was to compare the clinical efficacy of active ambulatory care management supported by short message services and mobile phone technology with traditional ambulatory care management in AH patients. The study included 97 hypertensive patients under active ambulatory care management and 102 patients under traditional ambulatory care management. Blood pressure levels, body mass, and smoking history of patients were analyzed in the study. The duration of study was 1 year. In the active ambulatory care management group, 36% of patients were withdrawn from the study within a year. At the end of the year, 77% of patients from the active care management group had achieved the goal blood pressure level. That was more than 5 times higher than that in the traditional ambulatory care management group (P mobile phone improves the quality of ambulatory care of hypertensive patients. Copyright © 2012 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.
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... for Every Season How to Choose the Best Skin Care Products In This Section Dermatologic Surgery What is dermatologic ... for Every Season How to Choose the Best Skin Care Products Ambulatory Phlebectomy What is ambulatory phlebectomy? Ambulatory phlebectomy ...
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West, David R; James, Katherine A; Fernald, Douglas H; Zelie, Claire; Smith, Maxwell L; Raab, Stephen S
2014-01-01
The majority of errors in laboratory medicine testing are thought to occur in the pre- and postanalytic testing phases, and a large proportion of these errors are secondary to failed handoffs. Because most laboratory tests originate in ambulatory primary care, understanding the gaps in handoff processes within and between laboratories and practices is imperative for patient safety. Therefore, the purpose of this study was to understand, based on information from primary care practice personnel, the perceived gaps in laboratory processes as a precursor to initiating process improvement activities. A survey was used to assess perceptions of clinicians, staff, and management personnel of gaps in handoffs between primary care practices and laboratories working in 21 Colorado primary care practices. Data were analyzed to determine statistically significant associations between categorical variables. In addition, qualitative analysis of responses to open-ended survey questions was conducted. Primary care practices consistently reported challenges and a desire/need to improve their efforts to systematically track laboratory test status, confirm receipt of laboratory results, and report results to patients. Automated tracking systems existed in roughly 61% of practices, and all but one of those had electronic health record-based tracking systems in place. One fourth of these electronic health record-enabled practices expressed sufficient mistrust in these systems to warrant the concurrent operation of an article-based tracking system as backup. Practices also reported 12 different procedures used to notify patients of test results, varying by test result type. The results highlight the lack of standardization and definition of roles in handoffs in primary care laboratory practices for test ordering, monitoring, and receiving and reporting test results. Results also identify high-priority gaps in processes and the perceptions by practice personnel that practice improvement
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Addressing Pediatric Obesity in Ambulatory Care: Where Are We and Where Are We Going?
Lenders, Carine M; Manders, Aaron J; Perdomo, Joanna E; Ireland, Kathy A; Barlow, Sarah E
2016-06-01
Since the "2007 summary report of child and adolescent overweight and obesity treatment" published by Barlow, many obesity intervention studies have been conducted in pediatric ambulatory care. Although several meta-analyses have been published in the interim, many studies were excluded because of the focus and criteria of these meta-analyses. Therefore, the primary goal of this article was to identify randomized case-control trials conducted in the primary care setting and to report on treatment approaches, challenges, and successes. We have developed four themes for our discussion and provide a brief summary of our findings. Finally, we identified major gaps and potential solutions and describe several urgent key action items.
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Transitioning the RN to Ambulatory Care: An Investment in Orientation.
Allen, Juliet Walshe
2016-01-01
Registered nurses (RNs) struggle when transitioning from the inpatient setting to the outpatient clinical environment because it results in a diverse skill-set shift. The RN, considered an outpatient revenue source, experiences a decrease in peer-to-peer relationships, changes in leadership responsibilities, and changes in workgroup dynamics (supervision of unlicensed clinical personnel who function under the direction of the physician, not the RN). Ambulatory organizations find themselves implementing clinical orientation programs that may not delineate the attributes of the RN. This diminishes their value while emphasizing the unlicensed technical skill set. Creating a core RN orientation program template is paramount for the transition of the RN to the ambulatory setting. The literature reveals several areas where improving the value of the RN will ultimately enhance recruitment and retention, patient care outcomes, and leverage the RN role within any organization. Eleven 30-minute in-depth telephone interviews were conducted in addition to 4 nurse observations to explore the lived experience of the RN in ambulatory care. The findings disclosed an overarching theme of nurse isolation and offered insightful underpinnings for the nurse leader as ambulatory growth continues and nurse leaders further endorse the RN presence in the ambulatory setting.
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Ambulatory Melanoma Care Patterns in the United States
International Nuclear Information System (INIS)
Ji, A. L.; Davis, S. A.; Feldman, S. R.; Fleischer, A. B.; Baze, M. R.; Feldman, S. R.; Feldman, S. R.; Fleischer, A. B.
2013-01-01
To examine trends in melanoma visits in the ambulatory care setting. Methods. Data from the National Ambulatory Medical Care Survey (NAMCS) from 1979 to 2010 were used to analyze melanoma visit characteristics including number of visits, age and gender of patients, and physician specialty. These data were compared to US Census population estimates during the same time period. Results. The overall rate of melanoma visits increased (ρ< 0.0001) at an apparently higher rate than the increase in population over this time. The age of patients with melanoma visits increased at approximately double the rate (0.47 year per interval year, ρ< 0.0001) of the population increase in age (0.23 year per interval year). There was a nonsignificant(ρ=0.19) decline in the proportion of female patients seen over the study interval. Lastly, ambulatory care has shifted towards dermatologists and other specialties managing melanoma patients and away from family/internal medicine physicians and general/plastic surgeons. Conclusions. The number and age of melanoma visits has increased over time with respect to the overall population, mirroring the increase in melanoma incidence over the past three decades. These trends highlight the need for further studies regarding melanoma management efficiency
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A PDA based Point of Care E-Health Solution for Ambulatory Care
Directory of Open Access Journals (Sweden)
Daniel Walsh
2005-11-01
Full Text Available The adoption of PDAs and mobile communication is expected to provide a solution to the use of computer technology by healthcare workers at the point-of-care. The Australian National Health Information Strategy, Health Online, is providing national leadership for approaches to address the quality and availability of information to assist in the planning and delivery of care. One area for potential growth is the availability and capture of information at the point of care by healthcare providers. A key factor in the lack of adoption of systems, is that traditionally health care information systems have been designed for desktop computing whereas many healthcare workers are highly mobile. This paper discusses phase one of a larger, four-phase project which aims to develop information access applications at point-of-care for Ambulatory Care Services. The initial phase of the research (phase one involves workflow analysis, requirements specification and the development and testing of a system prototype to assess the feasibility of achieving increased efficiencies in workflow at the Ambulatory Care Service.
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The financial and health burden of diabetic ambulatory care sensitive hospitalisations in Mexico.
Lugo-Palacios, David G; Cairns, John
2016-01-01
To estimate the financial and health burden of diabetic ambulatory care sensitive hospitalisations (ACSH) in Mexico during 2001-2011. We identified ACSH due to diabetic complications in general hospitals run by local health ministries and estimated their financial cost using diagnostic related groups. The health burden estimation assumes that patients would not have experienced complications if they had received appropriate primary care and computes the associated Disability-Adjusted Life Years (DALYs). The financial cost of diabetic ACSH increased by 125% in real terms and their health burden in 2010 accounted for 4.2% of total DALYs associated with diabetes in Mexico. Avoiding preventable hospitalisations could free resources within the health system for other health purposes. In addition, patients with ACSH suffer preventable losses of health that should be considered when assessing the performance of any primary care intervention.
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Patient Satisfaction with Kimbrough Ambulatory Care Center
1997-02-01
few are going to opt to change health plans. 14. SUBJECT TERMS PATIENT SATISFACTION; CONSUMER SATISFACTION; SURVEY 15. NUMBER OF PAGES 57 16...to address is overall patient satisfaction with Kimbrough’s current health care system. I surveyed customers on: how satisfied or dissatisfied they...research project was designed to determine how satisfied customers are with Kimbrough Ambulatory Care Center. A patient satisfaction survey developed by
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Defining your role in ambulatory care: clinical nurse specialist or nurse practitioner?
Sawyers, J E
1993-01-01
A collaborative practice was established at the University of Southern California/Kenneth Norris Jr. Cancer Hospital utilizing combined roles of the CNS and nurse practitioner. The role was created out of a specific need of the physicians of the gastrointestinal malignancy service. Increased administrative and clinical responsibilities necessitated another clinical expert to be readily available for the management of the acute care private practice patients. As a CNS for both the departments of medicine and nursing, my primary responsibilities are focused within the ambulatory care area. This paper presents the concept for this position, the professional and personal benefits, advantages and disadvantages, and recommendations for nursing practice.
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Ambulatory care pavilion takes its place out front by solving multiple needs.
Saukaitis, C A
1994-09-01
In sum, this structure exemplifies the fact that high-tech tertiary care medical centers can be user-friendly to the ambulatory health care consumer by serving their routine needs conveniently and efficiently. Says Gerald Miller, president of Crozer-Chester: "The ambulatory care pavilion has enabled Crozer to successfully and efficiently merge physicians' offices with institutional-based services and inpatient services. We are pleased with how the pavilion positions our medical center for the next century.
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Duc, Ha Anh; Sabin, Lora L.; Cuong, Le Quang; Thien, Duong Duc; Feeley, Rich
2012-01-01
Background Over the past two decades, health insurance in Vietnam has expanded nationwide. Concurrently, Vietnam's private health sector has developed rapidly and become an increasingly integral part of the health system. To date, however, little is understood regarding the potential for expanding public-private partnerships to improve health care access and outcomes in Vietnam. Objective To explore possibilities for public-private collaboration in the provision of ambulatory care at the primary level in the Mekong region, Vietnam. Design We employed a mixed methods research approach. Qualitative methods included focus group discussions with health officials and in-depth interviews with managers of private health facilities. Quantitative methods encompassed facility assessments, and exit surveys of clients at the same private facilities. Results Discussions with health officials indicated generally favorable attitudes towards partnerships with private providers. Concerns were also voiced, regarding the over- and irrational use of antibiotics, and in terms of limited capacity for regulation, monitoring, and quality assurance. Private facility managers expressed a willingness to collaborate in the provision of ambulatory care, and private providers facilites were relatively well staffed and equipped. The client surveys indicated that 80% of clients first sought treatment at a private facility, even though most lived closer to a public provider. This choice was motivated mainly by perceptions of quality of care. Clients who reported seeking care at both a public and private facility were more satisfied with the latter. Conclusions Public-private collaboration in the provision of ambulatory care at the primary level in Vietnam has substantial potential for improving access to quality services. We recommend that such collaboration be explored by Vietnamese policy-makers. If implemented, we strongly urge attention to effectively managing such partnerships, establishing a
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Meta-synthesis on nurse practitioner autonomy and roles in ambulatory care.
Wang-Romjue, Pauline
2018-04-01
Many healthcare stakeholders view nurse practitioners (NPs) as an important workforce resource to help fill the anticipated shortage of 20,400 ambulatory care physicians that is expected by 2020. Multiple quantitative studies revealed the attributes of NPs' practice autonomy and roles. However, there is no qualitative meta-synthesis that describes the experiences of NPs' practice autonomy and roles. To describe and understand the experiences of NPs regarding their practice autonomy and roles in various ambulatory settings through the exploration of existing qualitative studies: meta-synthesis. A qualitative meta-synthesis was conducted to gain insight into ambulatory NPs' practice autonomy and roles through content analysis and reciprocal translation. Articles published between 2000 and 2017 were retrieved by searching 7 databases using the following key words: U.S. qualitative studies, advance practice nurses, NP role in ambulatory care, NP autonomy, and outpatient care. Autonomy, NPs' roles and responsibilities, practice relationships, and organizational work environment pressures are the four main themes that emerged from the content analysis of the nine selected qualitative studies. Within and between states, NPs' experiences with autonomy and NPs' roles are multifaceted depending on state regulations, practice relationships, and organizational work environments. © 2017 Wiley Periodicals, Inc.
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The financial and health burden of diabetic ambulatory care sensitive hospitalisations in Mexico
Directory of Open Access Journals (Sweden)
David G Lugo-Palacios
2016-01-01
Full Text Available Objective.To estimate the financial and health burden of diabetic ambulatory care sensitive hospitalisations (ACSH in Mexico during 2001-2011. Materials and methods. We identified ACSH due to diabetic complications in general hospitals run by local health ministries and estimated their financial cost using diagnostic related groups. The health burden estimation assumes that patients would not have experienced complications if they had received appropriate primary care and computes the associated DisabilityAdjusted Life Years (DALYs. Results. The financial cost of diabetic ACSH increased by 125% in real terms and their health burden in 2010 accounted for 4.2% of total DALYs associated with diabetes in Mexico. Conclusion. Avoiding preventable hospitalisations could free resources within the health system for other health purposes. In addition, patients with ACSH suffer preventable losses of health that should be considered when assessing the performance of any primary care intervention.
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Physician Networks and Ambulatory Care-sensitive Admissions.
Casalino, Lawrence P; Pesko, Michael F; Ryan, Andrew M; Nyweide, David J; Iwashyna, Theodore J; Sun, Xuming; Mendelsohn, Jayme; Moody, James
2015-06-01
Research on the quality and cost of care traditionally focuses on individual physicians or medical groups. Social network theory suggests that the care a patient receives also depends on the network of physicians with whom a patient's physician is connected. The objectives of the study are: (1) identify physician networks; (2) determine whether the rate of ambulatory care-sensitive hospital admissions (ACSAs) varies across networks--even different networks at the same hospital; and (3) determine the relationship between ACSA rates and network characteristics. We identified networks by applying network detection algorithms to Medicare 2008 claims for 987,000 beneficiaries in 5 states. We estimated a fixed-effects model to determine the relationship between networks and ACSAs and a multivariable model to determine the relationship between network characteristics and ACSAs. We identified 417 networks. Mean size: 129 physicians; range, 26-963. In the fixed-effects model, ACSA rates varied significantly across networks: there was a 46% difference in rates between networks at the 25th and 75th performance percentiles. At 95% of hospitals with admissions from 2 networks, the networks had significantly different ACSA rates; the mean difference was 36% of the mean ACSA rate. Networks with a higher percentage of primary-care physicians and networks in which patients received care from a larger number of physicians had higher ACSA rates. Physician networks have a relationship with ACSAs that is independent of the physicians in the network. Physician networks could be an important focus for understanding variations in medical care and for intervening to improve care.
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Concistrè, A; Grillo, A; La Torre, G; Carretta, R; Fabris, B; Petramala, L; Marinelli, C; Rebellato, A; Fallo, F; Letizia, C
2018-04-01
Primary hyperparathyroidism is associated with a cluster of cardiovascular manifestations, including hypertension, leading to increased cardiovascular risk. The aim of our study was to investigate the ambulatory blood pressure monitoring-derived short-term blood pressure variability in patients with primary hyperparathyroidism, in comparison with patients with essential hypertension and normotensive controls. Twenty-five patients with primary hyperparathyroidism (7 normotensive,18 hypertensive) underwent ambulatory blood pressure monitoring at diagnosis, and fifteen out of them were re-evaluated after parathyroidectomy. Short-term-blood pressure variability was derived from ambulatory blood pressure monitoring and calculated as the following: 1) Standard Deviation of 24-h, day-time and night-time-BP; 2) the average of day-time and night-time-Standard Deviation, weighted for the duration of the day and night periods (24-h "weighted" Standard Deviation of BP); 3) average real variability, i.e., the average of the absolute differences between all consecutive BP measurements. Baseline data of normotensive and essential hypertension patients were matched for age, sex, BMI and 24-h ambulatory blood pressure monitoring values with normotensive and hypertensive-primary hyperparathyroidism patients, respectively. Normotensive-primary hyperparathyroidism patients showed a 24-h weighted Standard Deviation (P blood pressure higher than that of 12 normotensive controls. 24-h average real variability of systolic BP, as well as serum calcium and parathyroid hormone levels, were reduced in operated patients (P blood pressure variability is increased in normotensive patients with primary hyperparathyroidism and is reduced by parathyroidectomy, and may potentially represent an additional cardiovascular risk factor in this disease.
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Directory of Open Access Journals (Sweden)
David Little
2003-06-01
Full Text Available The Primary Care Informatics Working Group (PCIWG of the American Medical Informatics Association (AMIA has identified the absence of a national strategy for primary care informatics. Under PCIWG leadership, major national and international societies have come together to create the National Alliance for Primary Care Informatics (NAPCI, to promote a connection between the informatics community and the organisations that support primary care. The PCIWG clinical practice subcommittee has recognised the necessity of a global needs assessment, and proposed work in point-of-care technology, clinical vocabularies, and ambulatory electronic medical record development. Educational needs include a consensus statement on informatics competencies, recommendations for curriculum and teaching methods, and methodologies to evaluate their effectiveness. The research subcommittee seeks to define a primary care informatics research agenda, and to support and disseminate informatics research throughout the primary care community. The AMIA board of directors has enthusiastically endorsed the conceptual basis for this White Paper.
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Sánchez-Sagrado, T
Italy is not a country where Spanish doctors emigrate, as there is an over-supply of health care professionals. The Italian Servizio Sanitario Nazionale has some differences compared to the Spanish National Health System. The Servizio Sanitario Nazionale is financed by national and regional taxes and co-payments. There are taxes earmarked for health, and Primary Care receives 50% of the total funds. Italian citizens and residents in Italy have the right to free health cover. However, there are co-payments for laboratory and imaging tests, pharmaceuticals, specialist ambulatory services, and emergencies. Co-payments vary in the different regions. The provision of services is regional, and thus fragmentation and major inequities are the norm. Doctors in Primary Care are self-employed and from 2000 onwards, there are incentives to work in multidisciplinary teams. Salary is regulated by a national contract and it is the sum of per-capita payments and extra resources for specific activities. Responsibilities are similar to those of Spanish professionals. However, medical care is more personal. Relationships between Primary Care and specialised care depend on the doctors' relationships. Primary Care doctors are gatekeepers for specialised care, except for gynaecology, obstetrics and paediatrics. Specialised training is compulsory in order to work as general practitioner. The Italian Health Care System is a national health system like the Spanish one. However, health care professionals are self-employed, and there are co-payments. In spite of co-payments, Italians have one of the highest average life expectancy, and they support a universal and publicly funded health-care system. Copyright © 2017 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
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Differences in Treatment of Chlamydia trachomatis by Ambulatory Care Setting.
Pearson, William S; Gift, Thomas L; Leichliter, Jami S; Jenkins, Wiley D
2015-12-01
Chlamydia trachomatis (CT) is the most commonly reported sexually transmitted infection (STI) in the US and timely, correct treatment can reduce CT transmission and sequelae. Emergency departments (ED) are an important location for diagnosing STIs. This study compared recommended treatment of CT in EDs to treatment in physician offices. Five years of data (2006-2010) were analyzed from the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Surveys (NHAMCS), including the Outpatient survey (NHAMCS-OPD) and Emergency Department survey (NHAMCS-ED). All visits with a CT diagnosis and those with a diagnosis of unspecified venereal disease were selected for analysis. Differences in receipt of recommended treatments were compared between visits to physician offices and emergency departments using Chi square tests and logistic regression models. During the 5 year period, approximately 3.2 million ambulatory care visits had diagnosed CT or an unspecified venereal disease. A greater proportion of visits to EDs received the recommended treatment for CT compared to visits to physician offices (66.1 vs. 44.9 %, p < .01). When controlling for patients' age, sex and race/ethnicity, those presenting to the ED with CT were more likely to receive the recommended antibiotic treatment than patients presenting to a physician's office (OR 2.16; 95 % CI 1.04-4.48). This effect was attenuated when further controlling for patients' expected source of payment. These analyses demonstrate differences in the treatment of CT by ambulatory care setting as well as opportunities for increasing use of recommended treatments for diagnosed cases of this important STI.
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Robinson, Hal; Engelhardt, Thomas
2017-01-01
Myringotomy and tube placement is one of the most frequently performed ear, nose and throat (ENT) surgeries in the pediatric population. Effective anesthetic management is vital to ensuring successful ambulatory care and ensuring child and parental satisfaction. This review summarizes recently published studies about the long-term effects of general anesthesia in young children, novel approaches to preoperative fasting and simplified approaches to the assessment and management of emergence delirium (ED) and emergence agitation (EA). New developments in perioperative ambulatory care, including management of comorbidities and day care unit logistics, are discussed. Long-term follow-up of children exposed to general anesthesia before the age of 4 years has limited impact on academic achievement or cognitive performance and should not delay the treatment of common ENT pathology, which can impair speech and language development. A more liberal approach to fasting, employing a 6-4-0 regime allowing children fluids up until theater, may become an accepted practice in future. ED and EA should be discriminated from pain in recovery and, where the child is at risk of harm, should be treated promptly. Postoperative pain at home remains problematic in ambulatory surgery and better parental education is needed. Effective ambulatory care ultimately requires a well-coordinated team approach from effective preassessment to postoperative follow-up.
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Primary care pediatricians' perceptions of vaccine refusal in europe.
Grossman, Zachi; van Esso, Diego; Del Torso, Stefano; Hadjipanayis, Adamos; Drabik, Anna; Gerber, Andreas; Miron, Dan
2011-03-01
An electronic survey assessing primary care pediatricians' estimations and practices regarding parents' vaccination refusal was sent to 395 members of the European Academy of Pediatrics Research in Ambulatory Setting network, with a response rate of 87%. Of respondents who vaccinate in the clinic, 93% estimated the total vaccine refusal rate as refusing parents.
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Directory of Open Access Journals (Sweden)
Robinson H
2017-04-01
Full Text Available Hal Robinson, Thomas Engelhardt Department of Anaesthesia, Royal Aberdeen Children’s Hospital, Aberdeen, UK Purpose: Myringotomy and tube placement is one of the most frequently performed ear, nose and throat (ENT surgeries in the pediatric population. Effective anesthetic management is vital to ensuring successful ambulatory care and ensuring child and parental satisfaction.Recent findings: This review summarizes recently published studies about the long-term effects of general anesthesia in young children, novel approaches to preoperative fasting and simplified approaches to the assessment and management of emergence delirium (ED and emergence agitation (EA. New developments in perioperative ambulatory care, including management of comorbidities and day care unit logistics, are discussed.Summary: Long-term follow-up of children exposed to general anesthesia before the age of 4 years has limited impact on academic achievement or cognitive performance and should not delay the treatment of common ENT pathology, which can impair speech and language development. A more liberal approach to fasting, employing a 6–4–0 regime allowing children fluids up until theater, may become an accepted practice in future. ED and EA should be discriminated from pain in recovery and, where the child is at risk of harm, should be treated promptly. Postoperative pain at home remains problematic in ambulatory surgery and better parental education is needed. Effective ambulatory care ultimately requires a well-coordinated team approach from effective preassessment to postoperative follow-up. Keywords: myringotomy, ventilation tubes, anesthesia, pediatrics, ambulatory, day case
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Cognitive assessment on elderly people under ambulatory care
Directory of Open Access Journals (Sweden)
Bruna Zortea
2015-04-01
Full Text Available Objective: to evaluate the cognitive state of elderly people under ambulatory care and investigating the connection between such cognitive state and sociodemographic variables, health conditions, number of and adhesion to medicine. Methods: transversal, exploratory, and descriptive study, with a quantitative approach, realized with 107 elderly people under ambulatory care in a university hospital in southern Brazil, in november, 2013. The following variables were used: gender, age, civil status, income, schooling, occupation, preexisting noncommunicable diseases, number and type of prescribed medications, adhesion, mini-mental state examination score, and cognitive status. Data was analyzed through inferential and descriptive statistics. Results: the prevalence of cognitive deficit was of 42.1% and had a statistically significant connection to schooling, income, civil status, hypertension, and cardiopathy. Conclusion: nurses can intervene to avoid the increase of cognitive deficit through an assessment of the elderly person, directed to facilitative strategies to soften this deficit.
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Tourigny, Jocelyne; Chartrand, Julie; Massicotte, Julie
2008-01-01
Changes in health care delivery in Canada and Europe, especially the shift to ambulatory care, have modified the care that children and parents receive and have prompted the need for a partnership alliance. The objectives of this exploratory study were to identify Canadian and Belgian health professionals' beliefs and attitudes towards parental involvement in their child's ambulatory care and to determine if these beliefs varied according to cultural background. Health professionals from both countries generally were in favor of parental involvement in their child's care, but are uncertain about its advantages and disadvantages. Facilitators and barriers mentioned by the health care providers were related to parents' abilities or their attitudes toward partnership, and they also expressed a need for more education on the subject. Results of this study indicate that health professionals working in ambulatory care are not fully ready to utilize parents as true partners in their interventions with children and families. Staff education is an important step towards the establishment and maintenance of a real partnership.
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Wait watchers: the application of a waiting list active management program in ambulatory care.
de Belvis, Antonio Giulio; Marino, Marta; Avolio, Maria; Pelone, Ferruccio; Basso, Danila; Dei Tos, Gian Antonio; Cinquetti, Sandro; Ricciardi, Walter
2013-04-01
This study describes and evaluates the application of a waiting list management program in ambulatory care. Waiting list active management survey (telephone call and further contact); before and after controlled trial. Local Health Trust in Veneto Region (North-East of Italy) in 2008-09. Five hundred and one people on a 554 waiting list for C Class ambulatory care diagnostic and/or clinical investigations (electrocardiography plus cardiology ambulatory consultation, eye ambulatory consultation, carotid vessels Eco-color-Doppler, legs Eco-color-Doppler or colonoscopy, respectively). Active list management program consisting of a telephonic interview on 21 items to evaluate socioeconomic features, self-perceived health status, social support, referral physician, accessibility and patients' satisfaction. A controlled before-and-after study was performed to evaluate anonymously the overall impact on patients' self-perceived quality of care. The rate of patients with deteriorating healthcare conditions; rate of dropout; interviewed degree of satisfaction about the initiative; overall impact on citizens' perceived quality of care. 95.4% patients evaluated the initiative as useful. After the intervention, patients more likely to have been targeted with the program showed a statistically significant increase in self-reported quality of care. Positive impact of the program on some dimensions of ambulatory care quality (health status, satisfaction, willingness to remain in the queue), thus confirming the outstanding value of 'not to leave people alone' and 'not to leave them feeling themselves alone' in healthcare delivery.
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Adopting Ambulatory Breast Cancer Surgery as the Standard of Care in an Asian Population
Directory of Open Access Journals (Sweden)
Yvonne Ying Ru Ng
2014-01-01
Full Text Available Introduction. Ambulatory surgery is not commonly practiced in Asia. A 23-hour ambulatory (AS23 service was implemented at our institute in March 2004 to allow more surgeries to be performed as ambulatory procedures. In this study, we reviewed the impact of the AS23 service on breast cancer surgeries and reviewed surgical outcomes, including postoperative complications, length of stay, and 30-day readmission. Methods. Retrospective review was performed of 1742 patients who underwent definitive breast cancer surgery from 1 March 2004 to 31 December 2010. Results. By 2010, more than 70% of surgeries were being performed as ambulatory procedures. Younger women (P<0.01, those undergoing wide local excision (P<0.01 and those with ductal carcinoma-in situ or early stage breast cancer (P<0.01, were more likely to undergo ambulatory surgery. Six percent of patients initially scheduled for ambulatory surgery were eventually managed as inpatients; a third of these were because of perioperative complications. Wound complications, 30-day readmission and reoperation rates were not more frequent with ambulatory surgery. Conclusion. Ambulatory breast cancer surgery is now the standard of care at our institute. An integrated workflow facilitating proper patient selection and structured postoperativee outpatient care have ensured minimal complications and high patient acceptance.
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Ferrer, Robert L
2007-01-01
Long-term shifts in specialty choice and health workforce policy have raised concern about the future of primary care in the United States. The objective of this study was to examine current use of primary and specialty care across the US population for policy-relevant subgroups, such as disadvantaged populations and persons with chronic illness. Data from the Medical Expenditure Panel Survey from 2004 were analyzed using a probability sample patients or other participants from the noninstitutionalized US population in 2004 (N = 34,403). The main and secondary outcome measures were the estimates of the proportion of Americans who accessed different types of primary care and specialty physicians and midlevel practitioners, as well as the fraction of ambulatory visits accounted for by the different clinician types. Data were disaggregated by income, health insurance status, race/ethnicity, rural or urban residence, and presence of 5 common chronic diseases. Family physicians were the most common clinician type accessed by adults, seniors, and reproductive-age women, and they were second to pediatricians for children. Disadvantaged adults with 3 markers of disadvantage (poverty, disadvantaged minority, uninsured) received 45.6% (95% CI, 40.4%-50.7%) of their ambulatory visits from family physicians vs 30.5% (95% CI, 30.0%-32.1%) for adults with no markers. For children with 3 vs 0 markers of disadvantage, the proportion of visits from family physicians roughly doubled from 16.5% (95% CI, 14.4%-18.6%) to 30.1% (95% CI, 18.8%-41.2%). Family physicians constitute the only clinician group that does not show income disparities in access. Multivariate analyses show that patterns of access to family physicians and nurse-practitioners are more equitable than for other clinician types. Primary care clinicians, especially family physicians, deliver a disproportionate share of ambulatory care to disadvantaged populations. A diminished primary care workforce will leave
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Walsh, Carolyn O; Milliren, Carly E; Feldman, Henry A; Taveras, Elsie M
2013-08-01
To determine referral patterns from pediatric primary care to subspecialists for overweight/obesity and related comorbidities. We used the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to identify overweight/obesity and 5 related comorbidities in primary care visits between 2005 and 2009 by children 6 to 18 years. The primary outcome was whether the visit ended in referral. We used multivariable analysis to examine factors associated with referral. We identified 34,225 database visits. A total of 17.1% were with overweight (body mass index=85th to 94th percentile) or obese (body mass index≥95th percentile) patients. A total of 7.1% of primary care visits with overweight/obese children ended in referral. Referral was more likely when obesity was the reason for visit (odds ratio=2.83; 95% confidence interval=1.61-4.97) but was not associated with presence of a comorbidity (odds ratio=1.35; 95% confidence interval=0.75-2.44). Most overweight or obese children are not referred, regardless of comorbidity status. One reason may be low levels of appropriate diagnosis.
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Directory of Open Access Journals (Sweden)
Künzi Beat
2010-11-01
Full Text Available Abstract Background Swiss ambulatory care is characterized by independent, and primarily practice-based, physicians, receiving fee for service reimbursement. This study analyses supply sensitive services using ambulatory care claims data from mandatory health insurance. A first research question was aimed at the hypothesis that physicians with large patient lists decrease their intensity of services and bill less per patient to health insurance, and vice versa: physicians with smaller patient lists compensate for the lack of patients with additional visits and services. A second research question relates to the fact that several cantons are allowing physicians to directly dispense drugs to patients ('self-dispensation' whereas other cantons restrict such direct sales to emergencies only. This second question was based on the assumption that patterns of rescheduling patients for consultations may differ across channels of dispensing prescription drugs and therefore the hypothesis of different consultation costs in this context was investigated. Methods Complete claims data paid for by mandatory health insurance of all Swiss physicians in own practices were analyzed for the years 2003-2007. Medical specialties were pooled into six main provider types in ambulatory care: primary care, pediatrics, gynecology & obstetrics, psychiatrists, invasive and non-invasive specialists. For each provider type, regression models at the physician level were used to analyze the relationship between the number of patients treated and the total sum of treatment cost reimbursed by mandatory health insurance. Results The results show non-proportional relationships between patient numbers and total sum of treatment cost for all provider types involved implying that treatment costs per patient increase with higher practice size. The related additional costs to the health system are substantial. Regions with self-dispensation had lowest treatment cost for primary care
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Directory of Open Access Journals (Sweden)
Khatereh Mahori
2002-04-01
Full Text Available Background: Improvement of medical education is necessary for meeting health care demands. Participation of private practice physicians in ambulatory care training is an effective method for enhancing medical students' skills. Purpose This study was undertaken to determine clinical professors' views about participation of physicians with private office in ambulatory care training. Methods: Participants composed of 162 Shiraz Medical University faculty members from 12 disciplines. A questionnaire requesting faculty members' views on different aspects of ambulat01y care teaching and interaction of community-based organizations was distributed. Results: Of 120 (74.1% respondents, 64 (54.2% believed that clinical settings of medical university are appropriate for ambulatory care training. Private practice physicians believed more than academic physicians without private office that private offices have wider range of patients, more common cases, and better follow up chance; and is also a better setting for learning ambulatory care compared with medical university clinical centers. Overall, 32 (29.1% respondent’s found the participation of physicians with private practice on medical education positive. Key words medical education, ambulatory medicine, private practice
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Takaki, Hiroko; Onozuka, Daisuke; Hagihara, Akihito
2018-03-01
Many adults with migraine who require preventive therapy are often not prescribed the proper medications. The most likely reason is that primary care physicians are unacquainted with preventive medications for migraine. The present study assessed the migraine-preventive prescription patterns in office visits using data from the National Ambulatory Medical Care Survey from 2006 to 2009 in the United States. Patients who were 18 years or older and diagnosed with migraine were included in the analysis. In accordance with the recommendations of the headache guidelines, we included beta-blockers, antidepressants, triptans for short-term prevention of menstrual migraine, and other triptans for acute treatment. Weighted visits of adults with migraine prescribed with preventive medication ranged from 32.8% in 2006 to 38.6% in 2009. Visits to primary care physicians accounted for 72.6% of the analyzed adult migraine visits. Anticonvulsants (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.14-0.57, p < 0.001) and triptans for menstrual migraine (OR 0.50, 95% CI 0.28-0.91, p = 0.025) were less frequently prescribed by primary care physicians compared with specialty care physicians, such as neurologists and psychiatrists. There were no significant differences in the prescription patterns of antidepressants and beta-blockers between primary and specialty care physicians. Beta-blockers were prescribed to patients with comorbidity of hypertension, and antidepressants were used by patients with comorbidity of depression. There are differences in the prescription patterns of certain type of preventive medications between primary care physicians and specialty care physicians.
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Directory of Open Access Journals (Sweden)
Hiroko Takaki
2018-03-01
Full Text Available Many adults with migraine who require preventive therapy are often not prescribed the proper medications. The most likely reason is that primary care physicians are unacquainted with preventive medications for migraine. The present study assessed the migraine-preventive prescription patterns in office visits using data from the National Ambulatory Medical Care Survey from 2006 to 2009 in the United States. Patients who were 18 years or older and diagnosed with migraine were included in the analysis. In accordance with the recommendations of the headache guidelines, we included beta-blockers, antidepressants, triptans for short-term prevention of menstrual migraine, and other triptans for acute treatment. Weighted visits of adults with migraine prescribed with preventive medication ranged from 32.8% in 2006 to 38.6% in 2009. Visits to primary care physicians accounted for 72.6% of the analyzed adult migraine visits. Anticonvulsants (odds ratio [OR] 0.29, 95% confidence interval [CI] 0.14–0.57, p < 0.001 and triptans for menstrual migraine (OR 0.50, 95% CI 0.28–0.91, p = 0.025 were less frequently prescribed by primary care physicians compared with specialty care physicians, such as neurologists and psychiatrists. There were no significant differences in the prescription patterns of antidepressants and beta-blockers between primary and specialty care physicians. Beta-blockers were prescribed to patients with comorbidity of hypertension, and antidepressants were used by patients with comorbidity of depression. There are differences in the prescription patterns of certain type of preventive medications between primary care physicians and specialty care physicians.
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Electronic health record "super-users" and "under-users" in ambulatory care practices.
Rumball-Smith, Juliet; Shekelle, Paul; Damberg, Cheryl L
2018-01-01
This study explored variation in the extent of use of electronic health record (EHR)-based health information technology (IT) functionalities across US ambulatory care practices. Use of health IT functionalities in ambulatory care is important for delivering high-quality care, including that provided in coordination with multiple practitioners. We used data from the 2014 Healthcare Information and Management Systems Society Analytics survey. The responses of 30,123 ambulatory practices with an operational EHR were analyzed to examine the extent of use of EHR-based health IT functionalities for each practice. We created a novel framework for classifying ambulatory care practices employing 7 domains of health IT functionality. Drawing from the survey responses, we created a composite "use" variable indicating the extent of health IT functionality use across these domains. "Super-user" practices were defined as having near-full employment of the 7 domains of health IT functionalities and "under-users" as those with minimal or no use of health IT functionalities. We used multivariable logistic regression to investigate how the odds of super-use and under-use varied by practice size, type, urban or rural location, and geographic region. Seventy-three percent of practices were not using EHR technologies to their full capability, and nearly 40% were classified as under-users. Under-user practices were more likely to be of smaller size, situated in the West, and located outside a metropolitan area. To achieve the broader benefits of the EHR and health IT, health systems and policy makers need to identify and address barriers to full use of health IT functionalities.
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[Management of alcohol use disorders in ambulatory care: Which follow-up and for how long?].
Benyamina, A; Reynaud, M
2016-02-01
Alcohol consumption with its addictive potential may lead to physical and psychological dependence as well as systemic toxicity all of which have serious detrimental health outcomes in terms of morbimortality. Despite the harmful potential of alcohol use disorders, the disease is often not properly managed, especially in ambulatory care. Psychiatric and general practitioners in ambulatory care are first in line to detect and manage patients with excessive alcohol consumption. However, this is still often regarded as an acute medical condition and its management is generally considered only over the short-term. On the contrary, alcohol dependence has been defined as a primary chronic disease of the brain reward, motivation, memory and related circuitry, involving the signalling pathway of neurotransmitters such as dopamine, opioid peptides, and gamma-aminobutyric acid. Thus, it should be regarded in terms of long-term management as are other chronic diseases. To propose a standard pathway for the management of alcohol dependence in ambulatory care in terms of duration of treatment and follow-up. Given the lack of official recommendations from health authorities which may help ambulatory care physicians in long-term management of patients with alcohol dependence, we performed a review and analysis of the most recent literature regarding the long-term management of other chronic diseases (diabetes, bipolar disorders, and depression) drawing a parallel with alcohol dependence. Alcohol dependence shares many characteristics with other chronic diseases, including a prolonged duration, intermittent acute and chronic exacerbations, and need for prolonged and often-lifelong care. In all cases, this requires sustained psychosocial changes from the patient. Patient motivation is also a major issue and should always be taken into consideration by psychiatric and general practitioners in ambulatory care. In chronic diseases, such as diabetes, bipolar disorders, or depression
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Improving outpatient access and patient experiences in academic ambulatory care.
O'Neill, Sarah; Calderon, Sherry; Casella, Joanne; Wood, Elizabeth; Carvelli-Sheehan, Jayne; Zeidel, Mark L
2012-02-01
Effective scheduling of and ready access to doctor appointments affect ambulatory patient care quality, but these are often sacrificed by patients seeking care from physicians at academic medical centers. At one center, Beth Israel Deaconess Medical Center, the authors developed interventions to improve the scheduling of appointments and to reduce the access time between telephone call and first offered appointment. Improvements to scheduling included no redirection to voicemail, prompt telephone pickup, courteous service, complete registration, and effective scheduling. Reduced access time meant being offered an appointment with a physician in the appropriate specialty within three working days of the telephone call. Scheduling and access were assessed using monthly "mystery shopper" calls. Mystery shoppers collected data using standardized forms, rated the quality of service, and transcribed their interactions with schedulers. Monthly results were tabulated and discussed with clinical leaders; leaders and frontline staff then developed solutions to detected problems. Eighteen months after the beginning of the intervention (in June 2007), which is ongoing, schedulers had gone from using 60% of their registration skills to over 90%, customer service scores had risen from 2.6 to 4.9 (on a 5-point scale), and average access time had fallen from 12 days to 6 days. The program costs $50,000 per year and has been associated with a 35% increase in ambulatory volume across three years. The authors conclude that academic medical centers can markedly improve the scheduling process and access to care and that these improvements may result in increased ambulatory care volume.
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[Face-lift surgery in ambulatory].
Soulhiard, F
2017-10-01
The proposal is to demonstrate that facelift surgery is particularly suitable for the care in ambulatory. Between 2010 and 2016, 246 patients were operated for a facelift in ambulatory. No major complication arose in this series (241). Among the patients, 98% expressed their satisfaction and would accept again this intervention in ambulatory. The facelift can be realized in ambulatory with complete safety. The rate of satisfaction shows a very strong support of the patients for the ambulatory care. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
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Pracht, Etienne E; Bass, Elizabeth
2011-01-01
This paper explores the link between utilization of ambulatory care and the likelihood of rehospitalization for an avoidable reason in veterans served by the Veteran Health Administration (VA). The analysis used administrative data containing healthcare utilization and patient characteristics stored at the national VA data warehouse, the Corporate Franchise Data Center. The study sample consisted of 284 veterans residing in Florida who had been hospitalized at least once for an avoidable reason. A bivariate probit model with instrumental variables was used to estimate the probability of rehospitalization. Veterans who had at least 1 ambulatory care visit per month experienced a significant reduction in the probability of rehospitalization for the same avoidable hospitalization condition. The findings suggest that ambulatory care can serve as an important substitute for more expensive hospitalization for the conditions characterized as avoidable. © 2011 National Association for Healthcare Quality.
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The comprehensive care project: measuring physician performance in ambulatory practice.
Holmboe, Eric S; Weng, Weifeng; Arnold, Gerald K; Kaplan, Sherrie H; Normand, Sharon-Lise; Greenfield, Sheldon; Hood, Sarah; Lipner, Rebecca S
2010-12-01
To investigate the feasibility, reliability, and validity of comprehensively assessing physician-level performance in ambulatory practice. Ambulatory-based general internists in 13 states participated in the assessment. We assessed physician-level performance, adjusted for patient factors, on 46 individual measures, an overall composite measure, and composite measures for chronic, acute, and preventive care. Between- versus within-physician variation was quantified by intraclass correlation coefficients (ICC). External validity was assessed by correlating performance on a certification exam. Medical records for 236 physicians were audited for seven chronic and four acute care conditions, and six age- and gender-appropriate preventive services. Performance on the individual and composite measures varied substantially within (range 5-86 percent compliance on 46 measures) and between physicians (ICC range 0.12-0.88). Reliabilities for the composite measures were robust: 0.88 for chronic care and 0.87 for preventive services. Higher certification exam scores were associated with better performance on the overall (r = 0.19; pmeasures and by sampling feasible numbers of patients for each condition. © Health Research and Educational Trust.
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Anaesthesia for Ambulatory Paediatric Surgery: Common ...
African Journals Online (AJOL)
BACKGROUND: Ambulatory surgical care accounts for over 70% of elective procedures in Northern America. Ambulatory paediatric surgical practice is not widespread in Nigeria. This report examined clinical indicators for quality care in paediatric ambulatory surgery using common outcomes after day case procedures as ...
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Liyanage, H; Liaw, S-T; Kuziemsky, C; Terry, A L; Jones, S; Soler, J K; de Lusignan, S
2013-01-01
Most chronic diseases are managed in primary and ambulatory care. The chronic care model (CCM) suggests a wide range of community, technological, team and patient factors contribute to effective chronic disease management. Ontologies have the capability to enable formalised linkage of heterogeneous data sources as might be found across the elements of the CCM. To describe the evidence base for using ontologies and other semantic integration methods to support chronic disease management. We reviewed the evidence-base for the use of ontologies and other semantic integration methods within and across the elements of the CCM. We report them using a realist review describing the context in which the mechanism was applied, and any outcome measures. Most evidence was descriptive with an almost complete absence of empirical research and important gaps in the evidence-base. We found some use of ontologies and semantic integration methods for community support of the medical home and for care in the community. Ubiquitous information technology (IT) and other IT tools were deployed to support self-management support, use of shared registries, health behavioural models and knowledge discovery tools to improve delivery system design. Data quality issues restricted the use of clinical data; however there was an increased use of interoperable data and health system integration. Ontologies and semantic integration methods are emergent with limited evidence-base for their implementation. However, they have the potential to integrate the disparate community wide data sources to provide the information necessary for effective chronic disease management.
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Sánchez-Sagrado, T
2017-09-01
Belgium is an attractive country to work in, not just for doctors but for all Spanish workers, due to it having the headquarters of European Union. The health job allure is double; on the one hand, the opportunity to find a decent job, and on the other, because it is possible to develop their professional abilities with patients of the same nationality in a health system with a different way of working. The Belgium health care system is based on security social models. Health care is financed by the government, social security contributions, and voluntary private health insurance. Primary care in Belgium is very different to that in Spain. Citizens may freely choose their doctor (general practitioner or specialist) increasing the lack of coordination between primary and specialized care. This leads to serious patient safety problems and loss of efficiency within the system. Belgium is a European country with room to improve preventive coverage. General practitioners are self-employed professionals with free choice of setting, and their salary is linked to their professional activity. Ambulatory care is subjected to co-payment, and this fact leads to great inequities on access to care. The statistics say that there is universal coverage but, in 2010, 14% of the population did not seek medical contact due to economic problems. It takes 3 years to become a General Practitioner and continuing medical education is compulsory to be revalidated. In general, Belgian and Spaniards living and working in Belgium are happy with the functioning of the health care system. However, as doctors, we should be aware that it is a health care system in which access is constrained for some people, and preventive coverage could be improved. Copyright © 2016 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
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Directory of Open Access Journals (Sweden)
Amy B. Martin
2012-09-01
Full Text Available Disasters serve as shocks and precipitate unanticipated disturbances to the health care system. Public health surveillance is generally focused on monitoring latent health and environmental exposure effects, rather than health system performance in response to these local shocks. The following intervention study sought to determine the long-term effects of the 2005 chlorine spill in Graniteville, South Carolina on primary care access for vulnerable populations. We used an interrupted time-series approach to model monthly visits for Ambulatory Care Sensitive Conditions, an indicator of unmet primary care need, to quantify the impact of the disaster on unmet primary care need in Medicaid beneficiaries. The results showed Medicaid beneficiaries in the directly impacted service area experienced improved access to primary care in the 24 months post-disaster. We provide evidence that a health system serving the medically underserved can prove resilient and display improved adaptive capacity under adverse circumstances (i.e., technological disasters to ensure access to primary care for vulnerable sub-groups. The results suggests a new application for ambulatory care sensitive conditions as a population-based metric to advance anecdotal evidence of secondary surge and evaluate pre- and post-health system surge capacity following a disaster.
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Clarke, Martina A; Moore, Joi L; Steege, Linsey M; Koopman, Richelle J; Belden, Jeffery L; Canfield, Shannon M; Kim, Min S
2018-09-01
The purpose of this study was to determine the information needs of primary care patients as they review clinic visit notes to inform information that should be contained in an after-visit summary (AVS). We collected data from 15 patients with an acute illness and 14 patients with a chronic disease using semi-structured interviews. The acute patients reviewed seven major sections, and chronic patients reviewed eight major sections of a simulated, but realistic visit note to identify relevant information needs for their AVS. Patients in the acute illness group identified the Plan, Assessment and History of Present Illness the most as important note sections, while patients in the chronic care group identified Significant Lab Data, Plan, and Assessment the most as important note sections. This study was able to identify primary care patients' information needs after clinic visit. Primary care patients have information needs pertaining to diagnosis and treatment, which may be the reason why both patient groups identified Plan and Assessment as important note sections. Future research should also develop and assess an AVS based on the information gathered in this study and evaluate its usefulness among primary care patients. The results of this study can be used to inform the development of an after-visit summary that assists patients to fully understand their treatment plan, which may improve treatment adherence.
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Perceptions of Ambulatory Workflow Changes in an Academic Primary Care Setting.
Hanak, Michael A; McDevitt, Colleen; Dunham, Daniel P
As health care moves to a value-based system, the need for team-based models of care becomes increasingly important to adequately address the growing number of clinical quality metrics required of health care providers. Finding ways to better engage certified medical assistants (CMAs) in the process allows providers to focus on more complex tasks while improving the efficiency of each office visit. Although the roles and responsibilities for CMAs across the specialties can vary widely, standardizing the work can be a helpful step in scaling best practices across an institution. This article presents the results of a survey that evaluated various components of a CMA workflow in adult primary care practices within an academic medical center. Although the survey identified improved engagement and satisfaction with standardized changes overall, it also showed time constraints and provider discretion forcing unplanned modifications. Reviewing and reconciling medications seemed to be the most challenging for CMA staff, leading us to reconsider their involvement in this aspect of each visit. It will be important to continue innovating and testing team-based care models to keep up with the demands of a quality-based health care system.
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Correa-Velez, Ignacio; Ansari, Zahid; Sundararajan, Vijaya; Brown, Kaye; Gifford, Sandra M
2007-10-03
Hospitalisation for ambulatory care sensitive conditions (ACSHs) has become a recognised tool to measure access to primary care. Timely and effective outpatient care is highly relevant to refugee populations given the past exposure to torture and trauma, and poor access to adequate health care in their countries of origin and during flight. Little is known about ACSHs among resettled refugee populations. With the aim of examining the hypothesis that people from refugee backgrounds have higher ACSHs than people born in the country of hospitalisation, this study analysed a six-year state-wide hospital discharge dataset to estimate ACSH rates for residents born in refugee-source countries and compared them with the Australia-born population. Hospital discharge data between 1 July 1998 and 30 June 2004 from the Victorian Admitted Episodes Dataset were used to assess ACSH rates among residents born in eight refugee-source countries, and compare them with the Australia-born average. Rate ratios and 95% confidence levels were used to illustrate these comparisons. Four categories of ambulatory care sensitive conditions were measured: total, acute, chronic and vaccine-preventable. Country of birth was used as a proxy indicator of refugee status. When compared with the Australia-born population, hospitalisations for total and acute ambulatory care sensitive conditions were lower among refugee-born persons over the six-year period. Chronic and vaccine-preventable ACSHs were largely similar between the two population groups. Contrary to our hypothesis, preventable hospitalisation rates among people born in refugee-source countries were no higher than Australia-born population averages. More research is needed to elucidate whether low rates of preventable hospitalisation indicate better health status, appropriate health habits, timely and effective care-seeking behaviour and outpatient care, or overall low levels of health care-seeking due to other more pressing needs during
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[Travel times of patients to ambulatory care physicians in Germany].
Schang, Laura; Kopetsch, Thomas; Sundmacher, Leonie
2017-12-01
The time needed by patients to get to a doctor's office represents an important indicator of realised access to care. In Germany, findings on travel times are only available from surveys or for some regions. For the first time, this study examines nationwide and physician group-specific travel times in the ambulatory care sector in Germany and describes demographic, supply-side and spatial determinants of variations. Using a full review of patient consultations in the statutory health insurance system from 2009/2010 for 14 physician groups (approximately 518 million cases), case-related travel times by car between patients' places of residence and physician's practices were estimated at the municipal level. Physicians were reached in less than 30 min in 90.8% of cases for primary care physicians and up to 63% of cases for radiologists. Patients between 18 and under 30 years of age travel longer to get to the doctor than other age groups. The average travel time at the county level systematically differs between urban and rural planning areas. In the case of gynecologists, dermatologists and ophthalmologists, the average journey time decreases with increasing physician density at the county level, but remains approximately constant from a recognisable point of inflection. There is no association between primary care physician density and travel time at the district level. Spatial analyses show physician group-specific patterns of regional concentrations with an increased proportion of cases with very long travel times. Patients' travel times are influenced by supply- and demand-side determinants. Interactions between influential determinants should be analysed in depth to examine the extent to which the time travelled is an expression of regional under- or over-supply rather than an expression of patient preferences.
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Melzer, Sanford M; Richards, Gail E; Covington, Maxine L
2004-09-01
The ambulatory care for children with diabetes mellitus (DM) within an endocrinology specialty practice typically includes services provided by a multidisciplinary team. The resource-based relative value scale (RBRVS) is increasingly used to determine payments for ambulatory services in pediatrics. It is not known to what extent resource-based practice expenses and physician work values as allocated through the RBRVS for physician and non-physician practice expenses cover the actual costs of multidisciplinary ambulatory care for children with DM. A pediatric endocrinology and diabetes clinic staffed by faculty physicians and hospital support staff in a children's hospital. Data from a faculty practice plan billing records and income and expense reports during the period from 1 July 2000 to 30 June 2001 were used to determine endocrinologist physician ambulatory productivity, revenue collection, and direct expenses (salary, benefits, billing, and professional liability (PLI)). Using the RBRVS, ambulatory care revenue was allocated between physician, PLI, and practice expenses. Applying the activity-based costing (ABC) method, activity logs were used to determine non-physician and facility practice expenses associated with endocrine (ENDO) or diabetes visits. Of the 4735 ambulatory endocrinology visits, 1420 (30%) were for DM care. Physicians generated $866,582 in gross charges. Cash collections of 52% of gross charges provided revenue of $96 per visit. Using the actual Current Procedural Terminology (CPT)-4 codes reported for these services and the RBRVS system, the revenue associated with the 13,007 total relative value units (TRVUs) produced was allocated, with 58% going to cover physician work expenses and 42% to cover non-physician practice salary, facility, and PLI costs. Allocated revenue of $40.60 per visit covered 16 and 31% of non-physician and facility practice expenses per DM and general ENDO visit, respectively. RBRVS payments ($35/RVU) covered 46% of
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Utilisation of information technologies in ambulatory care in Switzerland.
Rosemann, Thomas; Marty, Franz; Bhend, Heinz; Wagner, Judith; Brunner, Lorenzo; Zoller, Marco
2010-09-13
The importance of electronic medical records for the healthcare system is well documented. IT enables easy storage, communication and decision support and can provide important tools in the care of chronically ill patients in the form of a reminder system. A questionnaire was developed and send out to 1200 physicians extracted from the official data base. After four weeks the non-responders received a written reminder. Data collection started in December 2007 and was completed in February 2008. 719 questionnaires were received back, representing a response rate of 59.9%. The data revealed a significant underuse of electronic medical records (EMRs) and IT compared to other European countries. Smaller practices, older physicians and especially primary care physicians tended to use less EMR. Only 10.2% of all physicians declared an interest in considering investment in IT in the next three years, 66.9% expressly denied wishing to do so. The most important barriers were the costs, the unclear benefit and a feared worsening of the doctor-patient-communication during consultation. IT and especially EMRs are underused in daily ambulatory care in Switzerland. To increase the use of EMRs, several approaches could be helpful. First of all, the benefit of EMRs in daily routine care have to be increased as, for example, by decision support systems, tools to avoid pharmaceutical interactions and reminder systems to enable a proactive treatment of chronically ill patients. Furthermore, adequate approaches to offer appropriate reimbursement for the financial investments have to considered such as an additional payment for electronically generated, evidence based quality indicators.
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Emergency service: a strategy for hospital-sponsored ambulatory care satellites.
Gregory, D; Klegon, D; Steinhauer, B
1984-01-01
This analysis of the overall market position of free-standing emergency care was based on a telephone survey of 300 randomly chosen households in a southeastern metropolitan area. Results show that consumer preferences for cost and convenience create a strong market for free-standing emergency facilities. Emergicare centers are in an ideal situation to capture the market for acute and minor emergency care. To be worthwhile, the emergency room in a more comprehensive ambulatory care facility should serve as a feeder of new patients and be profitable in its own right. However, free-standing emergency facilities must not only attract patients through convenience and price, but they must also maintain patients through assuring quality care and satisfaction.
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Directory of Open Access Journals (Sweden)
Brown Kaye
2007-10-01
Full Text Available Abstract Background Hospitalisation for ambulatory care sensitive conditions (ACSHs has become a recognised tool to measure access to primary care. Timely and effective outpatient care is highly relevant to refugee populations given the past exposure to torture and trauma, and poor access to adequate health care in their countries of origin and during flight. Little is known about ACSHs among resettled refugee populations. With the aim of examining the hypothesis that people from refugee backgrounds have higher ACSHs than people born in the country of hospitalisation, this study analysed a six-year state-wide hospital discharge dataset to estimate ACSH rates for residents born in refugee-source countries and compared them with the Australia-born population. Methods Hospital discharge data between 1 July 1998 and 30 June 2004 from the Victorian Admitted Episodes Dataset were used to assess ACSH rates among residents born in eight refugee-source countries, and compare them with the Australia-born average. Rate ratios and 95% confidence levels were used to illustrate these comparisons. Four categories of ambulatory care sensitive conditions were measured: total, acute, chronic and vaccine-preventable. Country of birth was used as a proxy indicator of refugee status. Results When compared with the Australia-born population, hospitalisations for total and acute ambulatory care sensitive conditions were lower among refugee-born persons over the six-year period. Chronic and vaccine-preventable ACSHs were largely similar between the two population groups. Conclusion Contrary to our hypothesis, preventable hospitalisation rates among people born in refugee-source countries were no higher than Australia-born population averages. More research is needed to elucidate whether low rates of preventable hospitalisation indicate better health status, appropriate health habits, timely and effective care-seeking behaviour and outpatient care, or overall low levels
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Sensitivity and specificity of obesity diagnosis in pediatric ambulatory care in the United States.
Walsh, Carolyn O; Milliren, Carly E; Feldman, Henry A; Taveras, Elsie M
2013-09-01
We examined the sensitivity and specificity of an obesity diagnosis in a nationally representative sample of pediatric outpatient visits. We used the 2005 to 2009 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care surveys. We included visits with children 2 to 18 years, yielding a sample of 48 145 database visits. We determined 3 methods of identifying obesity: documented body mass index (BMI) ≥95th percentile; International Classification of Diseases, Ninth Revision (ICD-9) code; and positive answer to the question, "Does the patient now have obesity?" Using BMI as the gold standard, we calculated the sensitivity and specificity of a clinical obesity diagnosis. Among the 19.5% of children who were obese by BMI, 7.0% had an ICD-9 code and 15.2% had a positive response to questioning. The sensitivity of an obesity diagnosis was 15.4%, and the specificity was 99.2%. The sensitivity of the obesity diagnosis in pediatric ambulatory visits is low. Efforts are needed to increase identification of obese children.
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Directory of Open Access Journals (Sweden)
William N. Mkanta
2016-09-01
Full Text Available Introduction: Preventable hospitalizations are responsible for increasing the cost of health care and reflect ineffectiveness of the health services in the primary care setting. The objective of this study was to assess expenditure for hospitalizations and utilize expenditure differentials to determine factors associated with ambulatory care - sensitive conditions (ACSCs hospitalizations. Methods: A cross-sectional study of hospitalizations among Medicaid enrollees in comprehensive managed care plans in 2009 was conducted. A total of 25 581 patients were included in the analysis. Expenditures on hospitalizations were examined at the 50th, 75th, 90th, and 95th expenditure percentiles both at the bivariate level and in the logistic regression model to determine the impact of differing expenditure on ACSC hospitalizations. Results: Compared with patients without ACSC admissions, a larger proportion of patients with ACSC hospitalizations required advanced treatment or died on admission. Overall mean expenditures were higher for the ACSC group than for non-ACSC group (US$18 070 vs US$14 452. Whites and blacks had higher expenditures for ACSC hospitalization than Hispanics at all expenditure percentiles. Patient’s age remained a consistent predictor of ACSC hospitalization across all expenditure percentiles. Patients with ACSC were less likely to have a procedure on admission; however, the likelihood decreased as expenditure percentiles increased. At the median expenditure, blacks and Hispanics were more likely than other race/ethnic groups to have ACSC hospitalizations (odds ratio [OR]: 1.307, 95% confidence interval [CI]: 1.013-1.686 and OR 1.252, 95% CI: 1.060-1.479, respectively. Conclusion: Future review of delivery and monitoring of services at the primary care setting should include managed care plans in order to enhance access and overall quality of care for optimal utilization of the resources.
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Development and validation of the primary care team dynamics survey.
Song, Hummy; Chien, Alyna T; Fisher, Josephine; Martin, Julia; Peters, Antoinette S; Hacker, Karen; Rosenthal, Meredith B; Singer, Sara J
2015-06-01
To develop and validate a survey instrument designed to measure team dynamics in primary care. We studied 1,080 physician and nonphysician health care professionals working at 18 primary care practices participating in a learning collaborative aimed at improving team-based care. We developed a conceptual model and administered a cross-sectional survey addressing team dynamics, and we assessed reliability and discriminant validity of survey factors and the overall survey's goodness-of-fit using structural equation modeling. We administered the survey between September 2012 and March 2013. Overall response rate was 68 percent (732 respondents). Results support a seven-factor model of team dynamics, suggesting that conditions for team effectiveness, shared understanding, and three supportive processes are associated with acting and feeling like a team and, in turn, perceived team effectiveness. This model demonstrated adequate fit (goodness-of-fit index: 0.91), scale reliability (Cronbach's alphas: 0.71-0.91), and discriminant validity (average factor correlations: 0.49). It is possible to measure primary care team dynamics reliably using a 29-item survey. This survey may be used in ambulatory settings to study teamwork and explore the effect of efforts to improve team-based care. Future studies should demonstrate the importance of team dynamics for markers of team effectiveness (e.g., work satisfaction, care quality, clinical outcomes). © Health Research and Educational Trust.
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Carrasco-Sanz, A; Leiva-Gea, I; Martin-Alvarez, L; Del Torso, S; van Esso, D; Hadjipanayis, A; Kadir, A; Ruiz-Canela, J; Perez-Gonzalez, O; Grossman, Z
2018-03-01
Primary care paediatricians' perception of migrant children's health in Europe has not been explored before. Our aim was to examine European paediatricians' knowledge on migrant children's health problems, needs, inequalities, and barriers to access health care. European primary care paediatricians were invited by the European Academy of Paediatrics Research in Ambulatory Setting Network country coordinators to complete a web-based survey concerning health care of migrant children. A descriptive analysis of all variables was performed. The survey was completed by 492 paediatricians. Sixty-three per cent of the respondents reported that the general health of migrant children is worse than that of nonmigrants, chronic diseases cited by 66% of the respondents as the most frequent health problem. Sixty-six per cent of the paediatricians reported that migrant children have different health needs compared to nonmigrant children, proper oral health care mentioned by 86% of the respondents. Cultural/linguistic factors have been reported as the most frequent barrier (90%).to access health care. However, only 37% of providers have access to professional interpreters and cultural mediators. Fifty-two per cent and 32% do not know whether one or more of the family members are undocumented and whether they are refugees/asylum seekers, respectively. Updated guidelines for care of migrant children are available for only 35% of respondents, and 80% of them have not received specific training on migrant children's care. European primary care paediatricians recognize migrant children as a population at risk with more frequent and specific health problems and needs, but they are often unaware of their legal state. Lack of interpreters augments the existing language barriers to access proper care and should be solved. Widespread lack of guidelines and specific providers' training should be addressed to optimize health care delivery to migrant children. © 2017 John Wiley & Sons Ltd.
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Heilmann, Rachel M F; Campbell, Stephanie M; Kroner, Beverly A; Proksel, Jenel R; Billups, Sarah J; Witt, Daniel M; Helling, Dennis K
2013-01-01
The impact of the declining number of primary care physicians is exacerbated by a growing elderly population in need of chronic disease management. Primary care clinical pharmacy specialists, with their unique knowledge and skill set, are well suited to address this gap. At Kaiser Permanente of Colorado (KPCO), primary care clinical pharmacy specialists have a long history of integration with medical practices and are located in close proximity to physicians, nurses, and other members of the health care team. Since 1992, Primary Care Clinical Pharmacy Services (PCCPS) has expanded from 4 to 30 full-time equivalents (FTEs) to provide services in all KPCO medical office buildings. With this growth in size, PCCPS has evolved to play a vital role in working with primary care medical teams to ensure that drug therapy is effective, safe, and affordable. In addition, PCCPS specialists provide ambulatory teaching sites for pharmacy students and pharmacy residents. There is approximately 1 specialist FTE for every 13,000 adult KPCO members and every 9 clinical FTEs of internal medicine and family medicine physicians. All clinical pharmacy specialists in the pharmacy department are required to have a PharmD degree, to complete postgraduate year 2 residencies, and, as a condition of employment, to become board certified in an applicable specialty. The evolution, current structure, and role of PCCPS at KPCO, including factors facilitating successful integration within the medical team, are highlighted. Patient and nonpatient care responsibilities are described.
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Measuring interdependence in ambulatory care.
Katerndahl, David; Wood, Robert; Jaen, Carlos R
2017-04-01
Complex systems differ from complicated systems in that they are nonlinear, unpredictable and lacking clear cause-and-effect relationships, largely due to the interdependence of their components (effects of interconnectedness on system behaviour and consequences). The purpose of this study was to demonstrate the potential for network density to serve as a measure of interdependence, assess its concurrent validity and test whether the use of valued or binary ties yields better results. This secondary analysis used the 2010 National Ambulatory Care Medical Survey to assess interdependence of 'top 20' diagnoses seen and medications prescribed for 14 specialties. The degree of interdependence was measured as the level of association between diagnoses and drug interactions among medications. Both valued and binary network densities were computed for each specialty. To assess concurrent validity, these measures were correlated with previously-derived valid measures of complexity of care using the same database, adjusting for diagnosis and medication diversity. Partial correlations between diagnosis density, and both diagnosis and total input complexity, were significant, as were those between medication density and both medication and total output complexity; for both diagnosis and medication densities, adjusted correlations were higher for binary rather than valued densities. This study demonstrated the feasibility and validity of using network density as a measure of interdependence. When adjusted for measure diversity, density-complexity correlations were significant and higher for binary than valued density. This approach complements other methods of estimating complexity of care and may be applicable to unique settings. © 2015 John Wiley & Sons, Ltd.
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Coyle, Natalie; Strumpf, Erin; Fiset-Laniel, Julie; Tousignant, Pierre; Roy, Yves
2014-06-01
New models of delivering primary care are being implemented in various countries. In Quebec, Family Medicine Groups (FMGs) are a team-based approach to enhance access to, and coordination of, care. We examined whether physicians' and patients' characteristics predicted their participation in this new model of primary care. Using provincial administrative data, we created a population cohort of Quebec's vulnerable patients. We collected data before the advent of FMGs on patients' demographic characteristics, chronic illnesses and health service use, and their physicians' demographics, and practice characteristics. Multivariate regression was used to identify key predictors of joining a FMG among both patients and physicians. Patients who eventually enrolled in a FMG were more likely to be female, reside outside of an urban region, have a lower SES status, have diabetes and congestive heart failure, visit the emergency department for ambulatory sensitive conditions and be hospitalized for any cause. They were also less likely to have hypertension, visit an ambulatory clinic and have a usual provider of care. Physicians who joined a FMG were less likely to be located in urban locations, had fewer years in medical practice, saw more patients in hospital, and had patients with lower morbidity. Physicians' practice characteristics and patients' health status and health care service use were important predictors of joining a FMG. To avoid basing policy decisions on tenuous evidence, policymakers and researchers should account for differential selection into team-based primary health care models. Copyright © 2014. Published by Elsevier Ireland Ltd.
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Ambulatory oral surgery: 1-year experience with 11680 patients from Zagreb district, Croatia.
Jokić, Dražen; Macan, Darko; Perić, Berislav; Tadić, Marinka; Biočić, Josip; Đanić, Petar; Brajdić, Davor
2013-02-01
To examine the types and frequencies of oral surgery diagnoses and ambulatory oral surgical treatments during one year period at the Department of Oral Surgery, University Hospital Dubrava in Zagreb, Croatia. Sociodemographic and clinical data on 11680 ambulatory patients, treated between January 1 and of December 31, 2011 were retrieved from the hospital database using a specific protocol. The obtained data were subsequently analyzed in order to assess the frequency of diagnoses and differences in sex and age. The most common ambulatory procedure was tooth extraction (37.67%) and the most common procedure in ambulatory operating room was alveolectomy (57.25%). The test of proportions showed that significantly more extractions (PZagreb than in patients residing in rural areas. The data from this study may be useful for planning of ambulatory oral surgery services, budgeting, and sustaining quality improvement, enhancing oral surgical curricula, training and education of primary health care doctors and oral surgery specialists, and promoting patients' awareness of the importance of oral health.
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Ambulatory care of children treated with anticonvulsants - pitfalls after discharge from hospital.
Bertsche, A; Dahse, A-J; Neininger, M P; Bernhard, M K; Syrbe, S; Frontini, R; Kiess, W; Merkenschlager, A; Bertsche, T
2013-09-01
Anticonvulsants require special consideration particularly at the interface from hospital to ambulatory care. Observational study for 6 months with prospectively enrolled consecutive patients in a neuropediatric ward of a university hospital (age 0-anticonvulsant. Assessment of outpatient prescriptions after discharge. Parent interviews for emergency treatment for acute seizures and safety precautions. We identified changes of the brand in 19/82 (23%) patients caused by hospital's discharge letters (4/82; 5%) or in ambulatory care (15/82; 18%). In 37/76 (49%) of patients who were deemed to require rescue medication, no recommendation for such a medication was included in the discharge letters. 17/76 (22%) of the respective parents stated that they had no immediate access to rescue medication. Safety precautions were applicable in 44 epilepsy patients. We identified knowledge deficits in 27/44 (61%) of parents. Switching of brands after discharge was frequent. In the discharge letters, rescue medications were insufficiently recommended. Additionally, parents frequently displayed knowledge deficits in risk management. © Georg Thieme Verlag KG Stuttgart · New York.
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A Break-Even Analysis of Optimum Faculty Assignment for Ambulatory Primary Care Training.
Xakellis, George C.; And Others
1996-01-01
A computer simulation was developed to estimate the number of medical residents one or two faculty teachers could supervise in a university-based primary medical care teaching clinic. With no non-teaching tasks, it was shown that two teachers could supervise 11 residents, while one teacher was able to supervise only three residents under similar…
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Managing anemia in low-income toddlers: barriers, challenges and context in primary care.
Crowell, Rebecca; Pierce, Michelle B; Ferris, Ann M; Slivka, Hilda; Joyce, Patricia; Bernstein, Bruce A; Russell-Curtis, Suzanne
2005-11-01
Iron-deficiency remains a concern among low-income toddlers in the U.S. This formative study describes how primary care providers serving high-risk 1- to 3-year-old children in an urban ambulatory care setting approach anemia. Data collection included a retrospective review of randomly selected medical records (n=264) and semi-structured interviews with clinicians (n=41). Thirty-eight percent of the children presented with anemia (Hgb variable. While providers felt clinically comfortable with anemia, they felt burdened and challenged by follow-up. Communication and system barriers weighed most heavily on perceived treatment outcomes.
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Chan, Raymond J; Marx, Wolfgang; Bradford, Natalie; Gordon, Louisa; Bonner, Ann; Douglas, Clint; Schmalkuche, Diana; Yates, Patsy
2018-02-21
With the increasing burden of chronic and age-related diseases, and the rapidly increasing number of patients receiving ambulatory or outpatient-based care, nurse-led services have been suggested as one solution to manage increasing demand on the health system as they aim to reduce waiting times, resources, and costs while maintaining patient safety and enhancing satisfaction. The aims of this review were to assess the clinical effectiveness, economic outcomes and key implementation characteristics of nurse-led services in the ambulatory care setting. A systematic review was conducted using the standard Cochrane Collaboration methodology and was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE EBSCO, CINAHL EBSCO, and PsycINFO Ovid (from inception to April 2016). Data were extracted and appraisal undertaken. We included randomised controlled trials; quasi-randomised controlled trials; controlled and non-controlled before-and-after studies that compared the effects of nurse-led services in the ambulatory or community care setting with an alternative model of care or standard care. Twenty-five studies of 180,308 participants were included in this review. Of the 16 studies that measured and reported on health-related quality of life outcomes, the majority of studies (n = 13) reported equivocal outcomes; with three studies demonstrating superior outcomes and one demonstrating inferior outcomes in comparison with physician-led and standard care. Nurse-led care demonstrated either equivalent or better outcomes for a number of outcomes including symptom burden, self-management and behavioural outcomes, disease-specific indicators, satisfaction and perception of quality of life, and health service use. Benefits of nurse-led services remain inconclusive in terms of economic outcomes. Nurse
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Caldart, Raquel Voges; Marrero, Lihsieh; Basta, Paulo Cesar; Orellana, Jesem Douglas Yamall
2016-05-01
In developing countries, pneumonia is the leading cause of sickness and mortality in childhood, especially among vulnerable groups. The scope of this study was to analyze the factors associated with pneumonia in Yanomami children hospitalized for Ambulatory Care Sensitive Conditions (ACSC). Hospital admissions were divided into two groups: i) pneumonia; and ii) other causes, according to the Brazilian ACSC list. Adjusted hospitalization rates were estimated and unconditional logistic regression was used to analyze factors associated with pneumonia. Over 90% of the registered cases were considered ACSC. The adjusted rate of ACSC was 18.6/1000. The odds ratio of hospitalization for pneumonia was 2.7 (CI: 1.3-5.4) times higher in children aged between 0.1 and 5.9 months; 1.9 (CI: 1.1-3.3) times higher in children who were hospitalized for 8-14 days; and three (CI: 1.2-7.5) times higher in children with a secondary diagnosis of malnutrition. The excess of avoidable hospitalizations is a clear indication of the low quality of care and limited accessibility to primary health care in indigenous territories, which is contrary to the assistance model proposed by the indigenous healthcare subsystem in Brazil, which should in theory focus on welfare technologies based on primary health care.
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Management of abnormal uterine bleeding – focus on ambulatory hysteroscopy
Directory of Open Access Journals (Sweden)
Kolhe S
2018-03-01
Full Text Available Shilpa Kolhe Ambulatory Gynaecology Unit, Royal Derby Hospital, Derby, UK Abstract: The rapid evolution in ambulatory hysteroscopy (AH has transformed the approach to diagnose and manage abnormal uterine bleeding (AUB. The medical management in primary care remains the mainstay for initial treatment of this common presentation; however, many women are referred to secondary care for further evaluation. To confirm the diagnosis of suspected intrauterine pathology, the traditional diagnostic tool of day case hysteroscopy and dilatation and curettage in a hospital setting under general anesthesia is now no longer required. The combination of ultrasound diagnostics and modern AH now allows thorough evaluation of uterine cavity in an outpatient setting. Advent of miniature hysteroscopic operative systems has revolutionized the ways in which clinicians can not only diagnose but also treat menstrual disorders such as heavy menstrual bleeding, intermenstrual bleeding and postmenopausal bleeding in most women predominantly in a one-stop clinic. This review discussed the approach to manage women presenting with AUB with a focus on the role of AH in the diagnosis and treatment of this common condition in an outpatient setting. Keywords: abnormal uterine bleeding, ambulatory hysteroscopy, endometrial polyps, one-stop clinic, vaginoscopic approach
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Directory of Open Access Journals (Sweden)
Iloh Gabriel Uche Pascal
2016-01-01
Full Text Available Background: Diabetic treatment satisfaction, medication adherence, and glycemic control are widely recognized as the cornerstones for successful management of diabetes and proxy indicators of quality of care. However, in Nigeria, nothing is known on the role of diabetic treatment satisfaction on medication adherence and blood glucose control. Aim: The study was aimed at determining the role of diabetes treatment satisfaction in medication adherence and glycemic control among ambulatory type 2 diabetic Nigerians in a primary care clinic in Southeast Nigeria. Materials and Methods: This was a descriptive study that was carried out on 120 type 2 diabetic Nigerians who were on treatment for at least 3 months at the primary care clinic of a tertiary hospital in Nigeria. Diabetes treatment satisfaction and medication adherence were assessed in the previous 30 days using pretested, interviewer-administered questionnaire on self-reported satisfaction and adherence to therapy, respectively. Glycemic control was assessed in the previous 1 month. A patient was defined to have goal glycemic control if the fasting blood glucose at the end of the study, visit was between 70 and 130 mg/dL. Results: Diabetic treatment satisfaction, medication adherence, and glycemic control rates were 85.8%, 72.5%, and 61.7%, respectively. Diabetic treatment satisfaction was significantly associated with medication adherence (P = 0.025 and glycemic control (P = 0.04. Conclusion: Diabetic treatment satisfaction was significantly associated with medication adherence and glycemic control. However, treatment satisfaction did not translate marginally to higher medication and glycemic control. Diabetic treatment satisfaction should be integrated into a standard care package for diabetic patients in primary care settings.
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Estimated time spent on preventive services by primary care physicians
Directory of Open Access Journals (Sweden)
Gradison Margaret
2008-12-01
Full Text Available Abstract Background Delivery of preventive health services in primary care is lacking. One of the main barriers is lack of time. We estimated the amount of time primary care physicians spend on important preventive health services. Methods We analyzed a large dataset of primary care (family and internal medicine visits using the National Ambulatory Medical Care Survey (2001–4; analyses were conducted 2007–8. Multiple linear regression was used to estimate the amount of time spent delivering each preventive service, controlling for demographic covariates. Results Preventive visits were longer than chronic care visits (M = 22.4, SD = 11.8, M = 18.9, SD = 9.2, respectively. New patients required more time from physicians. Services on which physicians spent relatively more time were prostate specific antigen (PSA, cholesterol, Papanicolaou (Pap smear, mammography, exercise counseling, and blood pressure. Physicians spent less time than recommended on two "A" rated ("good evidence" services, tobacco cessation and Pap smear (in preventive visits, and one "B" rated ("at least fair evidence" service, nutrition counseling. Physicians spent substantial time on two services that have an "I" rating ("inconclusive evidence of effectiveness", PSA and exercise counseling. Conclusion Even with limited time, physicians address many of the "A" rated services adequately. However, they may be spending less time than recommended for important services, especially smoking cessation, Pap smear, and nutrition counseling. Future research is needed to understand how physicians decide how to allocate their time to address preventive health.
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del Saz Moreno, Vicente; Alberquilla Menéndez-Asenjo, Ángel; Camacho Hernández, Ana M; Lora Pablos, David; Enríquez de Salamanca Lorente, Rafael; Magán Tapia, Purificación
2016-02-01
To determine if the process of care in primary health, affects the risk of avoidable hospitalizations for ambulatory care sensitive conditions (ACSH) for heart failure (HF). Case-control study analyzing the risk of hospitalization for HF. The exposure factor was the process of care for HF in primary health. Health area of the region of Madrid (n=466.901). There were included all adult patients (14 years or older) with a documented diagnosis of HF in the electronic medical record of primary health (n=3.277). The cases were patients who were hospitalized for HF while the controls did not require admission, during 2007. risk of ACSH for HF related to the process of care considered both overall and for each separate standard of appropiate care. Differences in clinical complexity of the groups were measured using the Adjusted Clinical Group (ACG) classification system. 227 cases and 3.050 controls. Clinical complexity was greater in cases. The standards of appropriate care were met to a greater degree in the control group, but none of the two groups met all the standards that would define a process of care as fully appropriate. A significantly lower risk of ACSH was seen for only two standards of appropriate care. For each additional standard of appropriate care not met, the probability of admission was significantly greater (OR: 1,33, 95% CI: 1,19-1,49). Higher quality in the process of care in primary health was associated with a lower risk of hospitalization for HF. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.
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Scaling Lean in primary care: impacts on system performance.
Hung, Dorothy Y; Harrison, Michael I; Martinez, Meghan C; Luft, Harold S
2017-03-01
We examined a wide range of performance outcomes after Lean methodology-a leading strategy to enhance efficiency and patient value-was implemented and scaled across all primary care clinics in a nonprofit, ambulatory care delivery system. Using a stepped wedge approach, we assessed changes associated with the phased introduction of Lean-based redesigns across 46 primary care departments in 17 different clinic locations. Longitudinal analysis of operational metrics included: workflow efficiency, physician productivity, operating expenses, clinical quality, and satisfaction among patients, physicians, and staff. We used interrupted time series analysis with generalized linear mixed models to estimate Lean impacts over time. Projected outcomes in the absence of changes (ie, counterfactuals) were compared with observed outcomes after Lean redesigns were implemented, and mean differences were assessed using 95% bias-corrected bootstrap confidence intervals (CIs). We observed systemwide improvements in workflow efficiencies (eg, 95% CI, 5.8-10.4) and physician productivity (95% CI, 3.9-27.2), with no adverse effects on clinical quality. Patient satisfaction increased with respect to access to care (95% CI, 15.2-20.7), handling of personal issues (95% CI, 2.1-6.9), and overall experience of care (95% CI, 11.0-17.0), but decreased with respect to interactions with care providers (95% CI, -13.4 to -5.7). Departmental operating costs decreased, and annual staff and physician satisfaction scores increased particularly among early adopters, with key improvements in employee engagement, connection to purpose, relationships with staff, and physician time spent working. Lean redesigns can benefit primary care patients, physicians, and staff without negatively impacting the quality of clinical care. Study results may lead other delivery system leaders to innovate using Lean techniques and may further enhance support for Lean learning among public and private payers.
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Cavalcante, Danyelle Monteiro; de Oliveira, Maria Regina Fernandes; Rehem, Tânia Cristina Morais Santa Bárbara
2016-03-01
This study analyzes hospitalizations due to ambulatory care-sensitive conditions with a focus on infectious and parasitic diseases (IPDs) and validates the Hospital Information System, Brazilian Unified National Health System (SIH/SUS) for recording hospitalizations due to ambulatory care-sensitive conditions in a hospital in the Federal District, Brazil, in 2012. The study estimates the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the SIH for recording hospitalizations due to ambulatory care-sensitive conditions, with the patient's medical file as the gold standard. There were 1,604 hospitalizations for hospitalizations due to ambulatory care-sensitive conditions (19.6%, 95%CI: 18.7-20.5), and the leading IPDs were renal and urinary tract infection, infection of the skin and subcutaneous tissue, and infectious gastroenteritis. IPDs were the leading cause of hospitalization in the 20 to 29-year age bracket and caused 28 deaths. Sensitivity was 70.1% (95%CI: 60.5-79.7), specificity 88.4% (95%CI: 85.6-91.2), PPV = 51.7% (95%CI: 42.7-60.7), and NPV = 94.3% (95%CI: 92.2-96.4). The findings for admissions due to ACSCs in this hospital were similar to those of other studies, featuring admissions for IPDs. The SIH/SUS database was more specific than sensitive.
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Forslund, Tomas; Wettermark, Björn; Wändell, Per; von Euler, Mia; Hasselström, Jan; Hjemdahl, Paul
2013-12-10
Earlier validation studies of risk scoring by CHA2DS2VASc for assessments of appropriateness of warfarin treatment in patients with atrial fibrillation have been performed solely with diagnoses recorded in hospital based care, even though many patients to a large extent are managed in primary care. Cross-sectional registry study of all 43 353 patients with a diagnosis of non-valvular atrial fibrillation recorded in inpatient care, specialist ambulatory care or primary care in the Stockholm County during 2006-2010. The mean CHA2DS2VASc score was 3.82 (4.67 for women and 3.14 for men). 64% of the entire cohort of patients with atrial fibrillation had the diagnosis in primary care (12% only there). The mean CHA2DS2VASc score of patients with a diagnosis only in inpatient care or specialist ambulatory care increased from 3.63 to 3.83 when comorbidities registered in primary care were added. In 2010 warfarin prescriptions were claimed by 47.2%, and ASA by 41.6% of the entire cohort. 34% of patients with CHA2DS2VASc=1 and 20% with CHA2DS2VASc=0 had warfarin treatment. ASA was more frequently used instead of warfarin among women and elderly patients. Registry CHA2DS2VASc scores were underestimated without co-morbidity data from primary care. Many individuals with scores 0 and 1 were treated with warfarin, despite poor documentation of clinical benefit. In contrast, warfarin appears to be underused and ASA overused among high risk atrial fibrillation patients. Lack of diagnoses from primary care underestimated CHA2DS2VASc scores and may thereby have overestimated treatment benefits in low-risk patients in earlier studies. © 2013.
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Providing value in ambulatory anesthesia.
Fosnot, Caroline D; Fleisher, Lee A; Keogh, John
2015-12-01
The purpose of this review is to discuss current practices and changes in the field of ambulatory anesthesia, in both hospital and ambulatory surgery center settings. New trends in ambulatory settings are discussed and a review of the most current and comprehensive guidelines for the care of ambulatory patients with comorbid conditions such as postoperative nausea and vomiting (PONV), obstructive sleep apnea and diabetes mellitus are reviewed. Future direction and challenges to the field are highlighted. Ambulatory anesthesia continues to be in high demand for many reasons; patients and surgeons want their surgical procedures to be swift, involve minimal postoperative pain, have a transient recovery time, and avoid an admission to the hospital. Factors that have made this possible for patients are improved surgical equipment, volatile anesthetic improvement, ultrasound-guided regional techniques, non-narcotic adjuncts for pain control, and the minimization of PONV. The decrease in time spent in a hospital also decreases the risk of wound infection, minimizes missed days from work, and is a socioeconomically favorable model, when possible. Recently proposed strategies which will allow surgeons and anesthesiologists to continue to meet the growing demand for a majority of surgical cases being same-day include pharmacotherapies with less undesirable side-effects, integration of ultrasound-guided regional techniques, and preoperative evaluations in appropriate candidates via a telephone call the night prior to surgery. Multidisciplinary communication amongst caregivers continues to make ambulatory settings efficient, safe, and socioeconomically favorable.It is also important to note the future impact that healthcare reform will have specifically on ambulatory anesthesia. The enactment of the Patient Protection and Affordable Care Act of 2010 will allow 32 million more people to gain access to preventive services that will require anesthesia such as screening
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Latour-Delfgaauw, C.H.M.; van der Windt, D.A.W.M.; de Jonge, P.; Riphagen, II; Vos, R.; Huyse, F.J.; Stalman, W.A.B.
2007-01-01
Objective: The aim of this study was to summarize the available literature on the effectiveness of ambulatory nurse-led case management for complex patients in general health care. Method: We searched MEDLINE, EMBASE, the Cochrane Controlled Trials Register, and Cinahl. We included randomized
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A survey of primary care resident attitudes toward continuity clinic patient handover
Directory of Open Access Journals (Sweden)
Victor O. Kolade
2014-11-01
Full Text Available Background: Transfer of clinic patients from graduating residents to interns or junior residents occurs every year, affecting large numbers of patients. Breaches in care continuity may occur, with potential for risk to patient safety. Several guidelines have been developed for implementing standardized inpatient sign-outs, but no specific guidelines exist for outpatient handover. Methods: Residents in primary care programs – internal medicine, family medicine, and pediatrics – at a US academic medical center were invited to participate in an online survey. The invitation was extended approximately 2 years after electronic medical record (EMR rollout began at the institution. Results: Of 71 eligible residents, 22 (31% responded to the survey. Of these, 18 felt that handover of ambulatory patients was at least moderately important – but only one affirmed the existence of a system for handover. IM residents perceived that they had the highest proportion of high-risk patients (p=0.042; transition-of-care letters were more important to IM residents than other respondents (p=0.041. Conclusion: There is room for improvement in resident acknowledgement of handover processes in continuity clinics. In this study, IM residents attached greater importance to a specific handover tool than other primary care residents. Thus, the different primary care specialties may need to have different handover tools available to them within a shared EMR system.
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Robinson H; Engelhardt T
2017-01-01
Hal Robinson, Thomas Engelhardt Department of Anaesthesia, Royal Aberdeen Children’s Hospital, Aberdeen, UK Purpose: Myringotomy and tube placement is one of the most frequently performed ear, nose and throat (ENT) surgeries in the pediatric population. Effective anesthetic management is vital to ensuring successful ambulatory care and ensuring child and parental satisfaction.Recent findings: This review summarizes recently published studies about the long-term effects of g...
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Hung, Dorothy; Martinez, Meghan; Yakir, Maayan; Gray, Caroline
2015-01-01
Although Lean management techniques are increasingly used in health care to improve quality and reduce costs, lessons about how to successfully implement this approach on the front lines of care delivery are not well documented. In this study, we highlight key facilitators and barriers to implementing Lean among frontline primary care providers. This case study took place at a large, ambulatory care delivery system serving nearly 1 million patients. In-depth interviews were conducted with primary care physicians, staff, and administrators to identify key factors impacting Lean redesigns in primary care. Overall, staff engagement and performance management, sensitivity to the professional values and culture of medicine, and perceived adequacy of organizational resources were critical when introducing Lean changes. Specific drivers of change included empowerment of staff at all levels, visual display of performance metrics, and a culture of innovation and collaboration. Barriers included physician resistance to standardized work, difficulty transferring management responsibilities to non-physician staff, and time and staffing required for participating in improvement efforts. Although Lean offers a new approach to delivering care, the implementation process itself is both complex and crucial to success. Understanding early facilitators and barriers can maximize Lean's, potential to improve health care delivery.
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Achieving Value in Primary Care: The Primary Care Value Model.
Rollow, William; Cucchiara, Peter
2016-03-01
The patient-centered medical home (PCMH) model provides a compelling vision for primary care transformation, but studies of its impact have used insufficiently patient-centered metrics with inconsistent results. We propose a framework for defining patient-centered value and a new model for value-based primary care transformation: the primary care value model (PCVM). We advocate for use of patient-centered value when measuring the impact of primary care transformation, recognition, and performance-based payment; for financial support and research and development to better define primary care value-creating activities and their implementation; and for use of the model to support primary care organizations in transformation. © 2016 Annals of Family Medicine, Inc.
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2013-01-01
Background Hypertensive patients (HTs) are usually attended in primary care (PC). We aimed to assess the diagnostic accuracy and cost-benefit ratio of 24-hour ambulatory blood pressure monitoring (ABPM) in all newly diagnosed hypertensive patients (HTs) attended in PC. Methods In a cross-sectional study ABPM was recorded in all 336 never treated HTs (Office BP ≥140 and/or ≥ 90 mm Hg) that were admitted during 16 months. Since benefits from drug treatment in white-coat hypertension (WCH) remain unproven, a cost benefit estimation of a general use of ABPM (vs absence of ABPM) in HTs was calculated comparing the cost of usual medical assistance of HTs only diagnosed in office with that based both on refraining from drug treatment all subjects identified as WCH and on the reduction by half of the frequency of biochemical exams and doctor visits. Results Women were 56%, age 51 ± 14 years and BMI 27 ± 4 Kg/m2. Out of these, 206 were considered as true HTs, daytime ABPM ≥ 135 and/or ≥85 mm Hg and 130 (38,7%) were identified as having white coat hypertension (WCH), daytime ABPM ABPM total medical expenses can be reduced by 23% (157.500 euros) with a strategy based on ABPM for 1000 patients followed for 2 years. Conclusions In PC, the widespread use of ABPM in newly diagnosed HTs increases diagnostic accuracy of hypertension, improves cardiovascular risk stratification, reduces health expenses showing a highly favourable benefit-cost ratio vs a strategy without ABPM. PMID:23937261
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Optimizing anesthesia techniques in the ambulatory setting
E. Galvin (Eilish)
2007-01-01
textabstractAmbulatory surgery refers to the process of admitting patients, administering anesthesia and surgical care, and discharging patients home following an appropriate level of recovery on the same day. The word ambulatory is derived from the latin word ambulare, which means ''to walk''. This
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Ewald, Dominik A; Huss, Gottfried; Auras, Silke; Caceres, Juan Ruiz-Canela; Hadjipanayis, Adamos; Geraedts, Max
2018-06-01
Paediatric ambulatory healthcare systems in Europe are, because of historical reasons, diverse and show strikingly different outcomes. All across Europe, the benchmarking of structures, processes and outcomes could reveal opportunities for improving Paediatric Primary Care (PPC). The aim of this study was to develop a set of Quality Indicators (QIs) to assess and monitor PPC in Europe. In a three-step process, we used the available external evidence and European expert consensus in a modified RAND/UCLA Appropriateness Method (RAM) to develop an indicator set. (1) A broad literature and online research of published QI and guidelines yielded an inventory of 1516 QI. (2) A collaborative panel of paediatric senior experts from the European Academy of Paediatrics (EAP) and the European Confederation of Primary Care Paediatricians (ECPCP) from 15 European countries participated in a first consensus process to reduce the initial indicator inventory by eliminating not PPC-focused indicators and duplicates. (3) In a second consensus process, the panel rated the QI regarding validity and feasibility. The final QI set "COSI-PPC-EU" consists of 42 indicators in five categories of PPC: (A) health promotion/prevention/screening (13 QI), (B) acute care (9 QI), (C) chronic care (8 QI), (D) practice management (3 QI) and (E) patient safety (9 QI). COSI-PPC-EU represents a consented set of a limited number of valid quality indicators for the application in paediatric primary care in different healthcare systems throughout Europe. What is Known: • Paediatric ambulatory healthcare systems in Europe are diverse and show strikingly different outcomes. • There are known gaps in quality performance measures of paediatric primary care in Europe. Pre-existing sets of quality indicators are predominantly limited to national populations, specific diseases and hospital care. What is New: • A set of 42 quality indicators for primary paediatric care in Europe was developed in a multi
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Ambulatory oral surgery: 1-year experience with 11 680 patients from Zagreb district, Croatia
Jokić, Dražen; Macan, Darko; Perić, Berislav; Tadić, Marinka; Biočić, Josip; Đanić, Petar; Brajdić, Davor
2013-01-01
Aim To examine the types and frequencies of oral surgery diagnoses and ambulatory oral surgical treatments during one year period at the Department of Oral Surgery, University Hospital Dubrava in Zagreb, Croatia. Methods Sociodemographic and clinical data on 11 680 ambulatory patients, treated between January 1 and of December 31, 2011 were retrieved from the hospital database using a specific protocol. The obtained data were subsequently analyzed in order to assess the frequency of diagnoses and differences in sex and age. Results The most common ambulatory procedure was tooth extraction (37.67%) and the most common procedure in ambulatory operating room was alveolectomy (57.25%). The test of proportions showed that significantly more extractions (P Zagreb than in patients residing in rural areas. Conclusion The data from this study may be useful for planning of ambulatory oral surgery services, budgeting, and sustaining quality improvement, enhancing oral surgical curricula, training and education of primary health care doctors and oral surgery specialists, and promoting patients’ awareness of the importance of oral health. PMID:23444246
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Prescribing Safety in Ambulatory Care: Physician Perspectives
National Research Council Canada - National Science Library
Rundall, Thomas G; Hsu, John; Lafata, Jennifer E; Fung, Vicki; Paez, Kathryn A; Simpkins, Jan; Simon, Steven R; Robinson, Scott B; Uratsu, Connie; Gunter, Margaret J; Soumerai, Stephen B; Selby, Joseph V
2005-01-01
.... We asked about current safety practices, perceptions of ambulatory prescribing safety. Using a content analysis approach, three investigators independently coded responses into thematic categories...
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Ambulatory Surgical Measures - Facility
U.S. Department of Health & Human Services — The Ambulatory Surgical Center Quality Reporting (ASCQR) Program seeks to make care safer and more efficient through quality reporting. ASCs eligible for this...
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Patterns of cancer screening in primary care from 2005 to 2010.
Martires, Kathryn J; Kurlander, David E; Minwell, Gregory J; Dahms, Eric B; Bordeaux, Jeremy S
2014-01-15
Cancer screening recommendations vary widely, especially for breast, prostate, and skin cancer screening. Guidelines are provided by the American Cancer Society, the US Preventive Services Task Force, and various professional organizations. The recommendations often differ with regard to age and frequency of screening. The objective of this study was to determine actual rates of screening in the primary care setting. Data from the National Ambulatory Medical Care Survey were used. Only adult visits to non-federally employed, office-based physicians for preventive care from 2005 through 2010 were examined. Prevalence rates for breast, pelvic, and rectal examinations were calculated, along with the rates for mammograms, Papanicolaou smears, and prostate-specific antigen tests. Factors associated with screening, including age, race, smoking status, and insurance type, were examined using t tests and chi-square tests. In total, 8521 visits were examined. The rates of most screening examinations and tests were stable over time. Clinical breast examinations took place significantly more than mammography was ordered (54.8% vs 34.6%; P<.001). White patients received more mammography (P=.031), skin examinations (P<.010), digital rectal examinations (P<.010), and prostate-specific antigen tests (P=.003) than patients of other races. Patients who paid with Medicare or private insurance received more screening than patients who had Medicaid or no insurance (P<.010). Current cancer screening practices in primary care vary significantly. Cancer screening may not follow evidence-based practices and may not be targeting patients considered most at risk. Racial and socioeconomic disparities are present in cancer screening in primary care. © 2013 American Cancer Society.
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Effect of the Economic Recession on Primary Care Access for the Homeless.
White, Brandi M; Jones, Walter J; Moran, William P; Simpson, Kit N
2016-01-01
Primary care access (PCA) for the homeless can prove challenging, especially during periods of economic distress. In the United States, the most recent recession may have presented additional barriers to accessing care. Limited safety-net resources traditionally used by the homeless may have also been used by the non-homeless, resulting in delays in seeking treatment for the homeless. Using hospitalizations for ambulatory care sensitivity (ACS) conditions as a proxy measure for PCA, this study investigated the recession's impact on PCA for the homeless and non-homeless in four states. The State Inpatient Databases were used to identify ACS admissions. Findings from this study indicate the recession was a barrier to PCA for homeless people who were uninsured. Ensuring that economically-disadvantaged populations have the ability to obtain insurance coverage is crucial to facilitating PCA. With targeted outreach efforts, the Affordable Care Act provides an opportunity for expanding coverage to the homeless.
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Making ambulatory blood pressure monitoring accessible in pharmacies.
James, Kirstyn; Dolan, Eamon; O'Brien, Eoin
2014-06-01
Ambulatory blood pressure measurement (ABPM), although recommended for the diagnosis and management of hypertension, has limited availability. The objective of this study was to show that if the characteristics of patients attending pharmacies for ABPM are similar to those attending primary care, the technique can be made more widely available to patients through pharmacies. A comparative study using a software program that allowed central collection, analysis and comparison of ABPM data from patients attending primary care and pharmacies for assessment of hypertension in Ireland. ABPM data from 46 978 patients attending primary care were compared with 1698 attending pharmacies between 2007 and 2013. The age, sex and blood pressure characteristics of patients attending primary care and pharmacies were similar. The mean pressures in all categories, except for systolic blood pressure recorded in primary care, were higher in men. The first ABPM measurements recorded in pharmacies were slightly higher than those in primary care (150.8 ± 19.5/88.7 ± 13.7 vs. 149.6 ± 20.7/88.0 ± 14.4 mmHg). More patients attending primary care were normotensive than those attending pharmacies (19.5 vs. 16.4%), whereas more patients attending pharmacies were hypertensive than those attending primary care (62.8 vs. 60.7%), particularly female patients (61.0 vs. 56.4%). White-coat hypertension was similar in patients attending primary care and pharmacies (19.8 vs. 20.8%), but it was more prevalent in men attending pharmacies (22.0 vs. 17.4%) and in women attending primary care (21.9 vs. 19.7%). There were more dippers in pharmacy then primary care ABPMs (84.7 vs. 79.4%). A preference for having ABPM on Fridays and Saturdays was evident in patients attending pharmacies (19.6 vs. 6.6%), whereas there was a preference for early morning recording in primary care (4.1 vs. 1.1%). This study, which is the first to report on ABPM data from the pharmacy setting, shows that the blood pressure
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[Day hospital in internal medicine: A chance for ambulatory care].
Grasland, A; Mortier, E
2018-04-16
Internal medicine is an in-hospital speciality. Along with its expertise in rare diseases, it shares with general medicine the global care of patients but its place in the ambulatory shift has yet to be defined. The objective of our work was to evaluate the benefits of an internal medicine day-hospital devoted to general medicine. Named "Centre Vi'TAL" to underline the link between the city and the hospital, this novel activity was implemented in order to respond quickly to general practitioners having difficulties to synthesize their complex patients or facing diagnostic or therapeutic problems. Using preferentially email for communication, the general practitioners can contact an internist who is committed to respond on the same day and take over the patient within 7 days if day-hospital is appropriate for his condition. The other patients are directed either to the emergency department, consultation or full hospitalization. In 14 months, the center has received 213 (144 women, 69 men) patients, mean age 53.6, addressed by 88 general practitioners for 282 day-hospital sessions. Requests included problem diagnoses (n=105), synthesis reviews for complex patients (n=65), and treatment (n=43). In the ambulatory shift advocated by the authorities, this experience shows that internal medicine should engage in the recognition of day-hospital as a place for diagnosis and synthesis reviews connected with the city while leaving the general practitioners coordinator of their patient care. This activity of synthesis in day-hospital is useful for the patients and efficient for our healthcare system. Copyright © 2018 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier SAS. All rights reserved.
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Acceptance of lean redesigns in primary care: A contextual analysis.
Hung, Dorothy; Gray, Caroline; Martinez, Meghan; Schmittdiel, Julie; Harrison, Michael I
Lean is a leading change strategy used in health care to achieve short-term efficiency and quality improvement while promising longer-term system transformation. Most research examines Lean intervention to address isolated problems, rather than to achieve broader systemic changes to care delivery. Moreover, no studies examine contextual influences on system-wide Lean implementation efforts in primary care. The aim of this study was to identify contextual factors most critical to implementing and scaling Lean redesigns across all primary care clinics in a large, ambulatory care delivery system. Over 100 interviews and focus groups were conducted with frontline physicians, clinical staff, and operational leaders. Data analysis was guided by a modified Consolidated Framework for Implementation Research (CFIR), a popular implementation science framework. On the basis of expert recommendations, the modified framework targets factors influencing the implementation of process redesigns. This modified framework, the CFIR-PR, informed our identification of contextual factors that most impacted Lean acceptance among frontline physicians and staff. Several domains identified by the CFIR-PR were critical to acceptance of Lean redesigns. Regarding the implementation process acceptance was influenced by time and intensity of exposure to changes, "top-down" versus "bottom-up" implementation styles, and degrees of employee engagement in developing new workflows. Important factors in the inner setting were the clinic's culture and style of leadership, along with availability of information about Lean's effectiveness. Last, implementation efforts were impacted by individual and team characteristics regarding changed work roles and related issues of professional identity, authority, and autonomy. This study underscores the need for change leaders to consider the contextual factors that surround efforts to implement Lean in primary care. As Lean redesigns are scaled across a system
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Spatial analysis of elderly access to primary care services
Directory of Open Access Journals (Sweden)
Lozano-Gracia Nancy
2006-05-01
Full Text Available Abstract Background Admissions for Ambulatory Care Sensitive Conditions (ACSCs are considered preventable admissions, because they are unlikely to occur when good preventive health care is received. Thus, high rates of admissions for ACSCs among the elderly (persons aged 65 or above who qualify for Medicare health insurance are signals of poor preventive care utilization. The relevant geographic market to use in studying these admission rates is the primary care physician market. Our conceptual model assumes that local market conditions serving as interventions along the pathways to preventive care services utilization can impact ACSC admission rates. Results We examine the relationships between market-level supply and demand factors on market-level rates of ACSC admissions among the elderly residing in the U.S. in the late 1990s. Using 6,475 natural markets in the mainland U.S. defined by The Health Resources and Services Administration's Primary Care Service Area Project, spatial regression is used to estimate the model, controlling for disease severity using detailed information from Medicare claims files. Our evidence suggests that elderly living in impoverished rural areas or in sprawling suburban places are about equally more likely to be admitted for ACSCs. Greater availability of physicians does not seem to matter, but greater prevalence of non-physician clinicians and international medical graduates, relative to U.S. medical graduates, does seem to reduce ACSC admissions, especially in poor rural areas. Conclusion The relative importance of non-physician clinicians and international medical graduates in providing primary care to the elderly in geographic areas of greatest need can inform the ongoing debate regarding whether there is an impending shortage of physicians in the United States. These findings support other authors who claim that the existing supply of physicians is perhaps adequate, however the distribution of them across
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Libby, Anne M; Pace, Wilson; Bryan, Cathy; Anderson, Heather Orton; Ellis, Samuel L; Allen, Richard Read; Brandt, Elias; Huebschmann, Amy G; West, David; Valuck, Robert J
2010-06-01
The Distributed Ambulatory Research in Therapeutics Network (DARTNet) is a federated network of electronic health record (EHR) data, designed as a platform for next-generation comparative effectiveness research in real-world settings. DARTNet links information from nonintegrated primary care clinics that use EHRs to deliver ambulatory care to overcome limitations with traditional observational research. Test the ability to conduct a remote, electronic point of care study in DARTNet practices by prompting clinic staff to obtain specific information during a patient encounter. Prospective survey of patients identified through queries of clinical data repositories in federated network organizations. On patient visit, survey is triggered and data are relinked to the EHR, de-identified, and copied for evaluation. Adult patients diagnosed with diabetes mellitus that scheduled a clinic visit for any reason in a 2-week period in DARTNet primary care practices. Survey on hypoglycemic events (past month) and over-the-counter and herbal supplement use. DARTNet facilitated point of care data collection triggered by an electronic prompt for additional information at a patient visit. More than one-third of respondents (33% response rate) reported either mild (45%) or severe hypoglycemic events (5%) in the month before the survey; only 3 of those were also coded using the ICD-9 (a significant difference in detection rates 37% vs. 1%). Nearly one-quarter of patients reported taking an OTC/herbal, 4% specifically for the treatment of symptoms of diabetes. Prospective data collection is feasible in DARTNet and can enable comparative effectiveness and safety research.
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West, Christopher E.
2010-01-01
Research objectives: This dissertation examines the state of development of each of the eight core electronic health record (EHR) functionalities as described by the IOM and describes how the current state of these functionalities limit quality improvement efforts in ambulatory care settings. There is a great deal of literature describing both the…
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Acupuncture in ambulatory anesthesia: a review
Directory of Open Access Journals (Sweden)
Norheim AJ
2015-09-01
Full Text Available Arne Johan Norheim,1 Ingrid Liodden,1 Terje Alræk1,2 1National Research Center in Complementary and Alternative Medicine (NAFKAM, Department of Community Medicine, Faculty of Health Sciences, University of Tromsø – The Arctic University of Norway, Tromsø, 2The Norwegian School of Health Sciences, Institute of Acupuncture, Kristiania University College, Oslo, NorwayBackground: Post-anesthetic morbidities remain challenging in our daily practice of anesthesia. Meta-analyses and reviews of acupuncture and related techniques for postoperative nausea and vomiting (POVN and postoperative vomiting (POV show promising results while many clinicians remain skeptical of the value of acupuncture. Given the interest in finding safe non-pharmacological approaches toward postoperative care, this body of knowledge needs to be considered. This review critically appraises and summarizes the research on acupuncture and acupressure in ambulatory anesthesia during the last 15 years.Methods: Articles were identified through searches of Medline, PubMed, and Embase using the search terms “acupuncture” or “acupuncture therapy” in combination with “ambulatory anesthesia” or “ambulatory surgery” or “day surgery” or “postoperative”. A corresponding search was done using “acupressure” and “wristbands”. The searches generated a total of 104, 118, and 122 references, respectively.Results: Sixteen studies were included; eight studies reported on acupuncture and eight on acupressure. Nine studies found acupuncture or acupressure effective on primary endpoints including postoperative nausea and vomiting, postoperative pain, sore throat, and emergence agitation. Four studies found acupuncture had a similar effect to antiemetic medication.Conclusion: Overall, the studies were of fairly good quality. A large proportion of the reviewed papers highlights an effect of acupuncture or acupressure on postoperative morbidities in an ambulatory setting
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Basu, Sanjay; Phillips, Russell S; Bitton, Asaf; Song, Zirui; Landon, Bruce E
2015-10-20
Physicians have traditionally been reimbursed for face-to-face visits. A new non-visit-based payment for chronic care management (CCM) of Medicare patients took effect in January 2015. To estimate financial implications of CCM payment for primary care practices. Microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements. National Ambulatory Medical Care Survey and other published sources. Medicare patients. 10 years. Practice-level. Comparison of CCM delivery approaches by staff and physicians. Net revenue per full-time equivalent (FTE) physician; time spent delivering CCM services. If nonphysician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. Practices could expect approximately $332 per enrolled patient per year (95% CI, $234 to $429) if CCM services were delivered by registered nurses (RNs), approximately $372 (CI, $276 to $468) if services were delivered by licensed practical nurses, and approximately $385 (CI, $286 to $485) if services were delivered by medical assistants. For a typical practice, this equates to more than $75 ,00 of net annual revenue per FTE physician and 12 hours of nursing service time per week if 50% of eligible patients enroll. At a minimum, 131 Medicare patients (CI, 115 to 140 patients) must enroll for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services. If physicians were to deliver all CCM services, approximately 25% of practices nationwide could expect net revenue losses due to opportunity costs of face-to-face visit time. The CCM program may alter long-term primary care use, which is difficult to predict. Practices that rely on nonphysician team members to deliver CCM services will probably experience substantial net revenue gains but must enroll a sufficient number of eligible patients to recoup costs. None.
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Halley, Meghan C; Rendle, Katharine A; Gugerty, Brian; Lau, Denys T; Luft, Harold S; Gillespie, Katherine A
2017-11-01
Objective This report examines ways to improve National Ambulatory Medical Care Survey (NAMCS) data on practice and physician characteristics in multispecialty group practices. Methods From February to April 2013, the National Center for Health Statistics (NCHS) conducted a pilot study to observe the collection of the NAMCS physician interview information component in a large multispecialty group practice. Nine physicians were randomly sampled using standard NAMCS recruitment procedures; eight were eligible and agreed to participate. Using standard protocols, three field representatives conducted NAMCS physician induction interviews (PIIs) while trained ethnographers observed and audio recorded the interviews. Transcripts and field notes were analyzed to identify recurrent issues in the data collection process. Results The majority of the NAMCS items appeared to have been easily answered by the physician respondents. Among the items that appeared to be difficult to answer, three themes emerged: (a) physician respondents demonstrated an inconsistent understanding of "location" in responding to questions; (b) lack of familiarity with administrative matters made certain questions difficult for physicians to answer; and (c) certain primary care‑oriented questions were not relevant to specialty care providers. Conclusions Some PII survey questions were challenging for physicians in a multispecialty practice setting. Improving the design and administration of NAMCS data collection is part of NCHS' continuous quality improvement process. All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.
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Pollmanns, Johannes; Romano, Patrick S; Weyermann, Maria; Geraedts, Max; Drösler, Saskia E
2018-04-01
To explore effects of disease prevalence adjustment on ambulatory care-sensitive hospitalization (ACSH) rates used for quality comparisons. County-level hospital administrative data on adults discharged from German hospitals in 2011 and prevalence estimates based on administrative ambulatory diagnosis data were used. A retrospective cross-sectional study using in- and outpatient secondary data was performed. Hospitalization data for hypertension, diabetes, heart failure, chronic obstructive pulmonary disease, and asthma were obtained from the German Diagnosis Related Groups (DRG) database. Prevalence estimates were obtained from the German Central Research Institute of Ambulatory Health Care. Crude hospitalization rates varied substantially across counties (coefficients of variation [CV] 28-37 percent across conditions); this variation was reduced by prevalence adjustment (CV 21-28 percent). Prevalence explained 40-50 percent of the observed variation (r = 0.65-0.70) in ACSH rates for all conditions except asthma (r = 0.07). Between 30 percent and 38 percent of areas moved into or outside condition-specific control limits with prevalence adjustment. Unadjusted ACSH rates should be used with caution for high-stakes public reporting as differences in prevalence may have a marked impact. Prevalence adjustment should be considered in models analyzing ACSH. © Health Research and Educational Trust.
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Experiences of primary care physicians and staff following lean workflow redesign.
Hung, Dorothy Y; Harrison, Michael I; Truong, Quan; Du, Xue
2018-04-10
In response to growing pressures on primary care, leaders have introduced a wide range of workforce and practice innovations, including team redesigns that delegate some physician tasks to nonphysicians. One important question is how such innovations affect care team members, particularly in view of growing dissatisfaction and burnout among healthcare professionals. We examine the work experiences of primary care physicians and staff after implementing Lean-based workflow redesigns. This included co-locating physician and medical assistant dyads, delegating significant responsibilities to nonphysician staff, and mandating greater coordination and communication among all care team members. The redesigns were implemented and scaled in three phases across 46 primary care departments in a large ambulatory care delivery system. We fielded 1164 baseline and 1333 follow-up surveys to physicians and other nonphysician staff (average 73% response rate) to assess workforce engagement (e.g., job satisfaction, motivation), perceptions of the work environment, and job-related burnout. We conducted multivariate regressions to detect changes in experiences after the redesign, adjusting for respondent characteristics and clustering of within-clinic responses. We found that both physicians and nonphysician staff reported higher levels of engagement and teamwork after implementing redesigns. However, they also experienced higher levels of burnout and perceptions of the workplace as stressful. Trends were the same for both occupational groups, but the increased reports of stress were greater among physicians. Additionally, members of all clinics, except for the pilot site that developed the new workflows, reported higher burnout, while perceptions of workplace stress increased in all clinics after the redesign. Our findings partially align with expectations of work redesign as a route to improving physician and staff experiences in delivering care. Although teamwork and engagement
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Irving, Greg; Neves, Ana Luisa; Dambha-Miller, Hajira; Oishi, Ai; Tagashira, Hiroko; Verho, Anistasiya; Holden, John
2017-11-08
To describe the average primary care physician consultation length in economically developed and low-income/middle-income countries, and to examine the relationship between consultation length and organisational-level economic, and health outcomes. This is a systematic review of published and grey literature in English, Chinese, Japanese, Spanish, Portuguese and Russian languages from 1946 to 2016, for articles reporting on primary care physician consultation lengths. Data were extracted and analysed for quality, and linear regression models were constructed to examine the relationship between consultation length and health service outcomes. One hundred and seventy nine studies were identified from 111 publications covering 28 570 712 consultations in 67 countries. Average consultation length differed across the world, ranging from 48 s in Bangladesh to 22.5 min in Sweden. We found that 18 countries representing about 50% of the global population spend 5 min or less with their primary care physicians. We also found significant associations between consultation length and healthcare spending per capita, admissions to hospital with ambulatory sensitive conditions such as diabetes, primary care physician density, physician efficiency and physician satisfaction. There are international variations in consultation length, and it is concerning that a large proportion of the global population have only a few minutes with their primary care physicians. Such a short consultation length is likely to adversely affect patient healthcare and physician workload and stress. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
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Shanley, Leticia; Mittal, Vineeta; Flores, Glenn
2013-07-01
The goal of this study was to identify the proportion of dehydration-related ambulatory care-sensitive condition hospitalizations, the reasons why these hospitalizations were preventable, and factors associated with preventability. A cross-sectional survey of primary care providers (PCPs), inpatient attending physicians, and parents was conducted in a consecutive series of children with ambulatory care-sensitive conditions admitted to an urban hospital over 14 months. Eighty-five children were diagnosed with dehydration. Their mean age was 1.6 years; most had public (74%) or no (17%) insurance, and were nonwhite (91%). The proportion of hospitalizations assessed as preventable varied from 12% for agreement among all 3 sources to 45% for any source. Parents identified inadequate prevention (50%), poor self-education (34%), and poor quality of care (38%) as key factors. PCPs identified parents providing insufficient home rehydration (33%), not visiting the clinic (25%), and not calling earlier (16%) as reasons. Inpatient attending physicians cited home rehydration (40%), delays in seeking care (40%), and lacking a PCP (20%) as contributors. Physicians (PCPs and inpatient attending physicians) were more likely than parents to describe the admission as inappropriate (75% vs 67% vs 0%; P dehydration-related hospitalizations may be preventable. Inadequate parental education by physicians, insufficient home rehydration, deferring clinic visits, insurance and cost barriers, inappropriate admissions, poor quality of care, and parental dissatisfaction with PCPs are the reasons that these hospitalizations might have been prevented.
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Bracco, Mario Maia; Mafra, Ana Carolina Cintra Nunes; Abdo, Alexandre Hannud; Colugnati, Fernando Antonio Basile; Dalla, Marcello Dala Bernardina; Demarzo, Marcelo Marcos Piva; Abrahamsohn, Ises; Rodrigues, Aline Pacífico; Delgado, Ana Violeta Ferreira de Almeida; Dos Prazeres, Glauber Alves; Teixeira, José Carlos; Possa, Silvio
2016-08-12
Better communication among field health care teams and points of care, together with investments focused on improving teamwork, individual management, and clinical skills, are strategies for achieving better outcomes in patient-oriented care. This research aims to implement and evaluate interventions focused on improving communication and knowledge among health teams based on points of care in a regional public health outreach network, assessing the following hypotheses: 1) A better-working communication process between hospitals and primary health care providers can improve the sharing of information on patients as well as patients' outcomes. 2) A skill-upgrading education tool offered to health providers at their work sites can improve patients' care and outcomes. A quasi-experimental study protocol with a mixed-methods approach (quantitative and qualitative) was developed to evaluate communication tools for health care professionals based in primary care units and in a general hospital in the southern region of São Paulo City, Brazil. The usefulness and implementation processes of the integration strategies will be evaluated, considering: 1) An Internet-based communication platform that facilitates continuity and integrality of care to patients, and 2) A tailored updating distance-learning course on ambulatory care sensitive conditions for clinical skills improvements. The observational study will evaluate a non-randomized cohort of adult patients, with historical controls. Hospitalized patients diagnosed with an ambulatory care sensitive condition will be selected and followed for 1 year after hospital discharge. Data will be collected using validated questionnaires and from patients' medical records. Health care professionals will be evaluated related to their use of education and communication tools and their demographic and psychological profiles. The primary outcome measured will be the patients' 30-day hospital readmission rates. A sample size of 560
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Nurse-Driven Training Courses: Impact on Implementation of Ambulatory Blood Pressure Monitoring
F?lez-Carrob?, Estel; Sagarra-Ti?, Maria; Romero, Araceli; Rubio, Montserrat; Planas, Lourdes; P?rez-Lucena, Mar?a Jos?; Baiget, Montserrat; Cabista?, Cristina; F?lez, Jordi
2013-01-01
Background: Ambulatory blood pressure monitoring (ABPM) predicts cardiovascular risk and identifies white-coat and masked hypertension, efficacy of treatment and the circadian cycle of hypertensive patients. Objective: To analyze the effectiveness of ABPM implementation thoughtout a nurse-driven training program. Materials and Methodology: Twenty eight professionals were involved in the study carried out in the primary care center of the metropolitan area of Barcelona that serves 34,289 inhab...
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Innovation in ambulatory care: a collaborative approach to redesigning the health care workplace.
Johnson, Paula A; Bookman, Ann; Bailyn, Lotte; Harrington, Mona; Orton, Piper
2011-02-01
To improve the quality of patient care and work satisfaction of the physicians and staff at an ambulatory practice that had recently started an innovative model of clinical care for women. The authors used an inclusive process, collaborative interactive action research, to engage all physicians and staff members in assessing and redesigning their work environment. Based on key barriers to working effectively and integrating work and family identified in that process, a pilot project with new work practices and structures was developed, implemented, and evaluated. The work redesign process established cross-occupational care teams in specific clinical areas. Members of the teams built skills in assessing clinical operations in their practice areas, developed new levels of collaboration, and constructed new models of distributed leadership. The majority of participants reported an improvement in how their area functioned. Integrating work and family/personal life-particularly practices around flexible work arrangements-became an issue for team discussion and solutions, not a matter of individual accommodation by managers. By engaging the workforce, collaborative interactive action research can help achieve lasting change in the health care workplace and increase physicians' and staff members' work satisfaction. This "dual agenda" may be best achieved through a collaborative process where cross-occupational teams are responsible for workflow and outcomes and where the needs of patients and providers are integrated.
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Profiling outcomes of ambulatory care: casemix affects perceived performance.
Berlowitz, D R; Ash, A S; Hickey, E C; Kader, B; Friedman, R; Moskowitz, M A
1998-06-01
The authors explored the role of casemix adjustment when profiling outcomes of ambulatory care. The authors reviewed the medical records of 656 patients with hypertension, diabetes, or chronic obstructive pulmonary disease (COPD) receiving care at one of three Department of Veterans Affairs medical centers. Outcomes included measures of physiological control for hypertension and diabetes, and of exacerbations for COPD. Predictors of poor outcomes, including physical examination findings, symptoms, and comorbidities, were identified and entered into regression models. Observed minus expected performance was described for each site, both before and after casemix adjustment. Risk-adjustment models were developed that were clinically plausible and had good performance properties. Differences existed among the three sites in the severity of the patients being cared for. For example, the percentage of patients expected to have poor blood pressure control were 35% at site 1, 37% at site 2, and 44% at site 3 (P Casemix-adjusted measures of performance were different from unadjusted measures. Sites that were outliers (P Casemix adjustment models can be developed for outpatient medical conditions. Sites differ in the severity of patients they treat, and adjusting for these differences can alter judgments of site performance. Casemix adjustment is necessary when profiling outpatient medical conditions.
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The primary care amplification model: taking the best of primary care forward
Directory of Open Access Journals (Sweden)
Nicholson Caroline
2008-12-01
Full Text Available Abstract Background Primary care internationally is approaching a new paradigm. The change agenda implicit in this threatens to de-stabilise and challenge established general practice and primary care. Discussion The Primary Care Amplification Model offers a means to harness the change agenda by 'amplifying' the strengths of established general practices around a 'beacon' practice. Conclusion Such 'beacon' practices can provide a mustering point for an expanded scope of practice for primary care, integrated primary/secondary service delivery, interprofessional learning, relevant local clinical research, and a focus on local service innovation, enhancing rather than fragmenting the collective capacity of existing primary care.
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Martínez, M A; Aguirre, A; Sánchez, M; Nevado, A; Laguna, I; Torre, A; Manuel, E; Villar, C; García-Puig, J
1999-12-11
In the present study we evaluated the influence of the observer's status--physician or nurse--on blood pressure levels and the relationship among clinic blood pressure measurement with ambulatory blood pressure and left ventricle mass. Cross sectional study performed in seven primary care centers. Participating physicians and nurses were trained for blood pressure measurement prior to the study and subsequently retrained at 3 month intervals during the study. Patients included in the study were 122 subjects with mild to moderate hypertension who underwent the following study protocol: a) measurement of clinic blood pressure by physician and nurse, in an independent fashion, on 3 visits; b) clinic-epidemiologic questionnaire; c) conventional hematological and biochemical study; d) electrocardiogram; e) 24-hour ambulatory blood pressure monitoring, f) M-mode and Doppler echocardiography (only in 58 subjects). Nurse-measured blood pressure levels were higher than those determined by physicians (mean differences: 3.9 [6.7] mmHg in systolic blood pressure and 2.6 [5.4] mmHg in diastolic blood pressure). The blood pressure level differences between the two observers were higher in female patients and subjects with low educational level, independently of the observer's gender. Nurse-measured blood pressure was more closely related to ambulatory blood pressure and left ventricle mass than physician-measured blood pressure. Nurse-measured blood pressure levels are lower than those determined by physicians and more closely related to ambulatory blood pressure and left ventricle mass than physician-measured blood pressure. These data support that nurses, instead of doctors, should routinely measure blood pressure in primary care centers.
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Haas, Sheila A; Vlasses, Frances; Havey, Julia
2016-01-01
There are multiple demands and challenges inherent in establishing staffing models in ambulatory heath care settings today. If health care administrators establish a supportive physical and interpersonal health care environment, and develop high-performing interprofessional teams and staffing models and electronic documentation systems that track performance, patients will have more opportunities to receive safe, high-quality evidence-based care that encourages patient participation in decision making, as well as provision of their care. The health care organization must be aligned and responsive to the community within which it resides, fully invested in population health management, and continuously scanning the environment for competitive, regulatory, and external environmental risks. All of these challenges require highly competent providers willing to change attitudes and culture such as movement toward collaborative practice among the interprofessional team including the patient.
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Ambulatory blood pressure and adherence monitoring: diagnosing pseudoresistant hypertension.
Burnier, Michel; Wuerzner, Gregoire
2014-01-01
A small proportion of the treated hypertensive population consistently has a blood pressure greater than 140/90 mm Hg despite a triple therapy including a diuretic, a calcium channel blocker, and a blocker of the renin-angiotensin system. According to guidelines, these patients have so-called resistant hypertension. The prevalence of this clinical condition is higher in tertiary than primary care centers and often is associated with chronic kidney disease, diabetes, obesity, and sleep apnea syndrome. Exclusion of pseudoresistant hypertension using ambulatory or home blood pressure monitoring is a crucial step in the investigation of patients with resistant hypertension. Thus, among the multiple factors to consider when investigating patients with resistant hypertension, ambulatory blood pressure monitoring should be performed very early. Among other factors to consider, physicians should investigate patient adherence to therapy, assess the adequacy of treatment, exclude interfering factors, and, finally, look for secondary forms of hypertension. Poor adherence to therapy accounts for 30% to 50% of cases of resistance to therapy depending on the methodology used to diagnose adherence problems. This review discusses the clinical factors implicated in the pathogenesis of resistant hypertension with a particular emphasis on pseudoresistance, drug adherence, and the use of ambulatory blood pressure monitoring for the diagnosis and management of resistant hypertension.
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Ambulatory cleft lip surgery: A value analysis.
Arneja, Jugpal S; Mitton, Craig
2013-01-01
Socialized health systems face fiscal constraints due to a limited supply of resources and few reliable ways to control patient demand. Some form of prioritization must occur as to what services to offer and which programs to fund. A data-driven approach to decision making that incorporates outcomes, including safety and quality, in the setting of fiscal prudence is required. A value model championed by Michael Porter encompasses these parameters, in which value is defined as outcomes divided by cost. To assess ambulatory cleft lip surgery from a quality and safety perspective, and to assess the costs associated with ambulatory cleft lip surgery in North America. Conclusions will be drawn as to how the overall value of cleft lip surgery may be enhanced. A value analysis of published articles related to ambulatory cleft lip repair over the past 30 years was performed to determine what percentage of patients would be candidates for ambulatory cleft lip repair from a quality and safety perspective. An economic model was constructed based on costs associated with the inpatient stay related to cleft lip repair. On analysis of the published reports in the literature, a minority (28%) of patients are currently discharged in an ambulatory fashion following cleft lip repair. Further analysis suggests that 88.9% of patients would be safe candidates for same-day discharge. From an economic perspective, the mean cost per patient for the overnight admission component of ambulatory cleft surgery to the health care system in the United States was USD$2,390 and $1,800 in Canada. The present analysis reviewed germane publications over a 30-year period, ultimately suggesting that ambulatory cleft lip surgery results in preservation of quality and safety metrics for most patients. The financial model illustrates a potential cost saving through the adoption of such a practice change. For appropriately selected patients, ambulatory cleft surgery enhances overall health care value.
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Effects of health information exchange adoption on ambulatory testing rates.
Ross, Stephen E; Radcliff, Tiffany A; Leblanc, William G; Dickinson, L Miriam; Libby, Anne M; Nease, Donald E
2013-01-01
To determine the effects of the adoption of ambulatory electronic health information exchange (HIE) on rates of laboratory and radiology testing and allowable charges. Claims data from the dominant health plan in Mesa County, Colorado, from 1 April 2005 to 31 December 2010 were matched to HIE adoption data on the provider level. Using mixed effects regression models with the quarter as the unit of analysis, the effect of HIE adoption on testing rates and associated charges was assessed. Claims submitted by 306 providers in 69 practices for 34 818 patients were analyzed. The rate of testing per provider was expressed as tests per 1000 patients per quarter. For primary care providers, the rate of laboratory testing increased over the time span (baseline 1041 tests/1000 patients/quarter, increasing by 13.9 each quarter) and shifted downward with HIE adoption (downward shift of 83, prates or imputed charges in either provider group. Ambulatory HIE adoption is unlikely to produce significant direct savings through reductions in rates of testing. The economic benefits of HIE may reside instead in other downstream outcomes of better informed, higher quality care.
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Directory of Open Access Journals (Sweden)
Carl Llor
2008-10-01
Full Text Available Carl Llor1, Silvia Hernández1, Anna Ribas2, Carmen Álvarez3, Josep Maria Cots4, Carolina Bayona5, Isabel González6, Marc Miravitlles7, BRAMOX Study Group 1Primary Care Centre Jaume I, Tarragona, Spain; 2Primary Care Centre Santa Eugènia de Berga, Spain; 3Primary Care Centre Manlleu, Spain; 4Primary Care Centre La Marina, Barcelona, Spain; 5Primary Care Centre Valls, Spain; 6Primary Care Centre Maragall, Barcelona, Spain; 7Pneumology Department. Institut Clínic del Tòrax (IDIBAPS, Hospital Clínic, Barcelona, CIBER de Enfermedades Respiratorias (CIBERES, SpainBackground: Amoxycillin/clavulanate is considered first-line treatment for ambulatory exacerbations of COPD. However, narrow-spectrum antibiotics may be as useful for mild to moderate patients.Objective: To compare the clinical efficacy of amoxycillin versus amoxicyllin/clavulanate in exacerbations of COPD in primary care.Methods: A randomized, double-blind, noninferiority clinical trial was carried out in eight primary care centers in Catalonia, Spain. Spirometrically-diagnosed patients older than 40 years with COPD, without criteria of hospitalization and Anthonisen’s types I or II exacerbations were included. The main outcome was clinical cure at the end of treatment (EOT visit on day 10.Results: A total of 137 patients were enrolled in the study (68 assigned to amoxycillin and 69 to amoxycillin/clavulanate. The mean forced expiratory flow in one second was 61.6% and the mean age was 71.4 years. At EOT, 92.8% of patients in the amoxycillin/clavulanate and 90.9% in the amoxycillin group were considered clinically cured, a statistically non-significant difference. Adverse effects were observed in 11 subjects, 3 in the amoxycillin group and 8 in the amoxycillin/clavulanate group, 2 of whom required a change in treatment.Conclusions: Amoxycillin was at least as effective clinically and as safe as amoxycilin/clavulanate in the treatment of acute exacerbations of COPD in mild to
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[Comparative analysis of efficiency indicators in ambulatory surgery].
Rodríguez Ortega, María; Porrero Carro, José Luis; Aranaz Andrés, Jesús María; Castillo Fe, María José; Alonso García, María Teresa; Sánchez-Cabezudo Díaz-Guerra, Carlos
2017-05-25
To find comparative elements for quality control in major ambulatory surgery (MAS) units. Descriptive and comparative study of the Ambulatory Care Index (AI) and Substitution Index (SI) in the Santa Cristina Hospital Surgery Service (Madrid, Spain) compared to Key Indicators (KI) of the National Health Service (NHS). 7,817 MAS procedures (between 2006 and 2014) were analysed. The average annual AI was 54%, higher (p <0.0001) than «ambulatory surgery» KI. The hernia outpatient procedures (average 72%) were also superior to the national KI (p <0.0001), but ambulatory haemorrhoidectomy (average 33.6%) was clearly lower (p <0.0001). KI of the NHS are useful and allow to establish a proper development in the global AI and hernia outpatient surgery with opportunities for improvement in haemorrhoidectomy. Their collection should be careful, not including minor surgeries. Also, their usefulness could be increased if data was broken down by speciality and by complexity. Copyright © 2017 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.
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LENUS (Irish Health Repository)
Flynn, E
2012-03-01
ABPM is an invaluable clinical tool, as it has been shown to improve blood pressure control in primary care. Many clinical guidelines for hypertension advocate ambulatory blood pressure monitoring. This study aims to quantify the use of clinical guidelines for hypertension and to explore the role of ABPM in Primary Care. A questionnaire survey was sent to GPs working in the West of Ireland. 88% (n=139) of GPs use clinical guidelines that recommend the use of ABPM. 82% (n=130) of GPs find use of clinic blood pressure monitoring insufficient for the diagnosis and monitoring of hypertension. Despite good access to ABPM, GPs report lack of remuneration, 72% (n=116), cost 68% (n=108), and lack of time, 51% (n=83) as the main limiting factors to use of ABPM. GPs recognise the clinical value of ABPM, but this study identifies definite barriers to the use of ABPM in Primary Care.
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Le-Abuyen, Sheila; Ng, Jessica; Kim, Susie; De La Franier, Anne; Khan, Bibi; Mosley, Jane; Gardam, Michael
2014-04-01
A survey pilot asked patients to observe the hand hygiene compliance of their health care providers. Patients returned 75.1% of the survey cards distributed, and the overall hand hygiene compliance was 96.8%. Survey results and patient commentary were used to motivate hand hygiene compliance. The patient-as-observer approach appeared to be a viable alternative for hand hygiene auditing in an ambulatory care setting because it educated, engaged, and empowered patients to play a more active role in their own health care. Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.
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Ambulatory anesthetic care in pediatric tonsillectomy: challenges and risks
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Collins C
2015-11-01
Full Text Available Corey Collins Massachusetts Eye and Ear Infirmary, Department of Anesthesiology, Harvard Medical School, Boston, MA, USA Abstract: Pediatric tonsillectomy is a common surgery around the world. Surgical indications are obstructive sleep apnea and recurrent tonsillitis. Despite the frequency of tonsillectomy in children, most aspects of perioperative care are supported by scant evidence. Recent guidelines provide important recommendations although clinician adherence or awareness of published guidance is variable and inconsistent. Current guidelines establish criteria for screening children for post-tonsillectomy observation, though most are based on low-grade evidence or consensus. Current recommendations for admission are: age <3 years; significant obstructive sleep apnea; obesity; and significant comorbid medical conditions. Recent reports have challenged each criterion and recommend admission criteria that are based on clinically relevant risks or observed clinical events such as adverse respiratory events in the immediate recovery period. Morbidity and mortality are low though serious complications occur regularly and may be amenable to improvements in postoperative monitoring, improved analgesic regimens, and parental education. Careful consideration of risks attributable to individual patients is vital to determine overall suitability for ambulatory discharge. Keywords: adverse airway events, complications, guidelines, mortality, OSA, pediatric anesthesia
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Role of the primary care provider in the diagnosis and management of heartburn.
Kushner, Pamela R
2010-04-01
Heartburn affects an estimated 42% of the US population. Often, patients are able to recognize symptoms and self-treat heartburn; however, patients with more persistent and/or troublesome symptoms should be evaluated by a physician or other healthcare provider. This review focuses on the role of the primary care provider in the diagnosis and treatment of heartburn. A search was conducted on PubMed (to November 2009) and articles relevant to the management of heartburn by a primary care provider topic were selected. Diagnostic tools, such as endoscopy, and ambulatory pH monitoring, are recommended for advanced assessment of patients with frequent heartburn to avert misdiagnosis and to identify complications of reflux disease. Over-the-counter and prescription treatments for frequent heartburn symptoms include antacids, histamine(2)-receptor antagonists (H(2)RAs), antacid/H(2)RA combinations, and proton pump inhibitors (PPIs). Among these, PPIs represent the mainstay of acute and maintenance treatment regimens in reflux disorders and are more effective than H(2)RAs for long-term use due to the development of tolerance to the latter therapy. While once-daily PPI therapy may be sufficient in most patients, a few may require twice-daily PPI therapy to alleviate their symptoms. This review is limited by its relatively narrow focus on articles cited in PubMed. The primary care provider is ideally situated to advise patients on the best treatment option for their condition and to provide follow-up care if required.
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Capitated payments to primary care providers and the delivery of patient education.
Pearson, William S; King, Dana E; Richards, Chesley
2013-01-01
Patient education is a critical component of the patient-centered medical home and is a powerful and effective tool in chronic disease management. However, little is known about the effect of practice payment on rates of patient education during office encounters. For this study we took data from the 2009 National Ambulatory Medical Care Survey. This was a cross-sectional analysis of patient visits to primary care providers to determine whether practice payment in the form of capitated payments is associated within patient education being included more frequently during office visits compared with other payment methods. In a sample size of 9863 visits in which capitation status was available and the provider was the patient's primary care provider, the weighted percentages of visits including patient education were measured as a percentages of education (95% confidence intervals): 75% capitation, 74.0% (52.2-88.1). In an adjusted logistic model controlling for new patients (yes/no), number of chronic conditions, number of medications managed, number of previous visits within the year, and age and sex of the patients, the odds of receiving education were reported as odds ratios (95% confidence intervals): 75% capitation, 3.38 (1.23-9.30). Patients are more likely to receive education if their primary care providers receive primarily capitated payment. This association is generally important for health policymakers constructing payment strategies for patient populations who would most benefit from interventions that incorporate or depend on patient education, such as populations requiring management of chronic diseases.
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Pattern of Ambulatory Care Visits to Obstetrician-Gynecologists in Taiwan: A Nationwide Analysis
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An-Min Lynn
2015-06-01
Full Text Available Although obstetrician-gynecologists (OB-GYNs are the main actors in the provision of health care to women, their practice patterns have rarely been analyzed. The current study investigated the nationwide ambulatory visits to OB-GYNs in Taiwan using the National Health Insurance Research Database. From the 1/500 sampling datasets indicating 619,760 ambulatory visits in 2012, it was found that 5.8% (n = 35,697 of the visits were made to OB-GYNs. Two-fifths of the services provided were performed by male OB-GYNs aged 50–59 years. Women of childbearing age accounted for more than half of the visits to OB-GYNs (57.2%, and elderly patients above 60 years accounted for only 7.7%. The most frequent diagnoses were menstrual disorders and other forms of abnormal bleeding from the female genital tract (13.1%. Anti-infective agents were prescribed in 15.1% of the visits to OB-GYNs. The study revealed the proportion of aging practicing OB-GYNs, and our detailed results could contribute to evidence-based discussions on health policymaking.
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Directory of Open Access Journals (Sweden)
Fernando Nobre
2002-02-01
Full Text Available OBJECTIVE: To evaluate the characteristics of the patients receiving medical care in the Ambulatory of Hypertension of the Emergency Department, Division of Cardiology, and in the Emergency Unit of the Clinical Hospital of the Ribeirão Preto Medical School. METHODS: Using a protocol, we compared the care of the same hypertensive patients in on different occasions in the 2 different places. The characteristics of 62 patients, 29 men with a mean age of 57 years, were analyzed between January 1996 and December 1997. RESULTS: The care of these patients resulted in different medical treatment regardless of their clinical features and blood pressure levels. Thus, in the Emergency Unit, 97% presented with symptoms, and 64.5% received medication to rapidly reduce blood pressure. In 50% of the cases, nifedipine SL was the elected medication. Patients who applied to the Ambulatory of Hypertension presenting with similar features, or, in some cases, presenting with similar clinically higher levels of blood pressure, were not prescribed medication for a rapid reduction of blood pressure at any of the appointments. CONCLUSION: The therapeutic approach to patients with high blood pressure levels, symptomatic or asymptomatic, was dependent on the place of treatment. In the Emergency Unit, the conduct was, in the majority of cases, to decrease blood pressure immediately, whereas in the Ambulatory of Hypertension, the same levels of blood pressure, in the same individuals, resulted in therapeutic adjustment with nonpharmacological management. These results show the need to reconsider the concept of hypertensive crises and their therapeutical implications.
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Patient satisfaction and positive patient outcomes in ambulatory anesthesia
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Shah U
2015-04-01
Full Text Available Ushma Shah, David T Wong, Jean Wong Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada Abstract: Most surgeries in North America are performed on an ambulatory basis, reducing health care costs and increasing patient comfort. Patient satisfaction is an important outcome indicator of the quality of health care services incorporated by the American Society of Anesthesiologists (ASA. Patient satisfaction is a complex concept that is influenced by multiple factors. A patient's viewpoint and knowledge plays an influential role in patient satisfaction with ambulatory surgery. Medical optimization and psychological preparation of the patient plays a pivotal role in the success of ambulatory surgery. Postoperative pain, nausea, and vomiting are the most important symptoms for the patient and can be addressed by multimodal drug regimens. Shared decision making, patient–provider relationship, communication, and continuity of care form the main pillars of patient satisfaction. Various psychometrically developed instruments are available to measure patient satisfaction, such as the Iowa Satisfaction with Anesthesia Scale and Evaluation du Vecu de I'Anesthesie Generale, but none have been developed specifically for ambulatory surgery. The ASA has made recommendations for data collection for patient satisfaction surveys and emphasized the importance of reporting the data to the Anesthesia Quality Institute. Future research is warranted to develop a validated tool to measure patient satisfaction in ambulatory surgery. Keywords: patient, satisfaction, anesthesia, outcomes, questionnaire, perspectives
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Carrol, N V; Gagon, J P
1983-01-01
Because of increasing competition, it is becoming more important that health care providers pursue consumer-based market segmentation strategies. This paper presents a methodology for identifying and describing consumer segments in health service markets, and demonstrates the use of the methodology by presenting a study of consumer segments in the ambulatory care pharmacy market.
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Phillips, J H
1989-01-01
Each stage of a product's life cycle requires marketing strategy modifications in response to changing demand levels. The purpose of this study was to investigate changes in ambulatory care center (ACC) operational characteristics indicative of product, market, and distribution channel adjustments that could have a competitive impact upon community pharmacy practice. A questionnaire was mailed to a national sample of 325 ACC managers. Evidence of new product feature additions includes increased emphasis on continued care and increased prevalence of prescription drug dispensing. Expansion into new market segments and distribution channels was demonstrated by increased participation in HMO and employer relationships. The observed adjustments in ACC marketing strategies present obvious challenges as well as less obvious opportunities for community pharmacy practice.
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Haynes-Maslow, Lindsey; Roberts, Megan C.; Dusetzina, Stacie B.
2016-01-01
Background Individuals with mental illness experience poor health and may die prematurely from chronic illness. Understanding whether the presence of co-occurring chronic physical health conditions complicates mental health treatment is important, particularly among patients seeking treatment in primary care settings. Objectives Examine (1) whether the presence of chronic physical conditions is associated with mental health service use for individuals with depression who visit a primary care physician, and (2) whether race modifies this relationship. Research Design Secondary analysis of the National Ambulatory Medical Care Survey, a survey of patient-visits collected annually from a random sample of 3,000 physicians in office-based settings. Subjects Office visits from 2007–2010 were pooled for adults ages 35–85 with a depression diagnosis at the time of visit (N=3,659 visits). Measures Mental health services were measured using a dichotomous variable indicating whether mental health services were provided during the office visit or a referral made for: (1) counseling, including psychotherapy and other mental health counseling and/or (2) prescribing of psychotropic medications. Results Most patient office visits (70%) where a depression diagnosis was recorded also had co-occurring chronic physical conditions recorded. The presence of at least one physical chronic condition was associated with a 6% decrease in the probability of receiving any mental health services (pneeded on medical care delivery among patients with co-occurring health conditions, particularly as the health care system moves towards an integrated care model. PMID:26147863
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Magistri, Paolo; Scordamaglia, Maria Rosa; Giulitti, Diego; Papaspyropoulos, Vassilios; Eleuteri, Edoardo; Coppola, Marcello
2014-01-01
The aim is to assess on which aspects of everyday-life the post surgery stoma-care ambulatory should physically and psychologically assist the patients. Seventy patients (33 male, 37 female, mean age 68 years) accepted to fill-in the Stoma-QoL questionnaire from January to December 2011. The questionnaire consists of 20 questions addressing different possible discomforts of everyday life. Our results demonstrate that patients with temporary ileostomy have a mean score of quality of life index of 63. Patients with ileostomy demonstrated a higher quality of life score compared to patients with colostomy. Our results confirmed that patients with ileostomy have a better perception of quality of life compared to patients with colostomy. Moreover, our data clearly show that patients are more concerned on stoma management compared to the hypothetical prejudice of society. The stoma care ambulatory have a crucial role, offering to the patient and his/her family an adequate psychological support, and teaching the management of the stoma and the pouch.
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African Primary Care Research: qualitative interviewing in primary care.
Reid, Steve; Mash, Bob
2014-06-05
This article is part of a series on African Primary Care Research and focuses on the topic of qualitative interviewing in primary care. In particular it looks at issues of study design, sample size, sampling and interviewing in relation to individual and focus group interviews.There is a particular focus on helping postgraduate students at a Masters level to write their research proposals.
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Why Aren't More Primary Care Residents Going into Primary Care? A Qualitative Study.
Long, Theodore; Chaiyachati, Krisda; Bosu, Olatunde; Sircar, Sohini; Richards, Bradley; Garg, Megha; McGarry, Kelly; Solomon, Sonja; Berman, Rebecca; Curry, Leslie; Moriarty, John; Huot, Stephen
2016-12-01
Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine. We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices. This was a qualitative study based on semi-structured, in-person interviews. Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed. We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis. We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program. Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue
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Ambulatory anesthesia: optimal perioperative management of the diabetic patient
Directory of Open Access Journals (Sweden)
Polderman JAW
2016-05-01
Full Text Available Jorinde AW Polderman, Robert van Wilpe, Jan H Eshuis, Benedikt Preckel, Jeroen Hermanides Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands Abstract: Given the growing number of patients with diabetes mellitus (DM and the growing number of surgical procedures performed in an ambulatory setting, DM is one of the most encountered comorbidities in patients undergoing ambulatory surgery. Perioperative management of ambulatory patients with DM requires a different approach than patients undergoing major surgery, as procedures are shorter and the stress response caused by surgery is minimal. However, DM is a risk factor for postoperative complications in ambulatory surgery, so should be managed carefully. Given the limited time ambulatory patients spend in the hospital, improvement in management has to be gained from the preanesthetic assessment. The purpose of this review is to summarize current literature regarding the anesthesiologic management of patients with DM in the ambulatory setting. We will discuss the risks of perioperative hyperglycemia together with the pre-, intra-, and postoperative considerations for these patients when encountered in an ambulatory setting. Furthermore, we provide recommendations for the optimal perioperative management of the diabetic patient undergoing ambulatory surgery. Keywords: diabetes mellitus, perioperative period, ambulatory surgery, insulin, complications, GLP-1 agonist, DPP-4 inhibitor
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Anesthesia for ambulatory anorectal surgery.
Gudaityte, Jūrate; Marchertiene, Irena; Pavalkis, Dainius
2004-01-01
The prevalence of minor anorectal diseases is 4-5% of adult Western population. Operations are performed on ambulatory or 24-hour stay basis. Requirements for ambulatory anesthesia are: rapid onset and recovery, ability to provide quick adjustments during maintenance, lack of intraoperative and postoperative side effects, and cost-effectiveness. Anorectal surgery requires deep levels of anesthesia. The aim is achieved with 1) regional blocks alone or in combination with monitored anesthesia care or 2) deep general anesthesia, usually with muscle relaxants and tracheal intubation. Modern general anesthetics provide smooth, quickly adjustable anesthesia and are a good choice for ambulatory surgery. Popular regional methods are: spinal anesthesia, caudal blockade, posterior perineal blockade and local anesthesia. The trend in regional anesthesia is lowering the dose of local anesthetic, providing selective segmental block. Adjuvants potentiating analgesia are recommended. Postoperative period may be complicated by: 1) severe pain, 2) urinary retention due to common nerve supply, and 3) surgical bleeding. Complications may lead to hospital admission. In conclusion, novel general anesthetics are recommended for ambulatory anorectal surgery. Further studies to determine an optimal dose and method are needed in the group of regional anesthesia.
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Edwards, Samuel T; Mafi, John N; Landon, Bruce E
2014-06-01
Although many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain. To describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs. Cross-sectional study and time trend analysis. Nationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997-2010. Proportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality. Among 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p = 0.04). The proportion of medical specialist visits in which the physician self-identified as the patient's PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p specialists. Medical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.
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Prediabetes Diagnosis and Treatment in Primary Care.
Mainous, Arch G; Tanner, Rebecca J; Baker, Richard
2016-01-01
The increasing prevalence of diabetes is a major health problem. The detection and treatment of prediabetes can delay the onset of diabetes and presents an important diabetes prevention strategy. Using data from the 2012 National Ambulatory Medical Care Survey, we studied visits by adults aged ≥45 years without diagnosed diabetes who had an HbA1c test within 90 days of the visit (n = 518 unweighted visits; n = 11,167,004 weighted visits). HbA1c results were categorized into normal, prediabetes, and diabetes, and we examined patient characteristics (age, sex, race, payer type, body mass index) and treatment of prediabetes. Among visiting adults, 54.6% had a normal HbA1c value, 33.6% had prediabetes, and 11.9% had diabetes. Of those patient visits with HbA1c consistent with prediabetes, the number of patients diagnosed with prediabetes was too low for a reliable population estimate. Indication of treatment in the medical record (lifestyle modification counseling and/or metformin) was present in 23.0% of those with diagnosed or undiagnosed prediabetes. The most common treatment was lifestyle modification counseling. Our findings show that there are missed opportunities for diabetes prevention in primary care. Providers need to change their approach to prediabetes and play a more effective role in preventing diabetes. © Copyright 2016 by the American Board of Family Medicine.
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Advances in the use of intravenous techniques in ambulatory anesthesia
Directory of Open Access Journals (Sweden)
Eng MR
2015-07-01
Full Text Available Matthew R Eng,1 Paul F White1,2 1Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; 2White Mountain Institute, The Sea Ranch, CA, USA Summary statement: Advances in the use of intravenous techniques in ambulatory anesthesia has become important for the anesthesiologist as the key perioperative physician in outpatient surgery. Key techniques and choices of anesthetics are important in accomplishing fast track goals of ambulatory surgery. Purpose of review: The anesthesiologist in the outpatient environment must focus on improving perioperative efficiency and reducing recovery times while accounting for patients' well-being and safety. This review article focuses on recent intravenous anesthetic techniques to accomplish these goals. Recent findings: This review is an overview of techniques in intravenous anesthesia for ambulatory anesthesia. Intravenous techniques may be tailored to accomplish outpatient surgery goals for the type of surgical procedure and individual patient needs. Careful anesthetic planning and the application of the plans are critical to an anesthesiologist's success with fast-track ambulatory surgery. Conclusion: Careful planning and application of intravenous techniques are critical to an anesthesiologist's success with fast-track ambulatory surgery. Keywords: intravenous anesthesia, outpatient anesthesia, fast-track surgery
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Goodwin, N
2001-01-01
This article reviews the impact of successive experiments in the development of primary care organisations in England and assesses the long-term importance of English primary care groups for the integration of health and community and health and social care and the deinstitutionalisation of hospital care. Governments in a number of Western countries are attempting to improve the efficiency, appropriateness and equity of their health systems. One of the main ways of doing this is to devolve provision and commissioning responsibility from national and regional organisations to more local agencies based in primary care. Such primary care organisations are allocated budgets that span both primary and secondary (hospital) services and also, potentially, social care. This article is based on a systematic review of the literature forthcoming from the UK Government's Department of Health-funded evaluations of successive primary care organisational developments. These include total purchasing pilots, GP commissioning group pilots, personal medical services pilots and primary care groups and trusts. Primary care organisations in England have proved to be a catalyst in facilitating the development of integrated care working between primary and community health services. Conversely, primary care organisations have proved less effective in promoting integration between health and social care agencies where most progress has been made at the strategic commissioning level. The development of primary care trusts in England is heralding an end to traditional community hospitals. The development of primary care groups in England are but an intermediate step of a policy progression towards future primary care-based organisations that will functionally integrate primary and community health services with local authority services under a single management umbrella.
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Directory of Open Access Journals (Sweden)
Nick Goodwin
2001-03-01
Full Text Available Purpose: This article reviews the impact of successive experiments in the development of primary care organisations in England and assesses the long-term importance of English primary care groups for the integration of health and community and health and social care and the deinstitutionalisation of hospital care. Theory: Governments in a number of Western countries are attempting to improve the efficiency, appropriateness and equity of their health systems. One of the main ways of doing this is to devolve provision and commissioning responsibility from national and regional organisations to more local agencies based in primary care. Such primary care organisations are allocated budgets that span both primary and secondary (hospital services and also, potentially, social care. Method: This article is based on a systematic review of the literature forthcoming from the UK Government's Department of Health-funded evaluations of successive primary care organisational developments. These include total purchasing pilots, GP commissioning group pilots, personal medical services pilots and primary care groups and trusts. Results: Primary care organisations in England have proved to be a catalyst in facilitating the development of integrated care working between primary and community health services. Conversely, primary care organisations have proved less effective in promoting integration between health and social care agencies where most progress has been made at the strategic commissioning level. The development of primary care trusts in England is heralding an end to traditional community hospitals. Conclusions: The development of primary care groups in England are but an intermediate step of a policy progression towards future primary care-based organisations that will functionally integrate primary and community health services with local authority services under a single management umbrella.
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Directory of Open Access Journals (Sweden)
Jessica W. Skelley
2015-01-01
Full Text Available Objectives: To assess the baseline knowledge of fourth year student pharmacists on their ability to properly identify and categorize medication related problems (MRP during their Advanced Pharmacy Practice Experience (APPE in the ambulatory care setting, and to assess the efficacy of a written resource designed to educate and train users on identification and documentation of MRP's and used for this purpose with participating students on their ambulatory care APPE. Methods: A pretest consisting of ten multiple-choice questions was administered electronically to fourth year student pharmacists (N=18 at the start of their ambulatory care APPE. The test was designed to assess both the students' baseline knowledge regarding MRP's, and their ability to identify a wide variety of medication-related problems. Students then received a written copy of The Medication Therapy Intervention & Safety Documentation Program training manual and were asked to read it in its entirety in the first week of their APPE. Finally, students were given a posttest survey (identical to the pretest to complete to assess if their knowledge had increased from baseline. Results: The average score for the 18 students taking the baseline knowledge pre-test was 63.33%, indicating limited baseline knowledge regarding the identification and classification of MRP's. In assessing the effectiveness of the written training document, the overall posttest results compared to pretest results did not indicate improvement in students' knowledge or ability to properly identify and classify medication related problems (MRP after reviewing the training manual. The average scores declined from 63.33% on the pretest to 62.78% on the posttest, although this was not found to be statistically significant (p = 0.884. However, a statistically significant decline in students' knowledge occurred on one specific question, which tested their ability to classify MRP's (p = 0.029. Conclusions: Based on the
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Quanjel, Tessa C C; Struijs, Jeroen N; Spreeuwenberg, Marieke D; Baan, Caroline A; Ruwaard, Dirk
2018-05-09
In an attempt to deal with the pressures on the healthcare system and to guarantee sustainability, changes are needed. This study is focused on a cardiology Primary Care Plus intervention in which cardiologists provide consultations with patients in a primary care setting in order to prevent unnecessary referrals to the hospital. This study explores which patients with non-acute and low-complexity cardiology-related health complaints should be excluded from Primary Care Plus and referred directly to specialist care in the hospital. This is a retrospective observational study based on quantitative data. Data collected between January 1 and December 31, 2015 were extracted from the electronic medical record system. Logistic regression analyses were used to select patient groups that should be excluded from referral to Primary Care Plus. In total, 1525 patients were included in the analyses. Results showed that male patients, older patients, those with the referral indication 'Stable Angina Pectoris' or 'Dyspnoea' and patients whose reason for referral was 'To confirm disease' or 'Screening of unclear pathology' had a significantly higher probability of being referred to hospital care after Primary Care Plus. To achieve efficiency one should exclude patient groups with a significantly higher probability of being referred to hospital care after Primary Care Plus. NTR6629 (Data registered: 25-08-2017) (registered retrospectively).
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PRIMARY PALLIATIVE CARE? - Treating terminally ill cancer patients in the primary care sector
DEFF Research Database (Denmark)
Neergaard, Mette Asbjørn; Jensen, Anders Bonde; Olesen, Frede
BACKGROUND. Palliative care for cancer patients is an important part of a GP's work. Although every GP is frequently involved in care for terminally ill cancer patients, only little is known about how these palliative efforts are perceived by the patients and their families, a knowledge...... that is vital to further improve palliative care in the primary sector.AIM. The aim of the study was to analyse the quality of palliative home care with focus on the GP's role based on evaluations by relatives of recently deceased cancer patients and professionals from both the primary and secondary health care...... approach.RESULTS. The analyses revealed several key areas, e.g.: 1) How to take, give and maintain professional responsibility for palliative home care. 2) A need for transparent communication both among primary care professionals and among professionals across the primary/secondary interface. 3...
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Torgovicky, Refael; Goldberg, Avishay; Shvarts, Shifra; Bar Dayan, Yosefa; Onn, Erez; Levi, Yehezkel; BarDayan, Yaron
2005-01-01
A number of typologies have been developed in the strategic management literature to categorize strategies that an organization can pursue at the business level. Extensive research has established Porter's generic strategies of (1) cost leadership, (2) differentiation, (3) differentiation focus, (4) cost focus, and (5) stuck-in-the-middle as the dominant paradigm in the literature. The purpose of the current study was to research competitive strategies in the Israeli ambulatory health care system, by comparing managerial perceptions of present and ideal business strategies in two Israeli sick funds. We developed a unique research tool, which reliably examines the gap between the present and ideal status managerial views. We found a relation between the business strategy and performance measures, thus strengthening Porter's original theory about the nonviability of the stuck-in-the-middle strategy, and suggesting the applicability Porter's generic strategies to not-for-profit institutes in an ambulatory health care system.
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Sánchez-Sagrado, T
Spanish doctors are still leaving the country to look for quality work. Ireland is not a country with many Spanish professionals but it is interesting to know its particular Health care system. Ireland is one of the countries with a national health care system, although it has a mixture of private health care insurance schemes. People have a right to health care if they have been living in Ireland at least for a year. Access to the primary care health system depends on age and income: free of charge for Category 1 and co-payments for the rest. This division generates great inequalities among the population. Primary Care doctors are self-employed, and they work independently. However, since 2001 they have tended to work in multidisciplinary teams in order to strengthen the Primary Care practice. Salary is gained from a combination of public and private incomes which are not differentiated. The role of the General Practitioner consists in the treatment of acute and chronic diseases, minor surgery, child care, etc. There is no coordination between Primary and Secondary care. Access to specialised medicine is regulated by the price of consultation. Primary Care doctors are not gatekeepers. To be able to work here, doctors must have three years of training after medical school. After that, Continuing Medical Education is compulsory, and the college of general practitioners monitors it annually. The Irish health care system does not fit into the European model. Lack of a clear separation between public and private health care generates great inequalities. The non-existence of coordination between primary and specialised care leads to inefficiencies, which Ireland cannot allow itself after a decade of economic crisis. Copyright © 2017 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
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Costs of health care across primary care models in Ontario.
Laberge, Maude; Wodchis, Walter P; Barnsley, Jan; Laporte, Audrey
2017-08-01
The purpose of this study is to analyze the relationship between newly introduced primary care models in Ontario, Canada, and patients' primary care and total health care costs. A specific focus is on the payment mechanisms for primary care physicians, i.e. fee-for-service (FFS), enhanced-FFS, and blended capitation, and whether providers practiced as part of a multidisciplinary team. Utilization data for a one year period was measured using administrative databases for a 10% sample selected at random from the Ontario adult population. Primary care and total health care costs were calculated at the individual level and included costs from physician services, hospital visits and admissions, long term care, drugs, home care, lab tests, and visits to non-medical health care providers. Generalized linear model regressions were conducted to assess the differences in costs between primary care models. Patients not enrolled with a primary care physicians were younger, more likely to be males and of lower socio-economic status. Patients in blended capitation models were healthier and wealthier than FFS and enhanced-FFS patients. Primary care and total health care costs were significantly different across Ontario primary care models. Using the traditional FFS as the reference, we found that patients in the enhanced-FFS models had the lowest total health care costs, and also the lowest primary care costs. Patients in the blended capitation models had higher primary care costs but lower total health care costs. Patients that were in multidisciplinary teams (FHT), where physicians are also paid on a blended capitation basis, had higher total health care costs than non-FHT patients but still lower than the FFS reference group. Primary care and total health care costs increased with patients' age, morbidity, and lower income quintile across all primary care payment types. The new primary care models were associated with lower total health care costs for patients compared to the
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Makowski, Suzana K E
2004-01-01
Complementary and alternative medicine (CAM) is one of the fastest growing segments of the health care industry today, with studies suggesting that between 30% and 50% of the adult population in the United States uses some form of CAM. Many ambulatory care centers are considering integrating CAM into their clinical services. This article will review some of the national trends and present a framework for assessing local market demand for CAM in order to help prioritize an organization's CAM integration strategy.
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Directory of Open Access Journals (Sweden)
Gabriel Uche Pascal Iloh
2018-01-01
Full Text Available Background: Depression is a family and public health condition that has negative consequences for the victim, family, friends, and society with significant socio-family dysfunction, especially when it is undiagnosed. Aim: The present study was aimed at determining the role of family bio-social variables in depression among ambulatory adult patients in a primary care clinic in the Eastern Nigerian. Materials and Methods: A clinic-based cross-sectional descriptive study was carried out on 400 adult patients in a primary care clinic in Nigeria. Data were collected using Patient Health Questionnaire-9, Family Assessment Device, Multidimensional Scale of Perceived Social Support and Brief Family Relationship Scale. Results: The age of the study participants ranged from 18 to 78 years. There were 40.5% of male and 59.5% of female. The prevalence of depression was 48.5% with the most common pattern being mild depression (32.3%. Depression was significantly associated with unhealthy family functioning (P = 0.002, low-acuity family support (P = 0.039, family with least cohesion (P = 0.044, least expressiveness (P = 0.013, and most conflict (P = 0.013. The most significant predictor of depression was unhealthy family functioning (Odds ratio = 3.14 [1.82–3.77]; P = 0.001. Depressed patients who had unhealthy family functioning were three times more likely to experience depressive illness compared to their counterparts who were from healthy functional family. Conclusion: Depression occurred among the study participants and was significantly associated with unhealthy family functioning, low family support, least family cohesion and expressiveness and most family conflict. Assessment of family biosocial factors should be part of the reason for encounter during consultation to unravel family variables that positively or negatively influence depression.
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Chang, Lo-Yi; Lai, Chou-Cheng; Chen, Chun-Jen; Cho, Ching-Yi; Luo, Yu-Cheng; Jeng, Mei-Jy; Wu, Keh-Gong
2017-08-01
Acute tonsillitis is the leading diagnosis in pediatric ambulatory care, and group A beta-hemolytic streptococcus is the main reason for antibiotic prescriptions in patients with acute tonsillitis. The aim of this study was to analyze trends in prescribing antibiotics and to investigate the prescription patterns for acute tonsillitis in pediatric ambulatory care in Taiwan from 2000 to 2009. Data on children younger than 18 years with a primary diagnosis of acute tonsillitis were retrieved from the National Health Insurance Research Database of Taiwan from 2000 to 2009. Concomitant bacterial infections were excluded. Sex, age, seasonality, location, level of medical institution, and physician specialty were analyzed. Annual and monthly changes in antibiotic prescriptions and classification were also evaluated. A total of 40,775 cases were enrolled, with an overall antibiotic prescription rate of 16.8%. There was a remarkable decline in the antibiotic prescription rates for tonsillitis from 28.4% in 2000 to 10.9% in 2009. Factors associated with a higher prescription rate included older age, visits from eastern Taiwan, medical centers, and nonpediatrician physicians. Otolaryngologists had higher antibiotic prescription rate, whereas pediatricians had the lowest (21.9% vs. 11.6%). The rates of obtaining throat cultures were low although the culture performing rate in the medical centers was significantly higher (12.3%, p < 0.001). From 2000 to 2009, there was a remarkable decline in the antibiotic prescription rates for tonsillitis. Further studies to evaluate diagnostic tools such as rapid antigen detection tests or throat cultures to decrease antibiotic prescriptions are warranted. Copyright © 2015. Published by Elsevier B.V.
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Primary care and pattern of skin diseases in a mediterranean island
Directory of Open Access Journals (Sweden)
Lyronis Ioannis
2006-01-01
Full Text Available Abstract Background In Greece where primary health care services are not fully developed, patients with simple or minor conditions have to attend to hospitals to be treated. We analysed the data of patients with cutaneous disorders attending the tertiary referral hospital on the Island of Crete, with the aim to identify the most common conditions that patients complain of, in order to define the areas where the education of General Practitioners in Dermatology must focus. Methods All patients attending the Dermatology ambulatory office in the Emergency Department of the University General Hospital of Heraklion from January 2003 to December 2003 were included in this retrospective analysis. The medical records of the patients (history, physical examination and laboratory investigations were analysed to ascertain the diagnosis and the management of cases. All patients were evaluated by qualified dermatologists. Results A total of 3715 patients attended the Dermatology Clinic. Most patients were young adults in the age group 21–40 years (38.4%, and the male to female ratio was 1 to 1.2. Allergic skin diseases, mostly dermatitis and urticaria (35.7% were the most common for attendance, followed by infectious diseases (26.1% and insect bites (10.2%. Inflammatory and autoimmune disorders accounted for 7.9% of the cases. Pruritus of unknown origin was diagnosed in 6.3% of patients. Skin tumors were detected in 2.7%. The management of the vast majority of cases (85.0% consisted of advice with or without a prescription, while only 4.8% of patients required admission. Conclusion Allergic and infectious skin diseases were the most common cutaneous diseases in patients attending this tertiary University hospital, while the management of most patients did not require specialised care. On the basis of the present data, the training of primary health care providers in Dermatology should emphasize these common conditions, with the aim of improving primary
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Directory of Open Access Journals (Sweden)
Forastiere Francesco
2009-12-01
Full Text Available Abstract Background A relationship between quality of primary health care and preventable hospitalizations has been described in the US, especially among the elderly. In Europe, there has been a recent increase in the evaluation of Ambulatory Care Sensitive Conditions (ACSC as an indicator of health care quality, but evidence is still limited. The aim of this study was to determine whether income level is associated with higher hospitalization rates for ACSC in adults in a country with universal health care coverage. Methods From the hospital registries in four Italian cities (Turin, Milan, Bologna, Rome, we identified 9384 hospital admissions for six chronic conditions (diabetes, hypertension, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, and asthma among 20-64 year-olds in 2000. Case definition was based on the ICD-9-CM coding algorithm suggested by the Agency for Health Research and Quality - Prevention Quality Indicators. An area-based (census block income index was used for each individual. All hospitalization rates were directly standardised for gender and age using the Italian population. Poisson regression analysis was performed to assess the relationship between income level (quintiles and hospitalization rates (RR, 95% CI separately for the selected conditions controlling for age, gender and city of residence. Results Overall, the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31 and for congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62. With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year
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An analysis of risk factors and adverse events in ambulatory surgery
Directory of Open Access Journals (Sweden)
Kent C
2014-06-01
Full Text Available Christopher Kent, Julia Metzner, Laurent BollagDepartment of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USAAbstract: Care for patients undergoing ambulatory procedures is a broad and expanding area of anesthetic and surgical practice. There were over 35 million ambulatory surgical procedures performed in the US in 2006. Ambulatory procedures are diverse in both type and setting, as they span the range from biopsies performed under local anesthesia to intra-abdominal laparoscopic procedures, and are performed in offices, freestanding ambulatory surgery centers, and ambulatory units of hospitals. The information on adverse events from these varied settings comes largely from retrospective reviews of sources, such as quality-assurance databases and closed malpractice claims. Very few if any ambulatory procedures are emergent, and in comparison to the inpatient population, ambulatory surgical patients are generally healthier. They are still however subject to most of the same types of adverse events as patients undergoing inpatient surgery, albeit at a lower frequency. The only adverse events that could be considered to be unique to ambulatory surgery are those that arise out of the circumstance of discharging a postoperative patient to an environment lacking skilled nursing care. There is limited information on these types of discharge-related adverse events, but the data that are available are reviewed in an attempt to assist the practitioner in patient selection and discharge decision making. Among ambulatory surgical patients, particularly those undergoing screening or cosmetic procedures, expectations from all parties involved are high, and a definition of adverse events can be expanded to include any occurrence that interrupts the rapid throughput of patients or interferes with early discharge and optimal patient satisfaction. This review covers all types of adverse events, but focuses on the more
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US National Practice Patterns in Ambulatory Operative Management of Lateral Epicondylitis.
Buller, Leonard T; Best, Matthew J; Nigen, David; Ialenti, Marc; Baraga, Michael G
2015-12-01
Lateral epicondylitis is a common cause of elbow pain, frequently responsive to nonoperative management. There are multiple operative techniques for persistently symptomatic patients who have exhausted conservative therapies. Little is known regarding US national trends in operative management of lateral epicondylitis. We conducted a study to investigate changes in use of ambulatory procedures for lateral epicondylitis. Cases of lateral epicondylitis were identified using the National Survey of Ambulatory Surgery and were analyzed for trends in demographics and use of ambulatory surgery. Between 1994 and 2006, the population-adjusted rate of ambulatory surgical procedures increased from 7.29 to 10.44 per 100,000 capita. The sex-adjusted rate of surgery for lateral epicondylitis increased by 85% among females and decreased by 31% among males. Most patients were between ages 40 and 49 years, and the largest percentage increase in age-adjusted rates was found among patients older than 50 years (275%) between 1994 and 2006. Use of regional anesthesia increased from 17% in 1994 to 30% in 2006. Private insurance remained the most common payer. Awareness of the increasing use of ambulatory surgery for lateral epicondylitis may lead to changes in health care policies and positively affect patient care.
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Primary care research in Denmark
DEFF Research Database (Denmark)
Vedsted, Peter; Kallestrup, Per
2016-01-01
International Perspectives on Primary Care Research examines how the evidence base from primary care research can strengthen health care services and delivery, tackle the growing burden of disease, improve quality and safety, and increase a person-centred focus to health care. Demonstrating...... the inter-professional nature of the discipline, the book also features a section on cross-nation organisations and primary care networks supporting research. National perspectives are offered from researchers in 20 countries that form part of the World Organization of Family Doctors, providing case...... histories from research-rich to resource-poor nations that illustrate the range of research development and capacity building. This book argues the importance of primary care research, especially to policy makers, decision makers and funders in informing best practice, training primary health care providers...
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van Andel, Judith; Thijs, Roland D.; de Weerd, Al; Arends, Johan; Leijten, Frans
OBJECTIVE: This study aimed to (1) evaluate available systems and algorithms for ambulatory automatic seizure detection and (2) discuss benefits and disadvantages of seizure detection in epilepsy care. METHODS: PubMed and EMBASE were searched up to November 2014, using variations and synonyms of
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The Coming Primary Care Revolution.
Ellner, Andrew L; Phillips, Russell S
2017-04-01
The United States has the most expensive, technologically advanced, and sub-specialized healthcare system in the world, yet it has worse population health status than any other high-income country. Rising healthcare costs, high rates of waste, the continued trend towards chronic non-communicable disease, and the growth of new market entrants that compete with primary care services have set the stage for fundamental change in all of healthcare, driven by a revolution in primary care. We believe that the coming primary care revolution ought to be guided by the following design principles: 1) Payment must adequately support primary care and reward value, including non-visit-based care. 2) Relationships will serve as the bedrock of value in primary care, and will increasingly be fostered by teams, improved clinical operations, and technology, with patients and non-physicians assuming an ever-increasing role in most aspects of healthcare. 3) Generalist physicians will increasingly focus on high-acuity and high-complexity presentations, and primary care teams will increasingly manage conditions that specialists managed in the past. 4) Primary care will refocus on whole-person care, and address health behaviors as well as vision, hearing, dental, and social services. Design based on these principles should lead to higher-value healthcare, but will require new approaches to workforce training.
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Adcock, G B
1999-07-01
Corporate-based nurse managed centers are not the national norm. More prevalent is the use of an occupational health or physician-directed medical model of care. The author describes how a 14-year-old primary care center at a North Carolina computer software company is just "business as usual" when viewed in the context of the company's philosophy, goals, and culture. Included are considerations for nurse practitioners interested in the successful transplantation of this primary care model to other settings.
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Primary care in Switzerland gains strength.
Djalali, Sima; Meier, Tatjana; Hasler, Susann; Rosemann, Thomas; Tandjung, Ryan
2015-06-01
Although there is widespread agreement on health- and cost-related benefits of strong primary care in health systems, little is known about the development of the primary care status over time in specific countries, especially in countries with a traditionally weak primary care sector such as Switzerland. The aim of our study was to assess the current strength of primary care in the Swiss health care system and to compare it with published results of earlier primary care assessments in Switzerland and other countries. A survey of experts and stakeholders with insights into the Swiss health care system was carried out between February and March 2014. The study was designed as mixed-modes survey with a self-administered questionnaire based on a set of 15 indicators for the assessment of primary care strength. Forty representatives of Swiss primary and secondary care, patient associations, funders, health care authority, policy makers and experts in health services research were addressed. Concordance between the indicators of a strong primary care system and the real situation in Swiss primary care was rated with 0-2 points (low-high concordance). A response rate of 62.5% was achieved. Participants rated concordance with five indicators as 0 (low), with seven indicators as 1 (medium) and with three indicators as 2 (high). In sum, Switzerland achieved 13 of 30 possible points. Low scores were assigned because of the following characteristics of Swiss primary care: inequitable local distribution of medical resources, relatively low earnings of primary care practitioners compared to specialists, low priority of primary care in medical education and training, lack of formal guidelines for information transfer between primary care practitioners and specialists and disregard of clinical routine data in the context of medical service planning. Compared to results of an earlier assessment in Switzerland, an improvement of seven indicators could be stated since 1995. As a
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Improving eye care in the primary health care setting
Directory of Open Access Journals (Sweden)
M de Wet
2000-09-01
Full Text Available One of the challenges facing primary health care in South Africa is the delivery of quality eye care to all South Africans. In this regard the role of the primary health care worker, as the first point of contact, is crucial. This paper reports on the problems primary health care workers experience in providing quality eye care in Region B of the Free State. Problems identified by those involved in the study include the cumbersome referral system, the unavailability of appropriate medicine at clinics, the insufficient knowledge of primary health care workers regarding eye conditions and the lack of communication between the various eye care service providers. Suggestions to address the problems identified included more in-service training of primary health care workers regarding eye conditions, liaison with NGO’s providing eye care, decentralisation of services and the establishment of an eye care committee in the region.
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Frasca-Beaulieu, K
1999-01-01
The following article illustrates some important factors to consider when designing ambulatory care facilities (ACFs), and focuses on how wayfinding, noise control, privacy, security, color and lighting, general ambience, textures, and nature can have a profound influence on patient and family stress, consumer satisfaction, health and well-being. Other important design issues: convenience and accessibility, accommodation to various populations, consumer and family focus, patient education, image, as well as current equipment needs and future growth are examined in light of the prevailing trends in health care delivery. In sum, this feature explores the important stress-reducing and health-promoting elements involved in successful ACF design.
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Directory of Open Access Journals (Sweden)
Radha S Vanmali
2013-01-01
Full Text Available Objective: Describe the role and integration of ambulatory care pharmacists in a Human Immunodeficiency Virus (HIV clinic within a free and bilingual clinic with regards to types of interventions made during the patient-pharmacist visit. Design: Retrospective, single-centered, chart review. Setting: Free, bilingual clinic in Richmond, VA. Participants: Thirty-two adult patients with diagnosed HIV receiving care in the clinic between June 30, 2010 and January 26, 2011. Main Outcome Measure: Types of interventions documented during the patient-pharmacist visit, categorized as medication review, patient education, or adherence monitoring. Results: Total of 32 patients accounted for 55 patient-pharmacist visits and 296 interventions. The most common interventions were medication review (66.9%, patient education (23.3%, and adherence monitoring (9.8%. Post-hoc analysis suggests Hispanic patients are more likely to be diagnosed with Acquired Immune Deficiency Syndrome (AIDS (P = 0.01, have current or history of opportunistic infection (OI (P=0.01, and have current or history of OI prophylaxis (P = 0.03. Adherence monitoring was less common amongst the non-Hispanics (7.1% compared to the Hispanic sub-population (16.5%, (P = 0.04. Conclusion: The role of ambulatory care pharmacists in a free and bilingual clinic goes beyond adherence monitoring. Pharmacists can be a valuable part of the patient care team by providing medication review and patient education for HIV and other co-morbidities within free clinics. Further research is warranted to assess outcomes and to further explore the underlying barriers to early HIV diagnosis and adherence within the Hispanic population. Type: Original Research
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Directory of Open Access Journals (Sweden)
Ann M. Fugit, Pharm.D., BCPS
2013-01-01
Full Text Available Objective: Describe the role and integration of ambulatory care pharmacists in a Human Immunodeficiency Virus (HIV clinic within a free and bilingual clinic with regards to types of interventions made during the patient-pharmacist visit. Design: Retrospective, single-centered, chart review. Setting: Free, bilingual clinic in Richmond, VA. Participants: Thirty-two adult patients with diagnosed HIV receiving care in the clinic between June 30, 2010 and January 26, 2011. Main Outcome Measure: Types of interventions documented during the patient-pharmacist visit, categorized as medication review, patient education, or adherence monitoring. Results: Total of 32 patients accounted for 55 patient-pharmacist visits and 296 interventions. The most common interventions were medication review (66.9%, patient education (23.3%, and adherence monitoring (9.8%. Post-hoc analysis suggests Hispanic patients are more likely to be diagnosed with Acquired Immune Deficiency Syndrome (AIDS (P = 0.01, have current or history of opportunistic infection (OI (P=0.01, and have current or history of OI prophylaxis (P = 0.03. Adherence monitoring was less common amongst the non-Hispanics (7.1% compared to the Hispanic sub-population (16.5%, (P = 0.04. Conclusion: The role of ambulatory care pharmacists in a free and bilingual clinic goes beyond adherence monitoring. Pharmacists can be a valuable part of the patient care team by providing medication review and patient education for HIV and other co-morbidities within free clinics. Further research is warranted to assess outcomes and to further explore the underlying barriers to early HIV diagnosis and adherence within the Hispanic population.
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Wilf-Miron, R; Lewenhoff, I; Benyamini, Z; Aviram, A
2003-02-01
The development of a medical risk management programme based on the aviation safety approach and its implementation in a large ambulatory healthcare organisation is described. The following key safety principles were applied: (1). errors inevitably occur and usually derive from faulty system design, not from negligence; (2). accident prevention should be an ongoing process based on open and full reporting; (3). major accidents are only the "tip of the iceberg" of processes that indicate possibilities for organisational learning. Reporting physicians were granted immunity, which encouraged open reporting of errors. A telephone "hotline" served the medical staff for direct reporting and receipt of emotional support and medical guidance. Any adverse event which had learning potential was debriefed, while focusing on the human cause of error within a systemic context. Specific recommendations were formulated to rectify processes conducive to error when failures were identified. During the first 5 years of implementation, the aviation safety concept and tools were successfully adapted to ambulatory care, fostering a culture of greater concern for patient safety through risk management while providing support to the medical staff.
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Infection Prevention and Control in Pediatric Ambulatory Settings.
Rathore, Mobeen H; Jackson, Mary Anne
2017-11-01
Since the American Academy of Pediatrics published its statement titled "Infection Prevention and Control in Pediatric Ambulatory Settings" in 2007, there have been significant changes that prompted this updated statement. Infection prevention and control is an integral part of pediatric practice in ambulatory medical settings as well as in hospitals. Infection prevention and control practices should begin at the time the ambulatory visit is scheduled. All health care personnel should be educated regarding the routes of transmission and techniques used to prevent the transmission of infectious agents. Policies for infection prevention and control should be written, readily available, updated every 2 years, and enforced. Many of the recommendations for infection control and prevention from the Centers for Disease Control and Prevention for hospitalized patients are also applicable in the ambulatory setting. These recommendations include requirements for pediatricians to take precautions to identify and protect employees likely to be exposed to blood or other potentially infectious materials while on the job. In addition to emphasizing the key principles of infection prevention and control in this policy, we update those that are relevant to the ambulatory care patient. These guidelines emphasize the role of hand hygiene and the implementation of diagnosis- and syndrome-specific isolation precautions, with the exemption of the use of gloves for routine diaper changes and wiping a well child's nose or tears for most patient encounters. Additional topics include respiratory hygiene and cough etiquette strategies for patients with a respiratory tract infection, including those relevant for special populations like patients with cystic fibrosis or those in short-term residential facilities; separation of infected, contagious children from uninfected children when feasible; safe handling and disposal of needles and other sharp medical devices; appropriate use of personal
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Directory of Open Access Journals (Sweden)
Varcher M
2016-07-01
Full Text Available Monica Varcher,1 Sofia Zisimopoulou,1 Olivia Braillard,1 Bernard Favrat,2 Noëlle Junod Perron1 1Department of Community, Primary and Emergency Care, Division of Primary Care, Geneva University Hospitals, Geneva, 2Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland Background: Iron deficiency is a common problem in primary care and is usually treated with oral iron substitution. With the recent simplification of intravenous (IV iron administration (ferric carboxymaltose and its approval in many countries for iron deficiency, physicians may be inclined to overutilize it as a first-line substitution.Objective: The aim of this study was to evaluate iron deficiency management and substitution practices in an academic primary care division 5 years after ferric carboxymaltose was approved for treatment of iron deficiency in Switzerland.Methods: All patients treated for iron deficiency during March and April 2012 at the Geneva University Division of Primary Care were identified. Their medical files were analyzed for information, including initial ferritin value, reasons for the investigation of iron levels, suspected etiology, type of treatment initiated, and clinical and biological follow-up. Findings were assessed using an algorithm for iron deficiency management based on a literature review.Results: Out of 1,671 patients, 93 were treated for iron deficiency. Median patients’ age was 40 years and 92.5% (n=86 were female. The average ferritin value was 17.2 μg/L (standard deviation 13.3 μg/L. The reasons for the investigation of iron levels were documented in 82% and the suspected etiology for iron deficiency was reported in 67%. Seventy percent of the patients received oral treatment, 14% IV treatment, and 16% both. The reasons for IV treatment as first- and second-line treatment were reported in 57% and 95%, respectively. Clinical and biological follow-up was planned in less than two-thirds of the
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Perspectives on ambulatory anesthesia: the patient’s point of view
Directory of Open Access Journals (Sweden)
Sehmbi H
2014-12-01
Full Text Available Herman Sehmbi, Jean Wong, David T WongDepartment of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, CanadaAbstract: Recent advances in anesthetic and surgical techniques have led to tremendous growth of ambulatory surgery. With patients with many co-morbid conditions undergoing complex procedures in an ambulatory setting, the challenges in providing ambulatory surgery and anesthesia are immense. In recent years, the paradigm has shifted from a health-care provider focus involving process compliance and clinical outcomes, to a patient-centered strategy that includes patients’ perspectives of desired outcomes. Improving preoperative patient education while reducing unnecessary testing, improving postoperative pain management, and reducing postoperative nausea and vomiting may help enhance patient satisfaction. The functional status of most patients is reduced postoperatively, and thus the pattern of recovery is an area of ongoing research. Standardized and validated psychometric questionnaires such as Quality of Recovery-40 and Postoperative Quality of Recovery Scale are potential tools to assess this. Patient satisfaction has been identified as an important outcome measure and dedicated tools to assess this in various clinical settings are needed. Identification of key aspects of ambulatory surgery deemed important from patients’ perspectives, and implementation of validated outcome questionnaires, are important in improving patient centered care and patient satisfaction.Keywords: ambulatory, patient, satisfaction, anesthesia, outcomes, questionnaire, perspectives
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Liu, Su; Yam, Carrie H K; Huang, Olivia H Y; Griffiths, Sian M
2013-10-01
How to provide better primary care and achieve the right level of public-private balance in doing so is at the centre of many healthcare reforms around the world. In a healthcare system like Hong Kong, where inpatient services are largely funded through general taxation and ambulatory services out of pocket, the family doctor model of primary care is underdeveloped. Since 2008, the Government has taken forward various initiatives to promote primary care and encourage more use of private services. However, little is known in Hong Kong or elsewhere about consumers' willingness to pay (WTP) for private services when care is available in the public sector. This study assessed willingness of the Hong Kong elderly to pay for specific primary care and preventive services in the private sector, through a cross-sectional in-person questionnaire survey and focus group discussions among respondents. The survey revealed that the WTP for private services in general was low among the elderly; particularly, reported WTP for chronic conditions and preventive care both fell below the current market prices. Sub-group analysis showed higher WTP among healthier and more affluent elderly. Among other things, concerns over affordability and uncertainty (of price and quality) in the private sector were associated with this low level of WTP. These results suggest that most elderly, who are heavy users of public health services but with limited income, may not use more private services without seeing significant reduction in price. Financial incentives for consumers alone may not be enough to promote primary care or public-private partnership. Public education on the value of prevention and primary care, as well as supply-side interventions should both be considered. Hong Kong's policy-making process of the initiative studied here may also provide lessons for other countries with ongoing healthcare reforms.
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Management of comorbidities in ambulatory anesthesia: a review
Directory of Open Access Journals (Sweden)
Dabu-Bondoc S
2015-06-01
Full Text Available Susan Dabu-Bondoc, Kirk Shelley Department of Anesthesiology, School of Medicine, Yale University, New Haven, CT, USAAbstract: Advances in medical science now allow people with significant medical issues to live at home. As the outpatient population ages and surgical techniques advance, the ambulatory anesthesiologist has to be prepared to handle these “walking wounded”. The days of restricting ambulatory surgery procedures to American Society of Anesthesiologists class 1 and 2 patients are rapidly fading into the past. To remain competitive and economically viable, the modern ambulatory surgery center needs to expand its practice to include patients with medical comorbidities. In an environment where production and economic pressures exist, maintaining safety and good outcomes in high-risk patients for ambulatory surgery can be arduous. Adding to the complexity of this challenge is the rapid evolution of the therapeutic approaches to a variety of medical issues. For example, there has been a significant increase in the number and types of insulin a diabetic patient might be prescribed in recent years. In the case of the patient with coronary artery disease, the variety of both drug and nondrug eluding stents or new antithrombotic agents has also increased the complexity of perioperative management. Complex patients need careful, timely, and team-based preoperative evaluation by an anesthesia provider who is knowledgeable of outpatient care. Optimizing comorbidities preoperatively is a crucial initial step in minimizing risk. This paper will examine a number of common medical issues and explore their impact on managing outpatient surgical procedures.Keywords: ambulatory surgery, medical comorbidities, diabetes, coronary artery disease, respiratory disease, obesity
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Schiff, Gordon D; Reyes Nieva, Harry; Griswold, Paula; Leydon, Nicholas; Ling, Judy; Federico, Frank; Keohane, Carol; Ellis, Bonnie R; Foskett, Cathy; Orav, E John; Yoon, Catherine; Goldmann, Don; Weissman, Joel S; Bates, David W; Biondolillo, Madeleine; Singer, Sara J
2017-08-01
Evaluate application of quality improvement approaches to key ambulatory malpractice risk and safety areas. In total, 25 small-to-medium-sized primary care practices (16 intervention; 9 control) in Massachusetts. Controlled trial of a 15-month intervention including exposure to a learning network, webinars, face-to-face meetings, and coaching by improvement advisors targeting "3+1" high-risk domains: test result, referral, and medication management plus culture/communication issues evaluated by survey and chart review tools. Chart reviews conducted at baseline and postintervention for intervention sites. Staff and patient survey data collected at baseline and postintervention for intervention and control sites. Chart reviews demonstrated significant improvements in documentation of abnormal results, patient notification, documentation of an action or treatment plan, and evidence of a completed plan (all Pcoaches, and learning network decreased selected ambulatory safety risks often seen in malpractice claims.
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Primary care workforce development in Europe.
Groenewegen, P.; Heinemann, S.; Gress, S.; Schäfer, W.
2014-01-01
Background: There is a large variation in the organization of primary care in Europe. In some health care systems, primary care is the gatekeeper to more specialized care, whilst in others patients have the choice between a wide range of providers. Primary care has increasingly become teamwork.
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Pathways to ambulatory sensitive hospitalisations for Māori in the Auckland and Waitemata regions.
Barker, Carol; Crengle, Sue; Bramley, Dale; Bartholomew, Karen; Bolton, Patricia; Walsh, Michael; Wignall, Jean
2016-10-28
Ambulatory Sensitive Hospitalisations (ASH) are a group of conditions potentially preventable through interventions delivered in the primary health care setting. ASH rates are consistently higher for Māori compared with non-Māori. This study aimed to establish Māori experience of factors driving the use of hospital services for ASH conditions, including barriers to accessing primary care. A telephone questionnaire exploring pathways to ASH was administered to Māori (n=150) admitted to Auckland and Waitemata District Health Board (DHB) hospitals with an ASH condition between January 1st-June 30th 2015. A cohort of 1,013 participants were identified; 842 (83.1%) were unable to be contacted. Of the 171 people contactable, 150 agreed to participate, giving an overall response rate of 14.8% and response rate of contactable patients of 87.7%. Results demonstrated high rates of self-reported enrolment, utilisation and preference for primary care. Many participants demonstrated appropriate health seeking behaviour and accurate recall of diagnoses. While financial barriers to accessing primary care were reported, non-financial barriers including lack of after-hours provision (12.6% adults, 37.7% children), appointment availability (7.4% adults, 17.0% children) and lack of transport (13.7% adults, 20.8% children) also featured in participant responses. Interventions to reduce Māori ASH include: timely access to primary care through electronic communications, increased appointment availability, extended opening hours, low cost after-hours care and consistent best management of ASH conditions in general practice through clinical pathways. Facilitated enrolment of ASH patients with no general practitioner could also reduce ASH. Research into transport barriers and enablers for Māori accessing primary care is required to support future interventions.
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Effectiveness of transmucosal sedation for special needs populations in the ambulatory care setting.
Tetef, Sue
2014-12-01
Transmucosal is an alternative route for administering medications (ie, dexmedetomidine, midazolam, naloxone) that can be effective for procedural or moderate sedation in patients with special needs when other routes are not practical or are contraindicated. Special needs populations include children, older adults, pregnant and breast-feeding women, and people with disabilities or conditions that limit their ability to function and cope. Understanding the perioperative nurse's role in the care of patients receiving medications via the transmucosal route can lead to better clinical outcomes. Successful use of the transmucosal route requires knowledge of when to administer a medication, how often and how much of a medication should be administered, the onset and duration of action, the adverse effects or contraindications, and the key benefits. In addition, a case study approach suggests that transmucosal sedation can decrease patient stress and anxiety related to undergoing medical procedures or surgery in the ambulatory care setting. Copyright © 2014 AORN, Inc. Published by Elsevier Inc. All rights reserved.
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Di Bella, Alexandra; Blake, Claire; Young, Adrienne; Pelecanos, Anita; Brown, Teresa
2018-02-01
The prevalence of malnutrition in patients with cancer is reported as high as 60% to 80%, and malnutrition is associated with lower survival, reduced response to treatment, and poorer functional status. The Malnutrition Screening Tool (MST) is a validated tool when administered by health care professionals; however, it has not been evaluated for patient-led screening. This study aims to assess the reliability of patient-led MST screening through assessment of inter-rater reliability between patient-led and dietitian-researcher-led screening and intra-rater reliability between an initial and a repeat patient screening. This cross-sectional study included 208 adults attending ambulatory cancer care services in a metropolitan teaching hospital in Queensland, Australia, in October 2016 (n=160 inter-rater reliability; n=48 intra-rater reliability measured in a separate sample). Primary outcome measures were MST risk categories (MST 0-1: not at risk, MST ≥2: at risk) as determined by screening completed by patients and a dietitian-researcher, patient test-retest screening, and patient acceptability. Percent and chance-corrected agreement (Cohen's kappa coefficient, κ) were used to determine agreement between patient-MST and dietitian-MST (inter-rater reliability) and MST completed by patient on admission to unit (patient-MSTA) and MST completed by patient 1 to 3 hours after completion of initial MST (patient-MSTB) (intra-rater reliability). High inter-rater reliability and intra-rater reliability were observed. Agreement between patient-MST and dietitian-MST was 96%, with "almost perfect" chance-adjusted agreement (κ=0.92, 95% CI 0.84 to 0.97). Agreement between repeated patient-MSTA and patient-MSTB was 94%, with "almost perfect" chance-adjusted agreement (κ=0.88, 95% CI 0.71 to 1.00). Based on dietitian-MST, 33% (n=53) of patients were identified as being at risk for malnutrition, and 40% of these reported not seeing a dietitian. Of 156 patients who provided
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Auras, Silke; Ostermann, Thomas; de Cruppé, Werner; Bitzer, Eva-Maria; Diel, Franziska; Geraedts, Max
2016-12-01
The study aimed to illustrate the effect of the patients' sex, age, self-rated health and medical practice specialization on patient satisfaction. Secondary analysis of patient survey data using multilevel analysis (generalized linear mixed model, medical practice as random effect) using a sequential modelling strategy. We examined the effects of the patients' sex, age, self-rated health and medical practice specialization on four patient satisfaction dimensions: medical practice organization, information, interaction, professional competence. The study was performed in 92 German medical practices providing ambulatory care in general medicine, internal medicine or gynaecology. In total, 9888 adult patients participated in a patient survey using the validated 'questionnaire on satisfaction with ambulatory care-quality from the patient perspective [ZAP]'. We calculated four models for each satisfaction dimension, revealing regression coefficients with 95% confidence intervals (CIs) for all independent variables, and using Wald Chi-Square statistic for each modelling step (model validity) and LR-Tests to compare the models of each step with the previous model. The patients' sex and age had a weak effect (maximum regression coefficient 1.09, CI 0.39; 1.80), and the patients' self-rated health had the strongest positive effect (maximum regression coefficient 7.66, CI 6.69; 8.63) on satisfaction ratings. The effect of medical practice specialization was heterogeneous. All factors studied, specifically the patients' self-rated health, affected patient satisfaction. Adjustment should always be considered because it improves the comparability of patient satisfaction in medical practices with atypically varying patient populations and increases the acceptance of comparisons. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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Fudin, J; Smith, H S; Toledo-Binette, C S; Kenney, E; Yu, A B; Boutin, R
2000-01-01
Health care practitioners are increasingly under pressure to curtail spending while trying to deliver excellent patient care. These issues are also affecting palliative care, particularly now that palliative care programs are expanding. A comparison of cost-effectiveness and feasibility of using continuous subcutaneous (s.q.) ambulatory infusion of hydromorphone versus intravenous (i.v.) ambulatory morphine is illustrated in this study. With the high doses of morphine required in chronic cancer pain, the use of subcutaneous morphine is not feasible due to the volume of solution required to be delivered. Hydromorphone can be prepared in concentrated solutions enabling it to be delivered by the subcutaneous route. Morphine stability data are available. However, hydromorphone stability has only been verified for seven days; thus, stability data were needed post-seven days. Concentrations of 10 mg/ml, 20 mg/ml, 50 mg/ml, and 100 mg/ml, in 0.9 percent normal saline or dextrose 5 percent water, were analyzed via high-performance liquid chromatography (HPLC) at seven and 28 days. Cost comparisons of supplies and associated costs with subcutaneous versus intravenous solutions were obtained. Hydromorphone was found to be stable for 28 days in both dilutants. Cost analysis of a hydromorphone 28-day supply resulted in substantial savings over the equivalent costs of morphine infusions.
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Hospitalization for uncomplicated hypertension: an ambulatory care sensitive condition.
Walker, Robin L; Chen, Guanmin; McAlister, Finlay A; Campbell, Norm R C; Hemmelgarn, Brenda R; Dixon, Elijah; Ghali, William; Rabi, Doreen; Tu, Karen; Jette, Nathalie; Quan, Hude
2013-11-01
Hospitalizations for ambulatory care sensitive conditions (ACSC) represent an indirect measure of access and quality of community care. This study explored hospitalization rates for 1 ACSC, uncomplicated hypertension, and the factors associated with hospitalization. A cohort of patients with incident hypertension, and their covariates, was defined using validated case definitions applied to International Classification of Disease administrative health data in 4 Canadian provinces between fiscal years 1997 and 2004. We applied the Canadian Institute for Health Information's case definition to detect all patients who had an ACSC hospitalization for uncomplicated hypertension. We employed logistic regression to assess factors associated with an ACSC hospitalization for uncomplicated hypertension. The overall rate of hospitalizations for uncomplicated hypertension in the 4 provinces was 3.7 per 1000 hypertensive patients. The risk-adjusted rate was lowest among those in an urban setting (2.6 per 1000; 95% confidence interval [CI], 2.3-2.7), the highest income quintile (3.4 per 1000; 95% CI, 2.8-4.2), and those with no comorbidities (3.6 per 1000; 95% CI, 3.2-3.9). Overall, Newfoundland had the highest adjusted rate (5.7 per 1000; 95% CI, 4.9-6.7), and British Columbia had the lowest (3.7 per 1000; 95% CI, 3.4-4.2). The adjusted rate declined from 5.9 per 1000 in 1997 to 3.7 per 1000 in 2004. We found that the rate of hospitalizations for uncomplicated hypertension has decreased over time, which might reflect improvements in community care. Geographic variations in the rate of hospitalizations indicate disparity among the provinces and those residing in rural regions. Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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Directory of Open Access Journals (Sweden)
Doris Burtscher
Full Text Available Kyrgyzstan is one of the 27 high multidrug-resistant tuberculosis (MDR-TB burden countries listed by the WHO. In 2012, Médecins Sans Frontières (MSF started a drug-resistant tuberculosis (DR-TB project in Kara Suu District. A qualitative study was undertaken to understand the perception of TB and DR-TB in order to improve the effectiveness and acceptance of the MSF intervention and to support advocacy strategies for an ambulatory model of care.This paper reports findings from 63 interviews with patients, caregivers, health care providers and members of communities. Data was analysed using a qualitative content analysis. Validation was ensured by triangulation and a 'thick' description of the research context, and by presenting deviant cases.Findings show that the general population interprets TB as the 'lungs having a cold' or as a 'family disease' rather than as an infectious illness. From their perspective, individuals facing poor living conditions are more likely to get TB than wealthier people. Vulnerable groups such as drug and alcohol users, homeless persons, ethnic minorities and young women face barriers in accessing health care. As also reported in other publications, TB is highly stigmatised and possible side effects of the long treatment course are seen as unbearable; therefore, people only turn to public health care quite late. Most patients prefer ambulatory treatment because of the much needed emotional support from their social environment, which positively impacts treatment concordance. Health care providers favour inpatient treatment only for a better monitoring of side effects. Health staff increasingly acknowledges the central role they play in supporting DR-TB patients, and the importance of assuming a more empathic attitude.Health promotion activities should aim at improving knowledge on TB and DR-TB, reducing stigma, and fostering the inclusion of vulnerable populations. Health seeking delays and adherence problems will
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Challenges to Safe Injection Practices in Ambulatory Care.
Anderson, Laura; Weissburg, Benjamin; Rogers, Kelli; Musuuza, Jackson; Safdar, Nasia; Shirley, Daniel
2017-05-01
Most recent infection outbreaks caused by unsafe injection practices in the United States have occurred in ambulatory settings. We utilized direct observation and a survey to assess injection practices at 31 clinics. Improper vial use was observed at 13 clinics (41.9%). Pharmacy support and healthcare worker education may improve injection practices. Infect Control Hosp Epidemiol 2017;38:614-616.
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Monitoring quality in Israeli primary care: The primary care physicians' perspective
Directory of Open Access Journals (Sweden)
Nissanholtz-Gannot Rachel
2012-06-01
Full Text Available Abstract Background Since 2000, Israel has had a national program for ongoing monitoring of the quality of the primary care services provided by the country's four competing non-profit health plans. Previous research has demonstrated that quality of care has improved substantially since the program's inception and that the program enjoys wide support among health plan managers. However, prior to this study there were anecdotal and journalistic reports of opposition to the program among primary care physicians engaged in direct service delivery; these raised serious questions about the extent of support among physicians nationally. Goals To assess how Israeli primary care physicians experience and rate health plan efforts to track and improve the quality of care. Method The study population consisted of primary care physicians employed by the health plans who have responsibility for the quality of care of a panel of adult patients. The study team randomly sampled 250 primary-care physicians from each of the four health plans. Of the 1,000 physicians sampled, 884 met the study criteria. Every physician could choose whether to participate in the survey by mail, e-mail, or telephone. The anonymous questionnaire was completed by 605 physicians – 69% of those eligible. The data were weighted to reflect differences in sampling and response rates across health plans. Main findings The vast majority of respondents (87% felt that the monitoring of quality was important and two-thirds (66% felt that the feedback and subsequent remedial interventions improved medical care to a great extent. Almost three-quarters (71% supported continuation of the program in an unqualified manner. The physicians with the most positive attitudes to the program were over age 44, independent contract physicians, and either board-certified in internal medicine or without any board-certification (i.e., residents or general practitioners. At the same time, support for the
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AMBULATORY CARE - SENSITIVE CONDITIONS IN CHILDREN UNDER FIVE YEARS
Directory of Open Access Journals (Sweden)
Maria Aparecida Araújo Figueiredo
2013-05-01
Full Text Available Objective:analyzethe extent to which the incidence rate of primary care sensitivehospitalizations in children under five years is influenced by the percentage of coverage of theprimary care.Methods:This was a cross-sectional ecological study that combines coverage ofprimary careand theambulatorycare-sensitiveconditionsin 2000 and 2010. We used data from theHospital Information System (HIS and the Information System of Primary Care (SIAB.Results:The data revealed that the increased coverage providedprimary carereductionrateofhospitalization diseases studied. In 2000 the reduction was greater for gastroenteritis (51% inchildren under 01 years and 30% in children 01-04 years in 2010 for respiratory diseases (51% inchildren under 01years and 33% in children aged 01-04 years.Conclusion:we found an association between the coverage ofprimary careand admission rates, however seem to affect othervariables, suggesting the need for further studies.
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Current state of information technology use in a US primary care practice-based research network.
Andrews, James E; Pearce, Kevin A; Sydney, Carey; Ireson, Carol; Love, Margaret
2004-01-01
To examine the current levels of information technology (IT) use in a primary care practice-based research network (PBRN) in order to inform future development of its infrastructure. Every primary care practitioner who is a member of the Kentucky Ambulatory Network (KAN),as well as the office managers of each practice. Practitioners included family practitioners, general practitioners, nurse practitioners and physician assistants. A cross-sectional study using two survey instruments: one for office managers and one for practitioners. The office manager survey included questions related to the current state of IT within the practice, plans for enhancement and general IT issues from the perspective of managing a practice. The practitioner survey was designed to measure current IT use and attitudes of primary care practitioners. Response rates for the surveys were 46% (n = 68) for the office managers and 51% (n = 116) for practitioners. All but one practice had internet access; however, 43% had only dial-up service. Only 21% of practitioners use an electronic medical record (EMR), with dollar cost being the barrier reported most frequently (58%). More than half of the office managers were either 'somewhat interested' (45%) or 'very interested' (17%) in a low-cost, standardised EMR that was, at the time, to be sponsored by the American Academy of Family Physicians. For practitioners, 71% were either 'somewhat' or 'very' interested in such a system. Responses to other IT issues are reported. While interest in enabling information technologies was high in KAN, adoption was variable, with use of several key technologies reported as low.The results suggest that research in this network that would be dependent on or enhanced by IT might be impeded and, generally, greater attention should be given to enhancing the IT infrastructure in primary care.
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Wilf-Miron, R; Lewenhoff, I; Benyamini, Z; Aviram, A
2003-01-01
The development of a medical risk management programme based on the aviation safety approach and its implementation in a large ambulatory healthcare organisation is described. The following key safety principles were applied: (1) errors inevitably occur and usually derive from faulty system design, not from negligence; (2) accident prevention should be an ongoing process based on open and full reporting; (3) major accidents are only the "tip of the iceberg" of processes that indicate possibilities for organisational learning. Reporting physicians were granted immunity, which encouraged open reporting of errors. A telephone "hotline" served the medical staff for direct reporting and receipt of emotional support and medical guidance. Any adverse event which had learning potential was debriefed, while focusing on the human cause of error within a systemic context. Specific recommendations were formulated to rectify processes conducive to error when failures were identified. During the first 5 years of implementation, the aviation safety concept and tools were successfully adapted to ambulatory care, fostering a culture of greater concern for patient safety through risk management while providing support to the medical staff. PMID:12571343
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Hsieh, Ronan Wenhan; Chen, Likwang; Chen, Tsung-Fu; Liang, Jyh-Chong; Lin, Tzu-Bin; Chen, Yen-Yuan; Tsai, Chin-Chung
2016-12-07
Compared with the traditional ways of gaining health-related information from newspapers, magazines, radio, and television, the Internet is inexpensive, accessible, and conveys diverse opinions. Several studies on how increasing Internet use affected outpatient clinic visits were inconclusive. The objective of this study was to examine the role of Internet use on ambulatory care-seeking behaviors as indicated by the number of outpatient clinic visits after adjusting for confounding variables. We conducted this study using a sample randomly selected from the general population in Taiwan. To handle the missing data, we built a multivariate logistic regression model for propensity score matching using age and sex as the independent variables. The questionnaires with no missing data were then included in a multivariate linear regression model for examining the association between Internet use and outpatient clinic visits. We included a sample of 293 participants who answered the questionnaire with no missing data in the multivariate linear regression model. We found that Internet use was significantly associated with more outpatient clinic visits (P=.04). The participants with chronic diseases tended to make more outpatient clinic visits (PInternet may be associated with patients' increasing need for interpreting and discussing the information with health care professionals, thus resulting in an increasing number of outpatient clinic visits. In addition, the media literacy of Web-based health-related information seekers may also affect their ambulatory care-seeking behaviors, such as outpatient clinic visits. ©Ronan Wenhan Hsieh, Likwang Chen, Tsung-Fu Chen, Jyh-Chong Liang, Tzu-Bin Lin, Yen-Yuan Chen, Chin-Chung Tsai. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 07.12.2016.
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Ambulatory laparoscopic minor hepatic surgery: Retrospective observational study.
Gaillard, M; Tranchart, H; Lainas, P; Tzanis, D; Franco, D; Dagher, I
2015-11-01
Over the last decade, laparoscopic hepatic surgery (LHS) has been increasingly performed throughout the world. Meanwhile, ambulatory surgery has been developed and implemented with the aims of improving patient satisfaction and reducing health care costs. The objective of this study was to report our preliminary experience with ambulatory minimally invasive LHS. Between 1999 and 2014, 172 patients underwent LHS at our institution, including 151 liver resections and 21 fenestrations of hepatic cysts. The consecutive series of highly selected patients who underwent ambulatory LHS were included in this study. Twenty patients underwent ambulatory LHS. Indications were liver cysts in 10 cases, liver angioma in 3 cases, focal nodular hyperplasia in 3 cases, and colorectal hepatic metastasis in 4 cases. The median operative time was 92 minutes (range: 50-240 minutes). The median blood loss was 35 mL (range: 20-150 mL). There were no postoperative complications or re-hospitalizations. All patients were hospitalized after surgery in our ambulatory surgery unit, and were discharged 5-7 hours after surgery. The median postoperative pain score at the time of discharge was 3 (visual analogue scale: 0-10; range: 0-4). The median quality-of-life score at the first postoperative visit was 8 (range: 6-10) and the median cosmetic satisfaction score was 8 (range: 7-10). This series shows that, in selected patients, ambulatory LHS is feasible and safe for minor hepatic procedures. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
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Depressive Disorders in Primary Health Care
Vuorilehto, Maria
2008-01-01
The Vantaa Primary Care Depression Study (PC-VDS) is a naturalistic and prospective cohort study concerning primary care patients with depressive disorders. It forms a collaborative research project between the Department of Mental and Alcohol Research of the National Public Health Institute, and the Primary Health Care Organization of the City of Vantaa. The aim is to obtain a comprehensive view on clinically significant depression in primary care, and to compare depressive patients in prima...
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Berendes, Sima; Heywood, Peter; Oliver, Sandy; Garner, Paul
2011-04-01
In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options. We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred. Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases.
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Directory of Open Access Journals (Sweden)
Sima Berendes
2011-04-01
Full Text Available BACKGROUND: In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options. METHODS AND FINDINGS: We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred. CONCLUSIONS: Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases.
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Diabetes care provision in UK primary care practices.
Directory of Open Access Journals (Sweden)
Gillian Hawthorne
Full Text Available Although most people with Type 2 diabetes receive their diabetes care in primary care, only a limited amount is known about the quality of diabetes care in this setting. We investigated the provision and receipt of diabetes care delivered in UK primary care.Postal surveys with all healthcare professionals and a random sample of 100 patients with Type 2 diabetes from 99 UK primary care practices.326/361 (90.3% doctors, 163/186 (87.6% nurses and 3591 patients (41.8% returned a questionnaire. Clinicians reported giving advice about lifestyle behaviours (e.g. 88% would routinely advise about calorie restriction; 99.6% about increasing exercise more often than patients reported having received it (43% and 42% and correlations between clinician and patient report were low. Patients' reported levels of confidence about managing their diabetes were moderately high; a median (range of 21% (3% to 39% of patients reporting being not confident about various areas of diabetes self-management.Primary care practices have organisational structures in place and are, as judged by routine quality indicators, delivering high quality care. There remain evidence-practice gaps in the care provided and in the self confidence that patients have for key aspects of self management and further research is needed to address these issues. Future research should use robust designs and appropriately designed studies to investigate how best to improve this situation.
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Integrated primary health care in Australia
Directory of Open Access Journals (Sweden)
Gawaine Powell Davies
2009-10-01
Full Text Available Introduction: To fulfil its role of coordinating health care, primary health care needs to be well integrated, internally and with other health and related services. In Australia, primary health care services are divided between public and private sectors, are responsible to different levels of government and work under a variety of funding arrangements, with no overarching policy to provide a common frame of reference for their activities. Description of policy: Over the past decade, coordination of service provision has been improved by changes to the funding of private medical and allied health services for chronic conditions, by the development in some states of voluntary networks of services and by local initiatives, although these have had little impact on coordination of planning. Integrated primary health care centres are being established nationally and in some states, but these are too recent for their impact to be assessed. Reforms being considered by the federal government include bringing primary health care under one level of government with a national primary health care policy, establishing regional organisations to coordinate health planning, trialling voluntary registration of patients with general practices and reforming funding systems. If adopted, these could greatly improve integration within primary health care. Discussion: Careful change management and realistic expectations will be needed. Also other challenges remain, in particular the need for developing a more population and community oriented primary health care.
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Integrated primary health care in Australia.
Davies, Gawaine Powell; Perkins, David; McDonald, Julie; Williams, Anna
2009-10-14
To fulfil its role of coordinating health care, primary health care needs to be well integrated, internally and with other health and related services. In Australia, primary health care services are divided between public and private sectors, are responsible to different levels of government and work under a variety of funding arrangements, with no overarching policy to provide a common frame of reference for their activities. Over the past decade, coordination of service provision has been improved by changes to the funding of private medical and allied health services for chronic conditions, by the development in some states of voluntary networks of services and by local initiatives, although these have had little impact on coordination of planning. Integrated primary health care centres are being established nationally and in some states, but these are too recent for their impact to be assessed. Reforms being considered by the federal government include bringing primary health care under one level of government with a national primary health care policy, establishing regional organisations to coordinate health planning, trialling voluntary registration of patients with general practices and reforming funding systems. If adopted, these could greatly improve integration within primary health care. Careful change management and realistic expectations will be needed. Also other challenges remain, in particular the need for developing a more population and community oriented primary health care.
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Primary care physician insights into a typology of the complex patient in primary care.
Loeb, Danielle F; Binswanger, Ingrid A; Candrian, Carey; Bayliss, Elizabeth A
2015-09-01
Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor-a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)-that complicated care for chronic medical illnesses. This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients. © 2015 Annals of Family Medicine, Inc.
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Blueprint for an Undergraduate Primary Care Curriculum.
Fazio, Sara B; Demasi, Monica; Farren, Erin; Frankl, Susan; Gottlieb, Barbara; Hoy, Jessica; Johnson, Amanda; Kasper, Jill; Lee, Patrick; McCarthy, Claire; Miller, Kathe; Morris, Juliana; O'Hare, Kitty; Rosales, Rachael; Simmons, Leigh; Smith, Benjamin; Treadway, Katherine; Goodell, Kristen; Ogur, Barbara
2016-12-01
In light of the increasing demand for primary care services and the changing scope of health care, it is important to consider how the principles of primary care are taught in medical school. While the majority of schools have increased students' exposure to primary care, they have not developed a standardized primary care curriculum for undergraduate medical education. In 2013, the authors convened a group of educators from primary care internal medicine, pediatrics, family medicine, and medicine-pediatrics, as well as five medical students to create a blueprint for a primary care curriculum that could be integrated into a longitudinal primary care experience spanning undergraduate medical education and delivered to all students regardless of their eventual career choice.The authors organized this blueprint into three domains: care management, specific areas of content expertise, and understanding the role of primary care in the health care system. Within each domain, they described specific curriculum content, including longitudinality, generalism, central responsibility for managing care, therapeutic alliance/communication, approach to acute and chronic care, wellness and prevention, mental and behavioral health, systems improvement, interprofessional training, and population health, as well as competencies that all medical students should attain by graduation.The proposed curriculum incorporates important core features of doctoring, which are often affirmed by all disciplines but owned by none. The authors argue that primary care educators are natural stewards of this curriculum content and can ensure that it complements and strengthens all aspects of undergraduate medical education.
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Directory of Open Access Journals (Sweden)
Emily J. Curry
2018-03-01
Full Text Available Identifying patient factors influencing operational throughput time is becoming more imperative due to an increasing focus on value and cost savings in healthcare. The primary objective of this study was to determine patient factors influencing throughput time for primary rotator cuff repairs. Demographic information, medical history and operative reports of 318 patients from one ambulatory care center were retrospectively reviewed. Operating room set up, incision to closure and recovery room time were collected from anesthesia records. Univariate analysis was performed for both continuous and categorical variables. A stepwise, multivariable regression analysis was performed to determine factors associated with operating room time (incision to closure and recovery room time. Of the 318 patients, the mean age was 54.4±10.0 and 197 (61% were male. Male patients had a significantly longer OR time than females (115.5 vs. 100.8 minutes; P<0.001. Furthermore, patients set up in the beach chair position had a significantly longer OR time than patients positioned lateral decubitus (115.8 vs. 89.6 mins, P<0.0001. Number of tendons involved, and inclusion of distal clavicle excision, biceps tenodesis and labral debridement also added significant OR time. Type and number of support staff present also significantly affected OR time. Recovery room time was significantly longer patients who had surgery in the beach chair position (+9.61 minutes and for those who had a cardiac-related medical comorbidity (+11.7 minutes. Our study found that patients positioned in a beach chair spent significantly more time in the operating and recovery rooms. While ease of set up has been a stated advantage ofbeach chair position, we found the perceived ease of set up does not result in more efficient OR throughput.
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Parents' satisfaction with pediatric ambulatory anesthesia in northeast of Thailand.
Boonmak, Suhattaya; Boonmak, Polpun; Pothiruk, Kittawan; Hoontanee, Nattakhan
2009-12-01
Study the satisfaction of parents with ambulatory anesthesia and associated factors, including characteristics of the patients and their parents. This was a prospective, descriptive, observation study. The authors included children who were scheduled for ambulatory anesthetic service between birth and 14 years of age and attended at Srinagarind Hospital, Khon Kaen, Thailand. The authors excluded patients whose parents could not be reached by telephone. Before anesthesia, the authors recorded the patients and parents' characteristics, level of information perception (pre-, peri- and post-anesthesia and complications). After anesthesia, the anesthesia technique and any complications were recorded. The day after anesthesia, the authors made phone calls to the patients to record the parents' satisfaction score (viz, of overall, pre-, peri- and post-anesthesia care, and information about the level of patient care at home), and any anesthesia related complications. Ninety-two patients and their parents were included in the present study. Overall parents 'satisfaction with the anesthesia service was 96.7% (i.e., 89/92) (95% CI 90.8-99.3). Parents' satisfaction with pre- and peri-anesthesia care was 100% (95% CI 96.1-100) and 97.9% (95% CI 92.4-99.7), respectively. Parents' satisfaction with the PACU care and information of patient care at home was 96.7% (95% CI 90.8-99.3) and 91.3% (95% CI 83.6-96.2), respectively. Associated factors where parents were dissatisfied included PACU care satisfaction (i.e., relative risk 22.5 (95% CI 3.2-158)) and patient care information at home (i.e., relative risk 13.3 (95% CI 1.3-136.0)). The present study showed a high level of parents' satisfaction. Parents' dissatisfaction associated with PACU care and information about post anesthesia care at home. Additionally information on parents' characteristics provides invaluable data for improving pediatric ambulatory anesthesia in Srinagarind Hospital.
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Sánchez-Sagrado, T
2016-01-01
The poor planning of health care professionals in Spain has led to an exodus of doctors leaving the country. France is one of the chosen countries for Spanish doctors to develop their professional career. The French health care system belongs to the Bismarck model. In this model, health care system is financed jointly by workers and employers through payroll deduction. The right to health care is linked to the job, and provision of services is done by sickness-funds controlled by the Government. Primary care in France is quite different from Spanish primary care. General practitioners are independent workers who have the right to set up a practice anywhere in France. This lack of regulation has generated a great problem of "medical desertification" with problems of health care access and inequalities in health. French doctors do not want to work in rural areas or outside cities because "they are not value for money". Medical salary is linked to professional activity. The role of doctors is to give punctual care. Team work team does not exist, and coordination between primary and secondary care is lacking. Access to diagnostic tests, hospitals and specialists is unlimited. Duplicity of services, adverse events and inefficiencies are the norm. Patients can freely choose their doctor, and they have a co-payment for visits and hospital care settings. Two years training is required to become a general practitioner. After that, continuing medical education is compulsory, but it is not regulated. Although the French medical Health System was named by the WHO in 2000 as the best health care system in the world, is it not that good. While primary care in Spain has room for improvement, there is a long way for France to be like Spain. Copyright © 2015 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
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Regional anesthesia techniques for ambulatory orthopedic surgery.
LENUS (Irish Health Repository)
O'Donnell, Brian D
2012-02-03
PURPOSE OF REVIEW: The purpose of this review is to present advances in the use of regional anesthetic techniques in ambulatory orthopedic surgery. New findings regarding the use of both neuraxial anesthesia and peripheral nerve block are discussed. RECENT FINDINGS: Neuraxial anesthesia: The use of short-acting local anesthetic agents such as mepivacaine, 2-chloroprocaine, and articaine permits rapid onset intrathecal anesthesia with early recovery profiles. Advantages and limitations of these agents are discussed.Peripheral nerve block: Peripheral nerve blocks in limb surgery have the potential to transform this patient cohort into a truly ambulatory, self-caring group. Recent trends and evidence regarding the benefits of regional anesthesia techniques are presented.Continuous perineural catheters permit extension of improved perioperative analgesia into the ambulatory home setting. The role and reported safety of continuous catheters are discussed. SUMMARY: In summary, shorter acting, neuraxial, local anesthetic agents, specific to the expected duration of surgery, may provide superior recovery profiles in the ambulatory setting. A trend towards more peripheral and selective nerve blocks exists. The infrapatellar block is a promising technique to provide analgesia following knee arthroscopy. Improved analgesia seen in the perioperative period can be safely and effectively extended to the postoperative period with the use of perineural catheters.
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Functioning of primary health care in opinion of managers of primary health care units.
Bojar, I; Wdowiak, L; Kwiatosz-Muc, M
2006-01-01
The aim of the research is to get to know opinions of primary health care managers concerning working of primary health care and concerning quality of medical services offered by family doctors out-patient clinics. The research among managers of primary health care units took place in all out-patient clinics in Lublin province. Research instrument was survey questionnaire of authors own construction. Results were statistically analyzed. From 460 surveys sent, 108 questionnaires were accepted to analysis. Majority of managers of out-patient clinics of primary health care is satisfied with the way and the quality of work of employed staff. In opinion of 71.3% of managers access to family doctor services is very good. Availability of primary health care services is better estimated by managers of not public units. The occupied local provide comfortable work for the staff in opinion of 78.5% of surveyed managers of out-patient clinics. Managers estimate the level of their services as very good (37.96%) and good (37.96%) comparing to other such a subjects present in the market. Internal program of improving quality is run in 22% of out-patient clinics, which were investigated. Managers of primary health care units assess the quality of their services as good and very good. They estimate positively the comfort and politeness in serving patients as well as technical status of equipment and the lodging. They assess availability of their services as very good. Large group of managers of family doctors practices recognizes neighborhood practices as a competitors.
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Brun, A
2005-03-01
To learn from errors is not always easy, especially if they happened to others! This paper describes the organization and management of a critical incident reporting system for primary care physicians in Switzerland and reports about the difficulties and experiences during the first 18 months since the start of the program. It seems to be particularly difficult to enhance the attentiveness of physicians for apparently harmless daily critical incidents and to motivate them to report it even in an anonymous reporting system. As incentives for more intensive participation there are the hope for comments on reported cases by other participants and the expectation that reported errors will be avoided by the readers.
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Pain Management in Ambulatory Surgery—A Review
Directory of Open Access Journals (Sweden)
Jan G. Jakobsson
2014-07-01
Full Text Available Day surgery, coming to and leaving the hospital on the same day as surgery as well as ambulatory surgery, leaving hospital within twenty-three hours is increasingly being adopted. There are several potential benefits associated with the avoidance of in-hospital care. Early discharge demands a rapid recovery and low incidence and intensity of surgery and anaesthesia related side-effects; such as pain, nausea and fatigue. Patients must be fit enough and symptom intensity so low that self-care is feasible in order to secure quality of care. Preventive multi-modal analgesia has become the gold standard. Administering paracetamol, NSIADs prior to start of surgery and decreasing the noxious influx by the use of local anaesthetics by peripheral block or infiltration in surgical field prior to incision and at wound closure in combination with intra-operative fast acting opioid analgesics, e.g., remifentanil, have become standard of care. Single preoperative 0.1 mg/kg dose dexamethasone has a combined action, anti-emetic and provides enhanced analgesia. Additional α-2-agonists and/or gabapentin or pregabalin may be used in addition to facilitate the pain management if patients are at risk for more pronounced pain. Paracetamol, NSAIDs and rescue oral opioid is the basic concept for self-care during the first 3–5 days after common day/ambulatory surgical procedures.
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Ambulatory Healthcare Utilization in the United States: A System Dynamics Approach
Diaz, Rafael; Behr, Joshua G.; Tulpule, Mandar
2011-01-01
Ambulatory health care needs within the United States are served by a wide range of hospitals, clinics, and private practices. The Emergency Department (ED) functions as an important point of supply for ambulatory healthcare services. Growth in our aging populations as well as changes stemming from broader healthcare reform are expected to continue trend in congestion and increasing demand for ED services. While congestion is, in part, a manifestation of unmatched demand, the state of the alignment between the demand for, and supply of, emergency department services affects quality of care and profitability. The central focus of this research is to provide an explanation of the salient factors at play within the dynamic demand-supply tensions within which ambulatory care is provided within an Emergency Department. A System Dynamics (SO) simulation model is used to capture the complexities among the intricate balance and conditional effects at play within the demand-supply emergency department environment. Conceptual clarification of the forces driving the elements within the system , quantifying these elements, and empirically capturing the interaction among these elements provides actionable knowledge for operational and strategic decision-making.
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Ambulatory orthopaedic surgery patients' knowledge with internet-based education.
Heikkinen, Katja; Leino-Kilpi, H; Salanterä, S
2012-01-01
There is a growing need for patient education and an evaluation of its outcomes. The aim of this study was to compare ambulatory orthopaedic surgery patients' knowledge with Internet-based education and face-to-face education with a nurse. The following hypothesis was proposed: Internet-based patient education (experiment) is as effective as face-to-face education with a nurse (control) in increasing patients' level of knowledge and sufficiency of knowledge. In addition, the correlations of demographic variables were tested. The patients were randomized to either an experiment group (n = 72) or a control group (n = 75). Empirical data were collected with two instruments. Patients in both groups showed improvement in their knowledge during their care. Patients in the experiment group improved their knowledge level significantly more in total than those patients in the control group. There were no differences in patients' sufficiency of knowledge between the groups. Knowledge was correlated especially with patients' age, gender and earlier ambulatory surgeries. As a conclusion, positive results concerning patients' knowledge could be achieved with the Internet-based education. The Internet is a viable method in ambulatory care.
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Ambulatory surgery for the patient with breast cancer: current perspectives
Directory of Open Access Journals (Sweden)
Pek CH
2016-08-01
Full Text Available Chong Han Pek,1 John Tey,2 Ern Yu Tan1 1Department of General Surgery, 2Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore, Singapore Abstract: Ambulatory breast cancer surgery is well accepted and is the standard of care at many tertiary centers. Rather than being hospitalized after surgery, patients are discharged on the day of surgery or within 23 hours. Such early discharge does not adversely affect patient outcomes and has the added benefits of better psychological adjustment for the patient, economic savings, and a more efficient utilization of health care resources. The minimal care needed post-discharge also means that the caregiver is not unduly burdened. Unplanned conversions to inpatient admission and readmission rates are low. Wound complications are infrequent and no issues with drain care have been reported. Because the period of postoperative observation is short and monitoring is not as intensive, ambulatory surgery is only suitable for low-risk procedures such as breast cancer surgery and in patients without serious comorbidities, where the likelihood of major perioperative events is low. Optimal management of pain, nausea, and vomiting is essential to ensure a quick recovery and return to normal function. Regional anesthesia such as the thoracic paravertebral block has been employed to improve pain control during the surgery and in the immediate postoperative period. The block provides excellent pain relief and reduces the need for opiates, which also consequently reduces the incidence of nausea and vomiting. The increasing popularity of total intravenous anesthesia with propofol has also helped reduce the incidence of nausea and vomiting in the postoperative period. Ambulatory surgery can be safely carried out in centers where there is a well-designed workflow to ensure proper patient selection, counseling, and education, and where patients and caregivers have easy access to
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2010-10-01
... 45 Public Welfare 1 2010-10-01 2010-10-01 false Primary care. 96.47 Section 96.47 Public Welfare... and Tribal Organizations § 96.47 Primary care. Applications for direct funding of Indian tribes and tribal organizations under the primary care block grant must comply with 42 CFR Part 51c (Grants for...
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DEFF Research Database (Denmark)
Sørensen, Kaspar; Kristensen, Kjeld S; Bang, Lia E
2004-01-01
The primary aim of the present study was to evaluate the impact of smoking status on both clinic and ambulatory blood pressure (BP) and heart rate (HR) by using 24-h ambulatory BP monitoring in treated and non-treated hypertensive smokers and non-smokers. A secondary aim was to evaluate...
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Diabetes care: model for the future of primary care.
Posey, L Michael; Tanzi, Maria G
2010-01-01
To review relevant trends threatening primary care and the evidence supporting use of nonphysicians in primary and chronic care of patients with diabetes. Current medical and pharmacy literature as selected by authors. The care needed by patients with diabetes does not fit well into our current medical model for primary care, and an adequate supply of physicians is not likely to be available for primary care roles in coming years. Patients with diabetes who are placed on evidence-based regimens, are educated about their disease, are coached in ways that motivate them to lose weight and adopt other therapeutic lifestyle changes, and are adhering to and persisting with therapy will soon have improved clinical parameters. These quickly translate into fewer hospitalizations and emergency department visits. A growing body of literature supports the use of pharmacists and other nonphysicians in meeting the needs of patients with diabetes. Pharmacists should join nurse practitioners, specially trained nurses, and physician assistants as integral members of the health care team in providing care to patients with diabetes and, by logical extension, other chronic conditions. Demand for primary care is likely to outstrip the available supply of generalist physicians in the coming years. In addition to nurse practitioners and physician assistants, pharmacists should be considered for key roles in future interdisciplinary teams that triage and provide direct care to patients, including those with diabetes and other chronic conditions.
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LENUS (Irish Health Repository)
Uzochukwu, I
2016-06-01
Ambulatory Gynaecology allows a “see-and-treat” approach to managing gynaecological conditions, providing a more streamlined, integrated care pathway than the traditional gynaecology clinic and inpatient care model. This study was designed to assess patient satisfaction and acceptability of Ambulatory Gynaecology services in Mayo University Hospital, Castlebar, Ireland. It also provided for feedback from patients as to how the service might be improved. \\r\
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Assessing primary care in Austria: room for improvement.
Stigler, Florian L; Starfield, Barbara; Sprenger, Martin; Salzer, Helmut J F; Campbell, Stephen M
2013-04-01
There is emerging evidence that strong primary care achieves better health at lower costs. Although primary care can be measured, in many countries, including Austria, there is little understanding of primary care development. Assessing the primary care development in Austria. A primary care assessment tool developed by Barbara Starfield in 1998 was implemented in Austria. This tool defines 15 primary care characteristics and distinguishes between system and practice characteristics. Each characteristic was evaluated by six Austrian primary care experts and rated as 2 (high), 1 (intermediate) or 0 (low) points, respectively, to their primary care strength (maximum score: n = 30). Austria received 7 out of 30 points; no characteristic was rated as '2' but 8 were rated as '0'. Compared with the 13 previously assessed countries, Austria ranks 10th of 14 countries and is classified as a 'low primary care' country. This study provides the first evidence concerning primary care in Austria, benchmarking it as weak and in need of development. The practicable application of an existing assessment tool can be encouraging for other countries to generate evidence about their primary care system as well.
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Directory of Open Access Journals (Sweden)
Sittig Dean F
2010-11-01
Full Text Available Abstract Background The United States (US Health Information Technology for Economic and Clinical Health Act of 2009 has spurred adoption of electronic health records. The corresponding meaningful use criteria proposed by the Centers for Medicare and Medicaid Services mandates use of computerized provider order entry (CPOE systems. Yet, adoption in the US and other Western countries is low and descriptions of successful implementations are primarily from the inpatient setting; less frequently the ambulatory setting. We describe prescriber and staff perceptions of implementation of a CPOE system for medications (electronic- or e-prescribing system in the ambulatory setting. Methods Using a cross-sectional study design, we conducted eight focus groups at three primary care sites in an independent medical group. Each site represented a unique stage of e-prescribing implementation - pre/transition/post. We used a theoretically based, semi-structured questionnaire to elicit physician (n = 17 and staff (n = 53 perceptions of implementation of the e-prescribing system. We conducted a thematic analysis of focus group discussions using formal qualitative analytic techniques (i.e. deductive framework and grounded theory. Two coders independently coded to theoretical saturation and resolved discrepancies through discussions. Results Ten themes emerged that describe perceptions of e-prescribing implementation: 1 improved availability of clinical information resulted in prescribing efficiencies and more coordinated care; 2 improved documentation resulted in safer care; 3 efficiencies were gained by using fewer paper charts; 4 organizational support facilitated adoption; 5 transition required time; resulted in workload shift to staff; 6 hardware configurations and network stability were important in facilitating workflow; 7 e-prescribing was time-neutral or time-saving; 8 changes in patient interactions enhanced patient care but required education; 9 pharmacy
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Gawron, Andrew J; Feinglass, Joseph; Pandolfino, John E; Tan, Bruce K; Bove, Michiel J; Shintani-Smith, Stephanie
2015-01-01
Introduction. Proton pump inhibitors (PPI) are one of the most commonly prescribed medication classes with similar efficacy between brand name and generic PPI formulations. Aims. We determined demographic, clinical, and practice characteristics associated with brand name PPI prescriptions at ambulatory care visits in the United States. Methods. Observational cross sectional analysis using the National Ambulatory Medical Care Survey (NAMCS) of all adult (≥18 yrs of age) ambulatory care visits from 2006 to 2010. PPI prescriptions were identified by using the drug entry code as brand name only or generic available formulations. Descriptive statistics were reported in terms of unweighted patient visits and proportions of encounters with brand name PPI prescriptions. Global chi-square tests were used to compare visits with brand name PPI prescriptions versus generic PPI prescriptions for each measure. Poisson regression was used to determine the incidence rate ratio (IRR) for generic versus brand PPI prescribing. Results. A PPI was prescribed at 269.7 million adult ambulatory visits, based on 9,677 unweighted visits, of which 53% were brand name only prescriptions. In 2006, 76.0% of all PPI prescriptions had a brand name only formulation compared to 31.6% of PPI prescriptions in 2010. Visits by patients aged 25-44 years had the greatest proportion of brand name PPI formulations (57.9%). Academic medical centers and physician-owned practices had the greatest proportion of visits with brand name PPI prescriptions (58.9% and 55.6% of visits with a PPI prescription, resp.). There were no significant differences in terms of median income, patient insurance type, or metropolitan status when comparing the proportion of visits with brand name versus generic PPI prescriptions. Poisson regression results showed that practice ownership type was most strongly associated with the likelihood of receiving a brand name PPI over the entire study period. Compared to HMO visits
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Berendes, Sima; Heywood, Peter; Oliver, Sandy; Garner, Paul
2011-01-01
Background In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options. Methods and Findings We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred. Conclusions Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases. Please see later in the article for the Editors' Summary PMID:21532746
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Costs of health care across primary care models in Ontario
Laberge, Maude; Wodchis, Walter P; Barnsley, Jan; Laporte, Audrey
2017-01-01
Background The purpose of this study is to analyze the relationship between newly introduced primary care models in Ontario, Canada, and patients? primary care and total health care costs. A specific focus is on the payment mechanisms for primary care physicians, i.e. fee-for-service (FFS), enhanced-FFS, and blended capitation, and whether providers practiced as part of a multidisciplinary team. Methods Utilization data for a one year period was measured using administrative databases for a 1...
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Quality Assessment in the Primary care
Directory of Open Access Journals (Sweden)
Muharrem Ak
2013-04-01
Full Text Available -Quality Assessment in the Primary care Dear Editor; I have read the article titled as “Implementation of Rogi Kalyan Samiti (RKS at Primary Health Centre Durvesh” with great interest. Shrivastava et all concluded that assessment mechanism for the achievement of objectives for the suggested RKS model was not successful (1. Hereby I would like to emphasize the importance of quality assessment (QA especially in the era of newly established primary care implementations in our country. Promotion of quality has been fundamental part of primary care health services. Nevertheless variations in quality of care exist even in the developed countries. Accomplishment of quality in the primary care has some barriers like administration and directorial factors, absence of evidence-based medicine practice lack of continuous medical education. Quality of health care is no doubt multifaceted model that covers all components of health structures and processes of care. Quality in the primary care set up includes patient physician relationship, immunization, maternal, adolescent, adult and geriatric health care, referral, non-communicable disease management and prescribing (2. Most countries are recently beginning the implementation of quality assessments in all walks of healthcare. Organizations like European society for quality and safety in family practice (EQuiP endeavor to accomplish quality by collaboration. There are reported developments and experiments related to the methodology, processes and outcomes of quality assessments of health care. Quality assessments will not only contribute the accomplishment of the program / project but also detect the areas where obstacles also exist. In order to speed up the adoption of QA and to circumvent the occurrence of mistakes, health policy makers and family physicians from different parts of the world should share their experiences. Consensus on quality in preventive medicine implementations can help to yield
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Sandoval, Brian E; Bell, Jennifer; Khatri, Parinda; Robinson, Patricia J
2017-12-12
Primary care continues to be at the center of health care transformation. The Primary Care Behavioral Health (PCBH) model of service delivery includes patient-centered care delivery strategies that can improve clinical outcomes, cost, and patient and primary care provider satisfaction with services. This article reviews the link between the PCBH model of service delivery and health care services quality improvement, and provides guidance for initiating PCBH model clinical pathways for patients facing depression, chronic pain, alcohol misuse, obesity, insomnia, and social barriers to health.
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Oczkowski, Simon J; Chung, Han-Oh; Hanvey, Louise; Mbuagbaw, Lawrence; You, John J
2016-01-01
Patients with serious illness, and their families, state that better communication and decision-making with healthcare providers is a high priority to improve the quality of end-of-life care. Numerous communication tools to assist patients, family members, and clinicians in end-of-life decision-making have been published, but their effectiveness remains unclear. To determine, amongst adults in ambulatory care settings, the effect of structured communication tools for end-of-life decision-making on completion of advance care planning. We searched for relevant randomized controlled trials (RCTs) or non-randomized intervention studies in MEDLINE, EMBASE, CINAHL, ERIC, and the Cochrane Database of Randomized Controlled Trials from database inception until July 2014. Two reviewers independently screened articles for eligibility, extracted data, and assessed risk of bias. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the quality of evidence for each of the primary and secondary outcomes. Sixty-seven studies, including 46 RCTs, were found. The majority evaluated communication tools in older patients (age >50) with no specific medical condition, but many specifically evaluated populations with cancer, lung, heart, neurologic, or renal disease. Most studies compared the use of communication tools against usual care, but several compared the tools to less-intensive advance care planning tools. The use of structured communication tools increased: the frequency of advance care planning discussions/discussions about advance directives (RR 2.31, 95% CI 1.25-4.26, p = 0.007, low quality evidence) and the completion of advance directives (ADs) (RR 1.92, 95% CI 1.43-2.59, pcare desired and care received by patients (RR 1.17, 95% CI 1.05-1.30, p = 0.004, low quality evidence, 2 RCTs). The use of structured communication tools may increase the frequency of discussions about and completion of advance directives, and concordance between
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Primary care nurses: effects on secondary care referrals for diabetes?
Dijk, C.E. van; Verheij, R.A.; Hansen, J.; Velden, L. van der; Nijpels, G.; Groenewegen, P.P.; Bakker, D.H. de
2010-01-01
BACKGROUND: Primary care nurses play an important role in diabetes care, and were introduced in GP-practice partly to shift care from hospital to primary care. The aim of this study was to assess whether the referral rate for hospital treatment for diabetes type II (T2DM) patients has changed with
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Applying organizational behavior theory to primary care.
Mullangi, Samyukta; Saint, Sanjay
2017-03-01
Addressing the mounting primary care shortage in the United States has been a focus of educators and policy makers, especially with the passage of the Affordable Care Act in 2010 and the Medicare Access and CHIP Reauthorization Act in 2015, placing increased pressure on the system. The Association of American Medical Colleges recently projected a shortage of as many as 65,000 primary care physicians by 2025, in part because fewer than 20% of medical students are picking primary care for a career. We examined the issue of attracting medical students to primary care through the lens of organizational behavior theory. Assuming there are reasons other than lower income potential for why students are inclined against primary care, we applied various principles of the Herzberg 2-factor theory to reimagine the operational flow and design of primary care. We conclude by proposing several solutions to enrich the job, such as decreasing documentation requirements, reducing the emphasis on specialty consultations, and elevating physicians to a supervisory role.
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Primary care and health reform in New Zealand.
Grant, C C; Forrest, C B; Starfield, B
1997-02-14
(1) To describe New Zealand's primary care system (2) to compare New Zealand to other Anglo-American members of the OECD with respect to the adequacy of primary care, and (3) to assess the cost-efficiency and effectiveness of New Zealand's system by comparing health spending and health indicators relevant to primary care. A cross-national comparison of primary care, health spending and health indicators in New Zealand, Australia, Canada, the United Kingdom and the United States of America. Main outcome measures were health spending measured in purchasing power parties. Health indicators: mean life expectancy in years, years of potential life lost and infant mortality rates. New Zealand's primary care system ranked below the UK, above the USA and similar to Canada and Australia. Favourable characteristics of New Zealand's primary care system were the use of generalists as the predominant type of practitioner and the low proportion of active physicians who were specialists. Compared to the other countries, New Zealand scored poorly for financial that are necessary for the practise of good primary care. New Zealand and the UK had the lowest spending per capita on health care. New Zealand and the USA scored lowest for all three of the health care indicators. The quality of primary care in New Zealand is limited by barriers to access to care and the intermediate level of practise characteristics essential to primary care. Compared to other AngloAmerican OECD nations, New Zealand has relatively low levels of national health expenditure. In order to improve the quality of primary care, future reform should aim to facilitate access to care, increase the gatekeeping role of primary care physicians, and promote the practise characteristics essential to primary care.
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Third sector primary care for vulnerable populations.
Crampton, P; Dowell, A; Woodward, A
2001-12-01
This paper aims to describe and explain the development of third sector primary care organisations in New Zealand. The third sector is the non-government, non-profit sector. International literature suggests that this sector fulfils an important role in democratic societies with market-based economies, providing services otherwise neglected by the government and private for-profit sectors. Third sector organisations provided a range of social services throughout New Zealand's colonial history. However, it was not until the 1980s that third sector organisations providing comprehensive primary medical and related services started having a significant presence in New Zealand. In 1994 a range of union health centres, tribally based Mäori health providers, and community-based primary care providers established a formal network -- Health Care Aotearoa. While not representing all third sector primary care providers in New Zealand, Health Care Aotearoa was the best-developed example of a grouping of third sector primary care organisations. Member organisations served populations that were largely non-European and lived in deprived areas, and tended to adopt population approaches to funding and provision of services. The development of Health Care Aotearoa has been consistent with international experience of third sector involvement -- there were perceived "failures" in government policies for funding primary care and private sector responses to these policies, resulting in lack of universal funding and provision of primary care and continuing patient co-payments. The principal policy implication concerns the role of the third sector in providing primary care services for vulnerable populations as a partial alternative to universal funding and provision of primary care. Such an alternative may be convenient for proponents of reduced state involvement in funding and provision of health care, but may not be desirable from the point of view of equity and social cohesion
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Touboul-Lundgren, Pia; Jensen, Siri; Drai, Johann; Lindbæk, Morten
2015-09-17
Inappropriate antibiotic prescribing, particularly for respiratory tract infections (RTI) in ambulatory care, has become a worldwide public health threat due to resulting antibiotic resistance. In spite of various interventions and campaigns, wide variations in antibiotic use persist between European countries. Cultural determinants are often referred to as a potential cause, but are rarely defined. To our knowledge, so far no systematic literature review has focused on cultural determinants of antibiotic use. The aim of this study was to identify cultural determinants, on a country-specific level in ambulatory care in Europe, and to describe the influence of culture on antibiotic use, using a framework of cultural dimensions. A computer-based systematic literature review was conducted by two research teams, in France and in Norway. Eligible publications included studies exploring antibiotic use in primary care in at least two European countries based on primary study results, featuring a description of cultural determinants, and published between 1997 and 2015. Quality assessment was conducted independently by two researchers, one in each team, using appropriate checklists according to study design. Each included paper was characterized according to method, countries involved, sampling and main results, and cultural determinants mentioned in each selected paper were extracted, described and categorized. Finally, the influence of Hofstede's cultural dimensions associated with antibiotic consumption within a primary care setting was described. Among 24 eligible papers, 11 were rejected according to exclusion criteria. Overall, 13 papers meeting the quality assessment criteria were included, of which 11 used quantitative methods and two qualitative or mixed methods. The study participants were patients (nine studies) and general practitioners (two studies). This literature review identified various cultural determinants either patient-related (illness perception
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Nurse-measured or ambulatory blood pressure in routine hypertension care
Veerman, D. P.; van Montfrans, G. A.
1993-01-01
Nurses are considered to evoke less white-coat hypertension, and might therefore be able to estimate average blood pressure as well as and more conveniently than ambulatory monitoring. The objective of the present study was to determine the correspondence between blood pressure measured by a doctor
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Diversity of primary care systems analysed.
Kringos, D.; Boerma, W.; Bourgueil, Y.; Cartier, T.; Dedeu, T.; Hasvold, T.; Hutchinson, A.; Lember, M.; Oleszczyk, M.; Pavlick, D.R.
2015-01-01
This chapter analyses differences between countries and explains why countries differ regarding the structure and process of primary care. The components of primary care strength that are used in the analyses are health policy-making, workforce development and in the care process itself (see Fig.
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Debernardi, G; Borgogna, E
1975-01-01
Ambulatory dental extraction was performed on 150 patients with various forms of heart disease. No serious complications were noted with an anaesthetic without vasoconstriction (plain 3% carbocaine). The prior history was carefully studied and pressure values were determined. It is felt that heart disease does not form an absolute contraindication to ambulatory dental extraction.
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Tanner, C; Gans, D; White, J; Nath, R; Pohl, J
2015-01-01
The role of electronic health records (EHR) in enhancing patient safety, while substantiated in many studies, is still debated. This paper examines early EHR adopters in primary care to understand the extent to which EHR implementation is associated with the workflows, policies and practices that promote patient safety, as compared to practices with paper records. Early adoption is defined as those who were using EHR prior to implementation of the Meaningful Use program. We utilized the Physician Practice Patient Safety Assessment (PPPSA) to compare primary care practices with fully implemented EHR to those utilizing paper records. The PPPSA measures the extent of adoption of patient safety practices in the domains: medication management, handoffs and transition, personnel qualifications and competencies, practice management and culture, and patient communication. Data from 209 primary care practices responding between 2006-2010 were included in the analysis: 117 practices used paper medical records and 92 used an EHR. Results showed that, within all domains, EHR settings showed significantly higher rates of having workflows, policies and practices that promote patient safety than paper record settings. While these results were expected in the area of medication management, EHR use was also associated with adoption of patient safety practices in areas in which the researchers had no a priori expectations of association. Sociotechnical models of EHR use point to complex interactions between technology and other aspects of the environment related to human resources, workflow, policy, culture, among others. This study identifies that among primary care practices in the national PPPSA database, having an EHR was strongly empirically associated with the workflow, policy, communication and cultural practices recommended for safe patient care in ambulatory settings.
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[Heart failure in primary care: Attitudes, knowledge and self-care].
Salvadó-Hernández, Cristina; Cosculluela-Torres, Pilar; Blanes-Monllor, Carmen; Parellada-Esquius, Neus; Méndez-Galeano, Carmen; Maroto-Villanova, Neus; García-Cerdán, Rosa Maria; Núñez-Manrique, M Pilar; Barrio-Ruiz, Carmen; Salvador-González, Betlem
2018-04-01
To determine the attitudes, knowledge, and self-care practices in patients with heart failure (HF) in Primary Care, as well as to identify factors associated with better self-care. Cross-sectional and multicentre study. Primary Care. Subjects over 18 years old with HF diagnosis, attended in 10 Primary Health Care Centres in the Metropolitan Area of Barcelona. Self-care was measured using the European Heart Failure Self-Care Behaviour Scale. Sociodemographic and clinical characteristics, tests on attitudes (Self-efficacy Managing Chronic Disease Scale), knowledge (Patient Knowledge Questionnaire), level of autonomy (Barthel), and anxiety and depression screening (Goldberg Test), were also gathered in an interview. A multivariate mixed model stratified by centre was used to analyse the adjusted association of covariates with self-care. A total of 295 subjects (77.6%) agreed to participate, with a mean age of 75.6 years (SD: 11), 56.6% women, and 62% with no primary education. The mean self-care score was 28.65 (SD: 8.22), with 25% of patients scoring lower than 21 points. In the final stratified multivariate model (n=282; R 2 conditional=0.3382), better self-care was associated with higher knowledge (coefficient, 95% confidence interval: -1.37; -1.85 to -0.90), and coronary heart disease diagnosis (-2.41; -4.36: -0.46). Self-care was moderate. The correlation of better self-care with higher knowledge highlights the opportunity to implement strategies to improve self-care, which should consider the characteristics of heart failure patients attended in Primary Care. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.
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Primary health care in Canada: systems in motion.
Hutchison, Brian; Levesque, Jean-Frederic; Strumpf, Erin; Coyle, Natalie
2011-06-01
During the 1980s and 1990s, innovations in the organization, funding, and delivery of primary health care in Canada were at the periphery of the system rather than at its core. In the early 2000s, a new policy environment emerged. This policy analysis examines primary health care reform efforts in Canada during the last decade, drawing on descriptive information from published and gray literature and from a series of semistructured interviews with informed observers of primary health care in Canada. Primary health care in Canada has entered a period of potentially transformative change. Key initiatives include support for interprofessional primary health care teams, group practices and networks, patient enrollment with a primary care provider, financial incentives and blended-payment schemes, development of primary health care governance mechanisms, expansion of the primary health care provider pool, implementation of electronic medical records, and quality improvement training and support. Canada's experience suggests that primary health care transformation can be achieved voluntarily in a pluralistic system of private health care delivery, given strong government and professional leadership working in concert. © 2011 Milbank Memorial Fund. Published by Wiley Periodicals Inc.
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Conway, Kyle S; Forbang, Nketi; Beben, Tomasz; Criqui, Michael H; Ix, Joachim H; Rifkin, Dena E
2015-12-01
Twenty-four-hour ambulatory blood pressure (BP) patterns have been associated with diminished cognitive function in hypertensive and very elderly populations. The relationship between ambulatory BP patterns and cognitive function in community-living older adults is unknown. We conducted a cross-sectional study in which 24-hour ambulatory BP, in-clinic BP, and cognitive function measures were obtained from 319 community-living older adults. The mean age was 72 years, 66% were female, and 13% were African-American. We performed linear regression with performance on the Montreal Cognitive Assessment (MoCA) as the primary outcome and 24-hour BP patterns as the independent variable, adjusting for age, sex, race/ethnicity, education, and comorbidities. Greater nighttime systolic dipping (P = 0.046) and higher 24-hour diastolic BP (DBP; P = 0.015) were both significantly associated with better cognitive function, whereas 24-hour systolic BP (SBP), average real variability, and ambulatory arterial stiffness were not. Higher 24-hour DBP and greater nighttime systolic dipping were significantly associated with improved cognitive function. Future studies should examine whether low 24-hour DBP and lack of nighttime systolic dipping predict future cognitive impairment. © American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
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Decker, Sandra L
2015-01-01
Objective To estimate the relationship between physicians' acceptance of new Medicaid patients and access to health care. Data Sources The National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records Survey and the National Health Interview Survey (NHIS) 2011/2012. Study Design Linear probability models estimated the relationship between measures of experiences with physician availability among children on Medicaid or the Children's Health Insurance Program (CHIP) from the NHIS and state-level estimates of the percent of primary care physicians accepting new Medicaid patients from the NAMCS, controlling for other factors. Principal Findings Nearly 16 percent of children with a significant health condition or development delay had a doctor's office or clinic indicate that the child's health insurance was not accepted in states with less than 60 percent of physicians accepting new Medicaid patients, compared to less than 4 percent in states with at least 75 percent of physicians accepting new Medicaid patients. Adjusted estimates and estimates for other measures of access to care were similar. Conclusions Measures of experiences with physician availability for children on Medicaid/CHIP were generally good, though better in states where more primary care physicians accepted new Medicaid patients. PMID:25683869
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Chiu, Yi-Wen; Chang, Jer-Ming; Lin, Li-Ing; Chang, Pi-Yu; Lo, Wan-Ching; Wu, Ling-Chu; Chen, Tun-Chieh; Hwang, Shang-Jyh
2009-04-01
Tight control of blood sugar improves the outcomes for diabetic patients, but it can only be achieved by adhering to a well-organized care plan. To evaluate the effect of a diabetes care plan with reinforcement of glycemic control in diabetic patients, 98 ambulatory patients with type 2 diabetes who visited our diabetes clinic every 3-4 months and who completed four education courses given by certified diabetes educators within 3 months after the first visit, were defined as the Intervention group. A total of 82 patients fulfilling the inclusion criteria for the Intervention group but who missed at least half of the diabetes education sessions were selected as controls. Both groups had comparable mean hemoglobin A1c (HbA1c) levels at baseline, which decreased significantly at 3 months and were maintained at approximately constant levels at intervals for up to 1 year. The HbA1c decrement in the Intervention group was significantly greater than that in the Control group over the 1-year follow-up period (HbA1c change: -2.5 +/- 1.8% vs. -1.1 +/- 1.7%, p decrement occurred during the first 3 months, and accounted for 95.6% and 94.6% of the total HbA1c decrements in the Intervention and Control groups, respectively. In the multiple regression model, after adjustment for age, body mass index, and duration of diabetes, the Intervention group may still have a 12.6% improvement in HbA1c from their original value to the end of 1 year treatment compared with the Control group (p < 0.05). Diabetes care, with reinforcement from certified diabetes educators, significantly improved and maintained the effects on glycemic control in ambulatory patients with type 2 diabetes.
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Directory of Open Access Journals (Sweden)
Yi-Wen Chiu
2009-04-01
Full Text Available Tight control of blood sugar improves the outcomes for diabetic patients, but it can only be achieved by adhering to a well-organized care plan. To evaluate the effect of a diabetes care plan with reinforcement of glycemic control in diabetic patients, 98 ambulatory patients with type 2 diabetes who visited our diabetes clinic every 3–4 months and who completed four education courses given by certified diabetes educators within 3 months after the first visit, were defined as the Intervention group. A total of 82 patients fulfilling the inclusion criteria for the Intervention group but who missed at least half of the diabetes education sessions were selected as controls. Both groups had comparable mean hemoglobin A1c (HbA1c levels at baseline, which decreased significantly at 3 months and were maintained at approximately constant levels at intervals for up to 1 year. The HbA1c decrement in the Intervention group was significantly greater than that in the Control group over the 1-year follow-up period (HbA1c change: −2.5 ± 1.8% vs. −1.1 ± 1.7%, p < 0.01. The maximal HbA1c decrement occurred during the first 3 months, and accounted for 95.6% and 94.6% of the total HbA1c decrements in the Intervention and Control groups, respectively. In the multiple regression model, after adjustment for age, body mass index, and duration of diabetes, the Intervention group may still have a 12.6% improvement in HbA1c from their original value to the end of 1 year treatment compared with the Control group (p < 0.05. Diabetes care, with reinforcement from certified diabetes educators, significantly improved and maintained the effects on glycemic control in ambulatory patients with type 2 diabetes.
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Pitts, Samantha I; Maruthur, Nisa M; Luu, Ngoc-Phuong; Curreri, Kimberly; Grimes, Renee; Nigrin, Candace; Sateia, Heather F; Sawyer, Melinda D; Pronovost, Peter J; Clark, Jeanne M; Peairs, Kimberly S
2017-11-01
While there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice. As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice. The concerns identified by team members were used to select two initial safety priorities. The impact of CUSP on safety climate and teamwork was assessed through a pre-post comparison of results on the validated Safety Attitudes Questionnaire. Ninety-six percent of staff completed science of safety training as part of CUSP implementation, and 100% of staff completed the two-question safety assessment. The most frequently identified safety concerns were related to medications (n = 11, 28.2), diagnostic testing (n = 9, 25), and communication (n = 5, 14). The CUSP team initially prioritized communication and infection control, which led to standardization of work flows within the practice. Six months following CUSP implementation, large but nonstatistically significant increases were found for the percentage of survey respondents who reported knowledge of the proper channels for questions about patient safety, felt encouraged to report safety concerns, and believed that the work setting made it easy to learn from the errors of others. CUSP is a promising tool to improve safety climate and to identify and address safety concerns within ambulatory health care. Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.
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Ambulatory surgery centers best practices for the 90s.
Hoover, J A
1994-05-01
Outpatient surgery will be the driving force in the continued growth of ambulatory care in the 1990s. Providing efficient, high-quality ambulatory surgical services should therefore be a priority among healthcare providers. Arthur Andersen conducted a survey to discover best practices in ambulatory surgical service. General success characteristics of best performers were business-focused relationships with physicians, the use of clinical protocols, patient convenience, cost management, strong leadership, teamwork, streamlined processes and efficient design. Other important factors included scheduling to maximize OR room use; achieving surgical efficiencies through reduced case pack assembly errors and equipment availability; a focus on cost capture rather than charge capture; sound materiel management practices, such as standardization and vendor teaming; and the appropriate use of automated systems. It is important to evaluate whether the best practices are applicable to your environment and what specific changes to your current processes would be necessary to adopt them.
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Leaders, leadership and future primary care clinical research
Directory of Open Access Journals (Sweden)
Qureshi Nadeem
2008-09-01
Full Text Available Abstract Background A strong and self confident primary care workforce can deliver the highest quality care and outcomes equitably and cost effectively. To meet the increasing demands being made of it, primary care needs its own thriving research culture and knowledge base. Methods Review of recent developments supporting primary care clinical research. Results Primary care research has benefited from a small group of passionate leaders and significant investment in recent decades in some countries. Emerging from this has been innovation in research design and focus, although less is known of the effect on research output. Conclusion Primary care research is now well placed to lead a broad re-vitalisation of academic medicine, answering questions of relevance to practitioners, patients, communities and Government. Key areas for future primary care research leaders to focus on include exposing undergraduates early to primary care research, integrating this early exposure with doctoral and postdoctoral research career support, further expanding cross disciplinary approaches, and developing useful measures of output for future primary care research investment.
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Loeb, Danielle F; Bayliss, Elizabeth A; Candrian, Carey; deGruy, Frank V; Binswanger, Ingrid A
2016-03-22
Complex patients are increasingly common in primary care and often have poor clinical outcomes. Healthcare system barriers to effective care for complex patients have been previously described, but less is known about the potential impact and meaning of caring for complex patients on a daily basis for primary care providers (PCPs). Our objective was to describe PCPs' experiences providing care for complex patients, including their experiences of health system barriers and facilitators and their strategies to enhance provision of effective care. Using a general inductive approach, our qualitative research study was guided by an interpretive epistemology, or way of knowing. Our method for understanding included semi-structured in-depth interviews with internal medicine PCPs from two university-based and three community health clinics. We developed an interview guide, which included questions on PCPs' experiences, perceived system barriers and facilitators, and strategies to improve their ability to effectively treat complex patients. To focus interviews on real cases, providers were asked to bring de-identified clinical notes from patients they considered complex to the interview. Interview transcripts were coded and analyzed to develop categories from the raw data, which were then conceptualized into broad themes after team-based discussion. PCPs (N = 15) described complex patients with multidimensional needs, such as socio-economic, medical, and mental health. A vision of optimal care emerged from the data, which included coordinating care, preventing hospitalizations, and developing patient trust. PCPs relied on professional values and individual care strategies to overcome local and system barriers. Team based approaches were endorsed to improve the management of complex patients. Given the barriers to effective care described by PCPs, individual PCP efforts alone are unlikely to meet the needs of complex patients. To fulfill PCP's expressed concepts of
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Screening and Identification in Pediatric Primary Care
Simonian, Susan J.
2006-01-01
This article reviews issues related to behavioral screening in pediatric primary care settings. Structural-organizational issues affecting the use of pediatric primary care screening are discussed. This study also reviewed selected screening instruments that have utility for use in the primary care setting. Clinical and research issues related to…
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Directory of Open Access Journals (Sweden)
Célina Lichtl
2017-11-01
Full Text Available Abstract Background Hospitalizations for ambulatory care sensitive (ACS conditions are established indicators for the availability and quality of ambulatory care. We aimed to assess the differences between asylum-seeking children and children of the general population in a German city with respect to (i the prevalence of ACS hospitalizations, and (ii the utilization of emergency outpatient services for ACS conditions. Methods Using anonymous account data, all children admitted to the University Hospital Heidelberg in 2015 were included in our study. A unique cost unit distinguished asylum seekers residing in a nearby reception center (exposed from the children of the general population. We adapted international lists of ACS conditions and calculated the prevalence of ACS hospitalizations and the utilization of emergency outpatient services for ACS conditions, attributable fractions among the exposed (Afe and the population attributable fraction among total admissions (PAF for each outcome. Differences in the prevalence of each outcome between exposed and controls were analyzed in logistic regression models adjusted for sex, age group and quarterly admission. Results Of the 32,015 admissions in 2015, 19.9% (6287 were from inpatient and 80.1% (25,638 from outpatient care. In inpatient care, 9.8% (622 of all admissions were hospitalizations for ACS conditions. The Afe of ACS hospitalizations was 46.57%, the PAF was 1.12%. Emergency service use for ACS conditions could be identified in 8.3% (3088 of all admissions (Afe: 79.57%, PAF: 5.08%. The odds ratio (OR of asylum-seeking children being hospitalized for ACS conditions in comparison to the control group was 1.81 [95% confidence interval, CI: 1.02; 3.2]. The OR of the asylumseeking population compared to the general population for the utilization of emergency service use for ACS conditions was 4.93 [95% CI: 4.11; 5.91]. Conclusions Asylum-seeking children had significantly higher odds of ACS
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Developing a business-practice model for pharmacy services in ambulatory settings.
Harris, Ila M; Baker, Ed; Berry, Tricia M; Halloran, Mary Ann; Lindauer, Kathleen; Ragucci, Kelly R; McGivney, Melissa Somma; Taylor, A Thomas; Haines, Stuart T
2008-02-01
A business-practice model is a guide, or toolkit, to assist managers and clinical pharmacy practitioners in the exploration, proposal, development and implementation of new clinical pharmacy services and/or the enhancement of existing services. This document was developed by the American College of Clinical Pharmacy Task Force on Ambulatory Practice to assist clinical pharmacy practitioners and administrators in the development of business-practice models for new and existing clinical pharmacy services in ambulatory settings. This document provides detailed instructions, examples, and resources on conducting a market assessment and a needs assessment, types of clinical services, operations, legal and regulatory issues, marketing and promotion, service development and exit plan, evaluation of service outcomes, and financial considerations in the development of a clinical pharmacy service in the ambulatory environment. Available literature is summarized, and an appendix provides valuable citations and resources. As ambulatory care practices continue to evolve, there will be increased knowledge of how to initiate and expand the services. This document is intended to serve as an essential resource to assist in the growth and development of clinical pharmacy services in the ambulatory environment.
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Donohue, SarahMaria; Haine, James E; Li, Zhanhai; Trowbridge, Elizabeth R; Kamnetz, Sandra A; Feldstein, David A; Sosman, James M; Wilke, Lee G; Sesto, Mary E; Tevaarwerk, Amye J
2017-09-20
Survivorship care plans (SCPs) have been recommended as tools to improve care coordination and outcomes for cancer survivors. SCPs are increasingly being provided to survivors and their primary care providers. However, most primary care providers remain unaware of SCPs, limiting their potential benefit. Best practices for educating primary care providers regarding SCP existence and content are needed. We developed an education program to inform primary care providers of the existence, content, and potential uses for SCPs. The education program consisted of a 15-min presentation highlighting SCP basics presented at mandatory primary care faculty meetings. An anonymous survey was electronically administered via email (n = 287 addresses) to evaluate experience with and basic knowledge of SCPs pre- and post-education. A total of 101 primary care advanced practice providers (APPs) and physicians (35% response rate) completed the baseline survey with only 23% reporting prior receipt of a SCP. Only 9% could identify the SCP location within the electronic health record (EHR). Following the education program, primary care physicians and APPs demonstrated a significant improvement in SCP knowledge, including improvement in their ability to locate one within the EHR (9 vs 59%, p educational program containing information about SCP existence, content, and location in the EHR increased primary care physician and APP knowledge in these areas, which are prerequisites for using SCP in clinical practice.
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Schmidt, Karen L; Lingler, Jennifer H; Schulz, Richard
2009-11-01
Primary care visits of patients with Alzheimer's disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual's verbal participation in these triadic interactions. To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty-three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed. PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver's own verbal participation. Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less. Encouraging verbal participation by AD patients and their caregivers may increase the AD patient's active role and caregiver satisfaction with primary care visits.
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Kriegel, Johannes; Rebhandl, Erwin; Hockl, Wolfgang; Stöbich, Anna-Maria
2017-10-01
The primary health care in rural areas in Austria is currently determined by challenges such as ageing of the population, the shift towards chronic and age-related illnesses, the specialist medical and hospital-related education and training of physicians' as well growing widespread difficulty of staffing doctor's office. The objective is to realize a general practitioner centered and team-oriented primary health care (PHC) approach by establishing networked primary health care in rural areas of Austria. Using literature research, online survey, expert interviews and expert workshops, we identified different challenges in terms of primary health care in rural areas. Further, current resources and capacities of primary health care in rural areas were identified using the example of the district of Rohrbach. Twelve design dimensions and 51 relevant measurement indicators of a PHC network were delineated and described. Based on this, 12 design approaches of PHC concept for the GP-centered and team-oriented primary health care in rural areas have been developed.
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[Strengthening primary health care: a strategy to maximize coordination of care].
de Almeida, Patty Fidelis; Fausto, Márcia Cristina Rodrigues; Giovanella, Lígia
2011-02-01
To describe and analyze the actions developed in four large cities to strengthen the family health strategy (FHS) in Brazil. Case studies were carried out in Aracaju, Belo Horizonte, Florianópolis, and Vitória based on semi-structured interviews with health care managers. In addition, a cross-sectional study was conducted with questionnaires administered to a sample of FHS workers and services users. Actions needed to strengthen primary health care services were identified in all four cities. These include increasing the number of services offered at the primary health care level, removing barriers to access, restructuring primary services as the entry point to the health care system, enhancing problem-solving capacity (diagnostic and therapeutic support and networking between health units to organize the work process, training, and supervision), as well as improving articulation between surveillance and care actions. The cities studied have gained solid experience in the reorganization of the health care model based on a strengthening of health primary care and of the capacity to undertake the role of health care coordinator. However, to make the primary care level the customary entry point and first choice for users, additional actions are required to balance supplier-induced and consumer-driven demands. Consumer driven demand is the biggest challenge for the organization of teamwork processes. Support for and recognition of FHS as a basis for primary health care is still an issue. Initiatives to make FHS better known to the population, health care professionals at all levels, and civil society organizations are still needed.
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A Participatory Model of the Paradox of Primary Care
Homa, Laura; Rose, Johnie; Hovmand, Peter S.; Cherng, Sarah T.; Riolo, Rick L.; Kraus, Alison; Biswas, Anindita; Burgess, Kelly; Aungst, Heide; Stange, Kurt C.; Brown, Kalanthe; Brooks-Terry, Margaret; Dec, Ellen; Jackson, Brigid; Gilliam, Jules; Kikano, George E.; Reichsman, Ann; Schaadt, Debbie; Hilfer, Jamie; Ticknor, Christine; Tyler, Carl V.; Van der Meulen, Anna; Ways, Heather; Weinberger, Richard F.; Williams, Christine
2015-01-01
PURPOSE The paradox of primary care is the observation that primary care is associated with apparently low levels of evidence-based care for individual diseases, but systems based on primary care have healthier populations, use fewer resources, and have less health inequality. The purpose of this article is to explore, from a complex systems perspective, mechanisms that might account for the effects of primary care beyond disease-specific care. METHODS In an 8-session, participatory group model-building process, patient, caregiver, and primary care clinician community stakeholders worked with academic investigators to develop and refine an agent-based computer simulation model to test hypotheses about mechanisms by which features of primary care could affect health and health equity. RESULTS In the resulting model, patients are at risk for acute illness, acute life-changing illness, chronic illness, and mental illness. Patients have changeable health behaviors and care-seeking tendencies that relate to their living in advantaged or disadvantaged neighborhoods. There are 2 types of care available to patients: primary and specialty. Primary care in the model is less effective than specialty care in treating single diseases, but it has the ability to treat multiple diseases at once. Primary care also can provide disease prevention visits, help patients improve their health behaviors, refer to specialty care, and develop relationships with patients that cause them to lower their threshold for seeking care. In a model run with primary care features turned off, primary care patients have poorer health. In a model run with all primary care features turned on, their conjoint effect leads to better population health for patients who seek primary care, with the primary care effect being particularly pronounced for patients who are disadvantaged and patients with multiple chronic conditions. Primary care leads to more total health care visits that are due to more disease
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Ambulatory Antibiotic Stewardship through a Human Factors Engineering Approach: A Systematic Review.
Keller, Sara C; Tamma, Pranita D; Cosgrove, Sara E; Miller, Melissa A; Sateia, Heather; Szymczak, Julie; Gurses, Ayse P; Linder, Jeffrey A
2018-01-01
In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation. We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment. Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS. A human factors engineering approach suggests that investigating the role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing may be a promising way to improve ambulatory AS. © Copyright 2018 by the American Board of Family Medicine.
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Sobczyk, Karolina; Woźniak-Holecka, Joanna; Holecki, Tomasz; Szałabska, Dorota
2016-01-01
The main objective of the project was the evaluation of the organizational and financial aspects of midwives in primary health care (PHC), functioning under The Population Program for the Early Detection of Cervical Cancer two years after the implementation of new law regulations, which enable this occupational group to collect cytological material for screening. Under this project, the data of the Program's Coordinating Centre, affecting midwives' postgraduate education in the field of pap smear tests, was taken into analysis. Furthermore, The National Health Fund (NFZ) reports on contracts entered in the field of the discussed topics, taking into consideration the value of health services performed within the Program in respect of ambulatory care and primary care units. NFZ concluded contracts for the provision of PHC service with 6124 service providers in 2016, including the contracts in the field of providing health services under the cervical cancer prevention program by PHC midwifes, which were entered into by 358 institutions (5.85%). The value of the basic services under the Program, carried out under NFZ contracts in 2014, amounted to approx. PLN 12.3 million, while the value of services performed by PHC midwives represented only 0.38% of this sum. The introduction of legislative changes, allowing PHC midwives to collect cytological material for screening, did not cause, in the period of the observation on a national scale, the expected growth of availability of basic stage services within the cervical cancer prevention program.
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[Rethinking the place of primary healthcare in France--role of general practice].
Gay, B
2013-06-01
Primary healthcare is poorly structured in France while it is well defined at the international level: it is the point of first medical contact of the population with the healthcare system. General practice is the clinical specialty oriented to primary healthcare. Data in the scientific literature highlight the need of refocusing the health system on primary care known to improve both morbi-mortality and care efficiency. In France, health authorities acknowledge general practitioners as playing a key role in the health care system: its time to move from intention to action. Structural changes are needed to achieve this reinforcement of primary healthcare: to re-orientate medical studies towards primary care; to develop research in primary care; to promote cooperation between care providers; to ease the daily workload of practitioners; to diversify methods of payment; to propose a guide for patient's use of primary care. The transformation of the healthcare system in France requires a real strategy of primary healthcare implementation. Regardless of financial constraints, it is possible to redistribute the resources towards ambulatory care. Strengthening the role of general practice and favoring its societal recognition will be the major stages of this change. Copyright © 2013 Elsevier Masson SAS. All rights reserved.
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VHA Support Service Center Primary Care Management Module (PCMM)
Department of Veterans Affairs — The Primary Care Management Module (PCMM) was developed to assist VA facilities in implementing Primary Care. PCMM supports both Primary Care and non-Primary Care...
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Kitas, George D; Abreu, Gabriel; Jedrychowicz-Rosiak, Krystyna; Miller, Jeffrey L; Nakov, Roumen; Panfilov, Seva; Vencovsky, Jiri; Wang, Millie; Weinblatt, Michael E; White, William B
2014-11-01
Clinical trials of fostamatinib in patients with rheumatoid arthritis showed blood pressure (BP) elevation using clinic measurements. The OSKIRA-ambulatory BP monitoring trial assessed the effect of fostamatinib on 24-hour ambulatory systolic BP (SBP) in patients with active rheumatoid arthritis. One hundred thirty-five patients were randomized to fostamatinib 100 mg twice daily (bid; n = 68) or placebo bid (n = 67) for 28 days. Ambulatory, clinic, and home BPs were measured at baseline and after 28 days of therapy. Primary end point was change from baseline in 24-hour mean SBP. Fostamatinib increased 24-hour mean SBP by 2.9 mm Hg (P = .023) and diastolic BP (DBP) by 3.5 mm Hg (P < .001) versus placebo. Clinic/home-measured BPs were similar to those observed with ambulatory BP monitoring. After treatment discontinuation (1 week), clinic BP values returned to baseline levels. Fostamatinib induced elevations in 24-hour mean ambulatory SBP and DBP. BP elevations resolved with fostamatinib discontinuation. Copyright © 2014 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.
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Raskin, Lynne
2010-01-01
The uptake of family health teams in Ontario has been tremendous. And the creation of group practices in primary care has taken root in other provinces as well. For many people, being involved with something new is exciting. At the same time, once they are committed, they discover the challenges that can be simultaneously exhilarating and frustrating. This issue of Healthcare Quarterly offers two articles that provide interesting reflections on what has been learned so far from the perspectives of both team leadership and the team members themselves within a transforming primary care system.
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Assessing primary care data quality.
Lim, Yvonne Mei Fong; Yusof, Maryati; Sivasampu, Sheamini
2018-04-16
Purpose The purpose of this paper is to assess National Medical Care Survey data quality. Design/methodology/approach Data completeness and representativeness were computed for all observations while other data quality measures were assessed using a 10 per cent sample from the National Medical Care Survey database; i.e., 12,569 primary care records from 189 public and private practices were included in the analysis. Findings Data field completion ranged from 69 to 100 per cent. Error rates for data transfer from paper to web-based application varied between 0.5 and 6.1 per cent. Error rates arising from diagnosis and clinical process coding were higher than medication coding. Data fields that involved free text entry were more prone to errors than those involving selection from menus. The authors found that completeness, accuracy, coding reliability and representativeness were generally good, while data timeliness needs to be improved. Research limitations/implications Only data entered into a web-based application were examined. Data omissions and errors in the original questionnaires were not covered. Practical implications Results from this study provided informative and practicable approaches to improve primary health care data completeness and accuracy especially in developing nations where resources are limited. Originality/value Primary care data quality studies in developing nations are limited. Understanding errors and missing data enables researchers and health service administrators to prevent quality-related problems in primary care data.
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Directory of Open Access Journals (Sweden)
Manulik S
2016-08-01
Full Text Available Stanisław Manulik,1 Joanna Rosińczuk,2 Piotr Karniej3 1Non-Public Health Care Institution, “Ambulatory of Cosmonauts” Ltd. Liability Company, 2Department of Nervous System Diseases, Faculty of Health Science, 3Department of Organization and Management, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland Introduction: Service quality and customer satisfaction are very important components of competitive advantage in the health care sector. The SERVQUAL method is widely used for assessing the quality expected by patients and the quality of actually provided services.Objectives: The main purpose of this study was to determine if patients from state and private health care facilities differed in terms of their qualitative priorities and assessments of received services.Materials and methods: The study included a total of 412 patients: 211 treated at a state facility and 201 treated at a private facility. Each of the respondents completed a 5-domain, 22-item SERVQUAL questionnaire. The actual quality of health care services in both types of facilities proved significantly lower than expected.Results: All the patients gave the highest scores to the domains constituting the core aspects of health care services. The private facility respondents had the highest expectations with regard to equipment, and the state facility ones regarding contacts with the medical personnel.Conclusion: Health care quality management should be oriented toward comprehensive optimization in all domains, rather than only within the domain identified as the qualitative priority for patients of a given facility. Keywords: health care service quality, patients’ expectations, qualitative priorities, outpatient health care facilities
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Valaitis, Ruta K; O'Mara, Linda; Wong, Sabrina T; MacDonald, Marjorie; Murray, Nancy; Martin-Misener, Ruth; Meagher-Stewart, Donna
2018-04-12
AimThe aim of this paper is to examine Canadian key informants' perceptions of intrapersonal (within an individual) and interpersonal (among individuals) factors that influence successful primary care and public health collaboration. Primary health care systems can be strengthened by building stronger collaborations between primary care and public health. Although there is literature that explores interpersonal factors that can influence successful inter-organizational collaborations, a few of them have specifically explored primary care and public health collaboration. Furthermore, no papers were found that considered factors at the intrapersonal level. This paper aims to explore these gaps in a Canadian context. This interpretative descriptive study involved key informants (service providers, managers, directors, and policy makers) who participated in one h telephone interviews to explore their perceptions of influences on successful primary care and public health collaboration. Transcripts were analyzed using NVivo 9.FindingsA total of 74 participants [from the provinces of British Columbia (n=20); Ontario (n=19); Nova Scotia (n=21), and representatives from other provinces or national organizations (n=14)] participated. Five interpersonal factors were found that influenced public health and primary care collaborations including: (1) trusting and inclusive relationships; (2) shared values, beliefs and attitudes; (3) role clarity; (4) effective communication; and (5) decision processes. There were two influencing factors found at the intrapersonal level: (1) personal qualities, skills and knowledge; and (2) personal values, beliefs, and attitudes. A few differences were found across the three core provinces involved. There were several complex interactions identified among all inter and intra personal influencing factors: One key factor - effective communication - interacted with all of them. Results support and extend our understanding of what influences
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Health information technology in ambulatory care in a developing country.
Deimazar, Ghasem; Kahouei, Mehdi; Zamani, Afsane; Ganji, Zahra
2018-02-01
Physicians need to apply new technologies in ambulatory care. At present, with regard to the extended use of information technology in other departments in Iran it has yet to be considerably developed by physicians and clinical technicians in the health department. To determine the rate of use of health information technology in the clinics of specialist- and subspecialist physicians in Semnan city, Iran. This was a 2016 cross-sectional study conducted in physicians' offices of Semnan city in Iran. All physicians' offices in Semnan (130) were studied in this research. A researcher made and Likert-type questionnaire was designed, and consisted of two sections: the first section included demographic items and the second section consisted of four subscales (telemedicine, patient's safety, electronic patient record, and electronic communications). In order to determine the validity, the primary questionnaire was reviewed by one medical informatics- and two health information management experts from Semnan University of Medical Sciences. Utilizing the experts' suggestions, the questionnaire was rewritten and became more focused. Then the questionnaire was piloted on forty participants, randomly selected from different physicians' offices. Participants in the pilot study were excluded from the study. Cronbach's alpha was used to calculate the reliability of the instruments. Finally, SPSS version 16 was used to conduct descriptive and inferential statistics. The minimum mean related to the physicians' use of E-mail services for the purpose of communicating with the patients, the physicians' use of computer-aided diagnostics to diagnose the patients' illnesses, and the level of the physicians' access to the electronic medical record of patients in the other treatment centers were 2.01, 3.58, and 1.43 respectively. The maximum mean score was related to the physicians' use of social networks to communicate with other physicians (3.64). The study showed that the physicians
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Xin, Haichang; Kilgore, Meredith L; Sen, Bisakha Pia; Blackburn, Justin
2015-09-01
A well-functioning primary care system has the capacity to provide effective care for patients to avoid nonurgent emergency department (ED) use and related costs. This study examined how patients' perceived deficiency in ambulatory care is associated with nonurgent ED care costs nationwide. This retrospective cohort study used data from the 2010-2011 Medical Expenditure Panel Survey. This study chose usual source of care, convenience of needed medical care, and patient evaluation of care quality as the main independent variables. The marginal effect following a multivariate logit model was employed to analyze the urgent vs. nonurgent ED care costs in 2011, after controlling for covariates in 2010. The endogeneity was accounted for by the time lag effect and controlling for education levels. Sample weights and variance were adjusted with the survey procedures to make results nationally representative. Patient-perceived poor and intermediate levels of primary care quality had higher odds of nonurgent ED care costs (odds ratio [OR] = 2.22, p = 0.035, and OR = 2.05, p = 0.011, respectively) compared to high-quality care, with a marginal effect (at means) of 13.0% and 11.5% higher predicted probability of nonurgent ED care costs. Costs related to these ambulatory care quality deficiencies amounted to $229 million for private plans (95% confidence interval [CI] $100 million-$358 million), $58.5 million for public plans (95% CI $33.9 million-$83.1 million), and an overall of $379 million (95% CI $229 million-$529 million) nationally. These findings highlight the improvement in ambulatory care quality as the potential target area to effectively reduce nonurgent ED care costs. Copyright © 2015 Elsevier Inc. All rights reserved.
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Atun, Rifat; Gurol-Urganci, Ipek; Hone, Thomas; Pell, Lisa; Stokes, Jonathan; Habicht, Triin; Lukka, Kaija; Raaper, Elin; Habicht, Jarno
2016-12-01
Following independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system. Using routinely collected health billing records for 2005-2012, we examine health system utilisation for seven ambulatory care sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2 diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by patient characteristics (gender, age, and number of co-morbidities). The data set contained 552 822 individuals. We use patient level data to test the significance of trends, and employ multivariate regression analysis to evaluate the probability of inpatient admission while controlling for patient characteristics, health system supply-side variables, and PHC use. Over the study period, utilisation of PHC increased, whilst inpatient admissions fell. Service mix in PHC changed with increases in phone, email, nurse, and follow-up (vs initial) consultations. Healthcare utilisation for diabetes, depression, IHD and hypertension shifted to PHC, whilst for COPD, heart failure and asthma utilisation in outpatient and inpatient settings increased. Multivariate regression indicates higher probability of inpatient admission for males, older patient and especially those with multimorbidity, but protective effect for PHC, with significantly lower hospital admission for those utilising PHC services. Our findings suggest health system reforms in Estonia have influenced the shift of ACSCs from secondary to primary care, with PHC having a protective effect in reducing hospital admissions.
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Tseng, Phillip; Kaplan, Robert S; Richman, Barak D; Shah, Mahek A; Schulman, Kevin A
2018-02-20
Administrative costs in the US health care system are an important component of total health care spending, and a substantial proportion of these costs are attributable to billing and insurance-related activities. To examine and estimate the administrative costs associated with physician billing activities in a large academic health care system with a certified electronic health record system. This study used time-driven activity-based costing. Interviews were conducted with 27 health system administrators and 34 physicians in 2016 and 2017 to construct a process map charting the path of an insurance claim through the revenue cycle management process. These data were used to calculate the cost for each major billing and insurance-related activity and were aggregated to estimate the health system's total cost of processing an insurance claim. Estimated time required to perform billing and insurance-related activities, based on interviews with management personnel and physicians. Estimated billing and insurance-related costs for 5 types of patient encounters: primary care visits, discharged emergency department visits, general medicine inpatient stays, ambulatory surgical procedures, and inpatient surgical procedures. Estimated processing time and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged emergency department visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure, and 100 minutes and $215.10 for an inpatient surgical procedure. Of these totals, time and costs for activities carried out by physicians were estimated at a median of 3 minutes or $6.36 for a primary care visit, 3 minutes or $10.97 for an emergency department visit, 5 minutes or $13.29 for a general inpatient stay, 15 minutes or $51.20 for an ambulatory surgical procedure, and 15 minutes or $51.20 for an inpatient surgical procedure. Of
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Donohue, SarahMaria; Haine, James E; Li, Zhanhai; Feldstein, David A; Micek, Mark; Trowbridge, Elizabeth R; Kamnetz, Sandra A; Sosman, James M; Wilke, Lee G; Sesto, Mary E; Tevaarwerk, Amye J
2017-11-02
Every cancer survivor and his/her primary care provider should receive an individualized survivorship care plan (SCP) following curative treatment. Little is known regarding point-of-care utilization at primary care visits. We assessed SCP utilization in the clinical context of primary care visits. Primary care physicians and advanced practice providers (APPs) who had seen survivors following provision of an SCP were identified. Eligible primary care physicians and APPs were sent an online survey, evaluating SCP utilization and influence on decision-making at the point-of-care, accompanied by copies of the survivor's SCP and the clinic note. Eighty-eight primary care physicians and APPs were surveyed November 2016, with 40 (45%) responding. Most respondents (60%) reported discussing cancer or related issues during the visit. Information needed included treatment (66%) and follow-up visits, and the cancer team was responsible for (58%) vs primary care (58%). Respondents acquired this information by asking the patient (79%), checking oncology notes (75%), the SCP (17%), or online resources (8%). Barriers to SCP use included being unaware of the SCP (73%), difficulty locating it (30%), and finding needed information faster via another mechanism (15%). Despite largely not using the SCP for the visit (90%), most respondents (61%) believed one would be quite or very helpful for future visits. Most primary care visits included discussion of cancer or cancer-related issues. SCPs may provide the information necessary to deliver optimal survivor care but efforts are needed to reduce barriers and design SCPs for primary care use.
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Phytotherapy in primary health care
Antonio, Gisele Damian; Tesser, Charles Dalcanale; Moretti-Pires, Rodrigo Otavio
2014-01-01
OBJECTIVE To characterize the integration of phytotherapy in primary health care in Brazil. METHODS Journal articles and theses and dissertations were searched for in the following databases: SciELO, Lilacs, PubMed, Scopus, Web of Science and Theses Portal Capes, between January 1988 and March 2013. We analyzed 53 original studies on actions, programs, acceptance and use of phytotherapy and medicinal plants in the Brazilian Unified Health System. Bibliometric data, characteristics of the actions/programs, places and subjects involved and type and focus of the selected studies were analyzed. RESULTS Between 2003 and 2013, there was an increase in publications in different areas of knowledge, compared with the 1990-2002 period. The objectives and actions of programs involving the integration of phytotherapy into primary health care varied: including other treatment options, reduce costs, reviving traditional knowledge, preserving biodiversity, promoting social development and stimulating inter-sectorial actions. CONCLUSIONS Over the past 25 years, there was a small increase in scientific production on actions/programs developed in primary care. Including phytotherapy in primary care services encourages interaction between health care users and professionals. It also contributes to the socialization of scientific research and the development of a critical vision about the use of phytotherapy and plant medicine, not only on the part of professionals but also of the population. PMID:25119949
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One-on-one care management and procurement of Naloxone for ambulatory use.
Whittington, Richard; Whittington, Kathleen; Whittington, John; Porter, Joel; Zimmermann, Karla; Case, Holly; Berg, Stacey
2018-02-16
Morbidity and mortality from prescription opioids has reached unprecedented levels. Opioids remain part of chronic pain treatment in primary care. This study was designed to determine whether one-on-one care management increases procurement of Naloxone, an opioid antagonist shown to reduce morbidity and mortality in opioid overdoses. Participants included all patients ≥18 years enrolled in a primary care-based chronic pain management program and who were prescribed a daily dose of opioids for treatment of chronic pain. In total, 153 patients chose to participate. Each had a 1 h one-on-one education meeting with a registered nurse. Among the enrolled, eight patients (5.2%) had procured Naloxone prior to intervention. Overall, 31 additional patients (20.2%) procured Naloxone after intervention, a 288% relative improvement in the attainment of Naloxone (P procured Naloxone, 69.3% believed it was unnecessary, 20% forgot about Naloxone, 8% said it was cost prohibitive, 3.5% had access concerns and 0.9% had concerns about side effects. Direct one-on-one nurse care management sessions were associated with an increased procurement of Naloxone in a primary care-based pain management program. A significant number of patients believed Naloxone was unnecessary after the intervention.
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Ambulatory EHR functionality: a comparison of functionality lists.
Drury, Barbara M
2006-01-01
There is a proliferation of lists intended to define and clarify the functionality of an ambulatory electronic health record system. These lists come from both private and public entities and vary in terminology, granularity, usability, and comprehensiveness. For example, functionality regarding a problem list includes the following possible definitions: * "Create and maintain patient-specific problem lists," from the HL7 Electronic Health Record Draft Standard for Trial Use. * "Provide a flexible mechanism for retrieval of encounter information that can be organized by diagnosis, problem, problem type," from the Bureau of Primary Health Care. * "The system shall associate encounters, orders, medications and notes with one or more problems," from the Certification Commission on Health Information Technology. * "Displays dates of problems on problem list," from COPIC Insurance Co. * "Shall automatically close acute problems using an automated algorithm," from the Physicians Foundations HIT Subcommittee. This article will compare the attributes of these five electronic health record functionality lists and their usefulness to different audiences-clinicians, application developers and payers.
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Verstappen, Wim; Gaal, Sander; Bowie, Paul; Parker, Diane; Lainer, Miriam; Valderas, Jose M.; Wensing, Michel; Esmail, Aneez
2015-01-01
ABSTRACT Background: Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. Objective: To outline a research agenda for patient safety improvement in primary care in Europe and beyond. Methods: The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. Results: This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Conclusion: Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement. PMID:26339841
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Verstappen, Wim; Gaal, Sander; Bowie, Paul; Parker, Diane; Lainer, Miriam; Valderas, Jose M; Wensing, Michel; Esmail, Aneez
2015-09-01
Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. To outline a research agenda for patient safety improvement in primary care in Europe and beyond. The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement.
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Verbakel, Jan Y; Lemiengre, Marieke B; De Burghgraeve, Tine; De Sutter, An; Aertgeerts, Bert; Bullens, Dominique M A; Shinkins, Bethany; Van den Bruel, Ann; Buntinx, Frank
2015-08-07
Acute infection is the most common presentation of children in primary care with only few having a serious infection (eg, sepsis, meningitis, pneumonia). To avoid complications or death, early recognition and adequate referral are essential. Clinical prediction rules have the potential to improve diagnostic decision-making for rare but serious conditions. In this study, we aimed to validate a recently developed decision tree in a new but similar population. Diagnostic accuracy study validating a clinical prediction rule. Acutely ill children presenting to ambulatory care in Flanders, Belgium, consisting of general practice and paediatric assessment in outpatient clinics or the emergency department. Physicians were asked to score the decision tree in every child. The outcome of interest was hospital admission for at least 24 h with a serious infection within 5 days after initial presentation. We report the diagnostic accuracy of the decision tree in sensitivity, specificity, likelihood ratios and predictive values. In total, 8962 acute illness episodes were included, of which 283 lead to admission to hospital with a serious infection. Sensitivity of the decision tree was 100% (95% CI 71.5% to 100%) at a specificity of 83.6% (95% CI 82.3% to 84.9%) in the general practitioner setting with 17% of children testing positive. In the paediatric outpatient and emergency department setting, sensitivities were below 92%, with specificities below 44.8%. In an independent validation cohort, this clinical prediction rule has shown to be extremely sensitive to identify children at risk of hospital admission for a serious infection in general practice, making it suitable for ruling out. NCT02024282. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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Characteristics of primary care practices associated with high quality of care.
Beaulieu, Marie-Dominique; Haggerty, Jeannie; Tousignant, Pierre; Barnsley, Janet; Hogg, William; Geneau, Robert; Hudon, Éveline; Duplain, Réjean; Denis, Jean-Louis; Bonin, Lucie; Del Grande, Claudio; Dragieva, Natalyia
2013-09-03
No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care. We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling. The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0-35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8-14.4), presence of allied health professionals (15.3; 95% CI 5.4-25.2) and/or specialist physicians (19.6; 95% CI 8.3-30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0-12.4) and average organizational access to the practice (4.9; 95% CI 2.6-7.2). The number of physicians (1.2; 95% CI 0.6-1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1-2.5) were modestly associated with high-quality care. We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.
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Bellicoso, Daniela; Trudeau, Maureen; Fitch, Margaret I; Ralph, Martin R
2017-01-01
Primary caregivers for victims of chronic illness and or trauma experience both positive and negative emotional consequences. These are broadly classified as compassion satisfaction (CS) and compassion fatigue (CF). Because one of the components of CF, burnout, varies with chronotype and sleep quality, we assessed the influence of chronobiological features on the broader constructs of CS and CF. Responses from primary ambulatory care oncology staff working dayshifts were assessed for potential relationships of chronotype and sleep quality with CS and CF using the professional quality of life scale. These were analyzed further in a multivariate model that included personality and job satisfaction as cofactors. We found that sleep quality was a key contributor to CS development and CF reduction. Morningness was positively linked to CS, but the univariate association was masked in the multivariate model. Job satisfaction (contingent rewards, nature of work and operating procedures) heavily influenced CS and CF development. Agreeableness and openness showed positive correlations with CS and negative with burnout, while emotional stability was linked to reduced CF. While job satisfaction and personality predictably played roles in the development of CS and CF, sleep quality and chronotype contributed significantly to benefits and negative consequences of providing care.
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New Pathways for Primary Care: An Update on Primary Care Programs From the Innovation Center at CMS
Baron, Richard J.
2012-01-01
Those in practice find that the fee-for-service system does not adequately value the contributions made by primary care. The Center for Medicare and Medicaid Innovation (Innovation Center) was created by the Affordable Care Act to test new models of health care delivery to improve the quality of care while lowering costs. All programs coming out of the Innovation Center are tests of new payment and service delivery models. By changing both payment and delivery models and moving to a payment model that rewards physicians for quality of care instead of volume of care, we may be able to achieve the kind of health care patients want to receive and primary care physicians want to provide. PMID:22412007
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Older Patients' Perspectives on Quality of Serious Illness Care in Primary Care.
Abu Al Hamayel, Nebras; Isenberg, Sarina R; Hannum, Susan M; Sixon, Joshua; Smith, Katherine Clegg; Dy, Sydney M
2018-01-01
Despite increased focus on measuring and improving quality of serious illness care, there has been little emphasis on the primary care context or incorporation of the patient perspective. To explore older patients' perspectives on the quality of serious illness care in primary care. Qualitative interview study. Twenty patients aged 60 or older who were at risk for or living with serious illness and who had participated in the clinic's quality improvement initiative. We used a semistructured, open-ended guide focusing on how older patients perceived quality of serious illness care, particularly in primary care. We transcribed interviews verbatim and inductively identified codes. We identified emergent themes using a thematic and constant comparative method. We identified 5 key themes: (1) the importance of patient-centered communication, (2) coordination of care, (3) the shared decision-making process, (4) clinician competence, and (5) access to care. Communication was an overarching theme that facilitated coordination of care between patients and their clinicians, empowered patients for shared decision-making, related to clinicians' perceived competence, and enabled access to primary and specialty care. Although access to care is not traditionally considered an aspect of quality, patients considered this integral to the quality of care they received. Patients perceived serious illness care as a key aspect of quality in primary care. Efforts to improve quality measurement and implementation of quality improvement initiatives in serious illness care should consider these aspects of care that patients deem important, particularly communication as an overarching priority.
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Sendagire, Ibrahim; Cobelens, Frank; Kambugu, Andrew; Konde-Lule, Joseph; Schim van der Loeff, Maarten
2012-01-01
Background: Access to antiretroviral treatment (ART) has improved greatly in many parts of the world, including Uganda, yet, many patients delay to start ART even when registered within the HIV services. We assessed, in a routine ambulatory care setting, what proportion of patients start ART late
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Baik, Seong-Yi; Crabtree, Benjamin F; Gonzales, Junius J
2013-11-01
Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered. This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions. Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n = 24, 2 h each), two surveys per clinician, and investigators' field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data. Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners. A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians' interactions with patients, practice, and the local community. A clinician's interactional familiarity ("familiarity capital") was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression. The clinician's ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.
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Suicidal ideation in German primary care
Wiborg, J.F.; Gieseler, D.; Lowe, B.
2013-01-01
OBJECTIVE: To examine suicidal ideation in a sample of German primary care patients. METHODS: We conducted a cross-sectional study and included 1455 primary care patients who visited 1 of 41 general practitioners (GPs) working at 19 different sites. Suicidal ideation and psychopathology were
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LGBTQ Youth's Perceptions of Primary Care.
Snyder, Barbara K; Burack, Gail D; Petrova, Anna
2017-05-01
Despite published guidelines on the need to provide comprehensive care to lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) youth, there has been limited research related to the deliverance of primary health care to this population. The goals of this study were to learn about LGBTQ youth's experiences with their primary care physicians and to identify areas for improvement. Youth attending 1 of 5 community-based programs completed a written questionnaire and participated in a focus group discussion regarding experiences at primary care visits, including topics discussed, counselling received, and physician communication. Most of the youth did not feel their health care needs were well met. The majority acknowledged poor patient-provider communication, disrespect, and lack of discussions about important topics such as sexual and emotional health. Participants cited concerns about confidentiality and inappropriate comments as barriers to care. Youth expressed a strong desire to have physicians be more aware of their needs and concerns.
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Directory of Open Access Journals (Sweden)
Kit Sang Leung
2015-01-01
Conclusions: Substance use disorder is statistically associated with hospitalizations for most Ambulatory Care Sensitive Conditions but not with length of hospital stay for Ambulatory Care Sensitive Conditions, after adjusting for covariates. The significant associations between substance use disorder and Ambulatory Care Sensitive Condition admissions suggest unmet primary health care needs for substance use disorder beneficiaries and a need for integrated primary/behavioral healthcare.
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Hammersen, Friederike; Goetz, Katja; Soennichsen, Andreas; Emcke, Timo; Steinhaeuser, Jost
2016-04-02
Primary care physicians account for the majority of antibiotic prescribing in ambulatory care in Germany. Respiratory diseases are, regardless of effectiveness, often treated with antibiotics. Research has found this use without indication to be caused largely by communication problems (e.g. expectations on the patient's part or false assumptions about them by the physician). The present randomised controlled trial (RCT) study evaluates whether communication training for primary care physicians can reduce the antibiotic prescribing rate for respiratory tract infections. The study consists of three groups: group A will receive communication training; group B will be given the same, plus additional, access to an evidence-based point-of-care tool; and group C will function as the control group. The primary endpoint is the difference between intervention and control groups regarding the antibiotic prescribing rate before and after the intervention assessed through routine data. The communication skills are captured with the help of the communication instrument MAAS-Global-D, as well as individual videos of physician-patient consultations recorded by the primary care physicians. These skills will also be regarded with respect to the antibiotic prescribing rate. A process evaluation using qualitative as well as quantitative methods should provide information about barriers and enablers to implementing the communication training. The trial contributes to an insight into the effectiveness of the different components to reduce antibiotic prescribing, which will also be supported by an extensive evaluation. Communication training could be an effective method of reducing antibiotic prescribing in primary care. DRKS00009566 DATE REGISTRATION: 5 November 2015.
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Proactive cancer care in primary care: a mixed-methods study.
Kendall, Marilyn; Mason, Bruce; Momen, Natalie; Barclay, Stephen; Munday, Dan; Lovick, Roberta; Macpherson, Stella; Paterson, Euan; Baughan, Paul; Cormie, Paul; Kiehlmann, Peter; Free, Amanda; Murray, Scott A
2013-06-01
Current models of post-treatment cancer care are based on traditional practices and clinician preference rather than evidence of benefit. To assess the feasibility of using a structured template to provide holistic follow-up of patients in primary care from cancer diagnosis onwards. A two-phase mixed methods action research project. An electronic cancer ongoing review document (CORD) was first developed with patients and general practitioners, and used with patients with a new diagnosis of cancer. This was evaluated through documentary analysis of the CORDs, qualitative interviews with patients, family carers and health professionals and record reviews. The records of 107 patients from 13 primary care teams were examined and 45 interviews conducted. The document was started in 54% of people with newly diagnosed cancer, and prompted clear documentation of multidimension needs and understanding. General practitioners found using the document helped to structure consultations and cover psychosocial areas, but they reported it needed to be better integrated in their medical records with computerized prompts in place. Few clinicians discussed the review openly with patients, and the template was often completed afterwards. Anticipatory cancer care from diagnosis to cure or death, 'in primary care', is feasible in the U.K. and acceptable to patients, although there are barriers. The process promoted continuity of care and holism. A reliable system for proactive cancer care in general practice supported by hospital specialists may allow more survivorship care to be delivered in primary care, as in other long-term conditions.
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Time Spent in Face-to-Face Patient Care and Work Outside the Examination Room
Gottschalk, Andrew; Flocke, Susan A.
2005-01-01
PURPOSE Contrary to physicians’ concerns that face-to-face patient time is decreasing, data from the National Ambulatory Medical Care Survey (NAMCS) indicate that between 1988 and 1998, durations of primary care outpatient visits have increased. This study documented how physicians spend time during the workday, including time outside the examination room, and compared observed face-to-face patient care time with that reported in NAMCS.
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Butler, Danielle C; Thurecht, Linc; Brown, Laurie; Konings, Paul
2013-10-01
Recent Australian policy initiatives regarding primary health care focus on planning services around community needs and delivering these at the local area. As in many other countries, there has also been a growing concern over social inequities in health outcomes. The aims of the analysis presented here were firstly to describe small area variations in hospital admissions for ambulatory care sensitive conditions (ACSC) among children aged 0-4 years between 2003 and 2009 in the state of Victoria, Australia, and secondly to explore the relationship of ACSC hospitalisations with socio-economic disadvantage using a comparative analysis of the Child Social Exclusion (CSE) index and the Composite Score of Deprivation (CSD). This is a cross sectional secondary data analysis, with data sourced from 2003 to 2009 ACSC data from the Victorian State Government Department of Health; the Australian Standard Geographical Classification of remoteness; the Australian 2006 Census of Population and Housing; and AMPCo General Practitioner data from 2010. The relationship between the indexes and child health outcomes was examined through bivariate analysis and visually through a series of maps. The results show there is significant variation in the geographical distribution of the relationship between ACSCs and socio-economic disadvantage, with both indexes capturing important social gradients in child health conditions. However, measures of access, such as geographical accessibility and workforce supply, detect additional small area variation in child health outcomes. This research has important implications for future primary health care policy and planning of services, as these findings confirm that not all areas are the same in terms of health outcomes, and there may be benefit in tailoring mechanisms for identifying areas of need depending on the outcome intended to be affected. Copyright © 2013 Elsevier Ltd. All rights reserved.
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The evolution of ambulatory ECG monitoring.
Kennedy, Harold L
2013-01-01
Ambulatory Holter electrocardiographic (ECG) monitoring has undergone continuous technological evolution since its invention and development in the 1950s era. With commercial introduction in 1963, there has been an evolution of Holter recorders from 1 channel to 12 channel recorders with increasingly smaller storage media, and there has evolved Holter analysis systems employing increasingly technologically advanced electronics providing a myriad of data displays. This evolution of smaller physical instruments with increasing technological capacity has characterized the development of electronics over the past 50 years. Currently the technology has been focused upon the conventional continuous 24 to 48 hour ambulatory ECG examination, and conventional extended ambulatory monitoring strategies for infrequent to rare arrhythmic events. However, the emergence of the Internet, Wi-Fi, cellular networks, and broad-band transmission has positioned these modalities at the doorway of the digital world. This has led to an adoption of more cost-effective strategies to these conventional methods of performing the examination. As a result, the emergence of the mobile smartphone coupled with this digital capacity is leading to the recent development of Holter smartphone applications. The potential of point-of-care applications utilizing the Holter smartphone and a vast array of new non-invasive sensors is evident in the not too distant future. The Holter smartphone is anticipated to contribute significantly in the future to the field of global health. © 2013.
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Directory of Open Access Journals (Sweden)
Sudeep Karve
2012-01-01
Full Text Available Objective. Study objectives were to assess temporal trends and identify patient- and practice-level predictors of the prescription of antiplatelet medications in a national sample of ischemic stroke (IS patients seeking ambulatory care. Methods. IS-related outpatient visits by adults were identified using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey for the years 2000–2007. We assessed prescribing of antiplatelet medications using the generic drug code and drug entry codes in these data. Temporal trends in antiplatelet prescribing were assessed using the Cochran-Mantel-Haenszel test for trend. Results. We identified 9.5 million IS-related ambulatory visits. Antiplatelet medications were prescribed at 35.5% of visits. Physician office prescribing of the clopidogrel-aspirin combination increased significantly from 0.5% in 2000 to 22.0% in 2007 (P=0.05, whereas prescribing of aspirin decreased from 17.9% to 7.0% (P=0.50 during the same period. Conclusion. We observed a continued increase in prescription of the aspirin-clopidogrel combination from 2000 to 2007. Clinical trial evidence suggests that the aspirin-clopidogrel combination does not provide any additional benefit compared with clopidogrel alone; however, our study findings indicate that even with lack of adequate clinical evidence physician prescribing of this combination has increased in real-world community settings.
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A future for primary care for the Greek population.
Groenewegen, Peter P; Jurgutis, Arnoldas
2013-01-01
Greece is hit hard by the state debt crisis. This calls for comprehensive reforms to restore sustainable and balanced growth. Healthcare is one of the public sectors needing reform. The European Union (EU) Task Force for Greece asked the authors to assess the situation of primary care and to make recommendations for reform. Primary healthcare is especially relevant in that it might increase the efficiency of the healthcare system, and improve access to good quality healthcare. Assessment of the state of primary care in Greece was made on the basis of existing literature, site visits in primary care and consultations with stakeholders. The governance of primary care (and healthcare in general) is fragmented. There is no system of gatekeeping or patient lists. Private payments (formal and informal) are high. There are too many physicians, but too few general practitioners and nurses, and they are unevenly spread across the country. As a consequence, there are problems of access, continuity, co-ordination and comprehensiveness of primary care. The authors recommend the development of a clear vision and development strategy for strengthening primary care. Stepped access to secondary care should be realised through the introduction of mandatory referrals. Primary care should be accessible through the lowest possible out-of-pocket payments. The roles of purchaser and provider of care should be split. Quality of care should be improved through development of clinical guidelines and quality indicators. The education of health professionals should put more emphasis on primary care and medical specialists working in primary care should be (re-)trained to acquire the necessary competences to satisfy the job descriptions to be developed for primary care professionals. The advantages of strong primary care should be communicated to patients and the wider public.
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Leadership in primary health care: an international perspective.
McMurray, Anne
2007-08-01
A primary health care approach is essential to contemporary nursing roles such as practice nursing. This paper examines the evolution of primary health care as a global strategy for responding to the social determinants of health. Primary health care roles require knowledge of, and a focus on social determinants of health, particularly the societal factors that allow and perpetuate inequities and disadvantage. They also require a depth and breadth of leadership skills that are responsive to health needs, appropriate in the social and regulatory context, and visionary in balancing both workforce and client needs. The key to succeeding in working with communities and groups under a primary health care umbrella is to balance the big picture of comprehensive primary health care with operational strategies for selective primary health care. The other essential element involves using leadership skills to promote inclusiveness, empowerment and health literacy, and ultimately, better health.
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Exploring primary care activities in ACT teams.
Vanderlip, Erik R; Williams, Nancy A; Fiedorowicz, Jess G; Katon, Wayne
2014-05-01
People with serious mental illness often receive inadequate primary and preventive care services. Federal healthcare reform endorses team-based care that provides high quality primary and preventive care to at risk populations. Assertive community treatment (ACT) teams offer a proven, standardized treatment approach effective in improving mental health outcomes for the seriously mentally ill. Much is known about the effectiveness of ACT teams in improving mental health outcomes, but the degree to which medical care needs are addressed is not established. The purpose of this study was to explore the extent to which ACT teams address the physical health of the population they serve. ACT team leaders were invited to complete an anonymous, web-based survey to explore attitudes and activities involving the primary care needs of their clients. Information was collected regarding the use of health screening tools, physical health assessments, provision of medical care and collaboration with primary care systems. Data was analyzed from 127 team leaders across the country, of which 55 completed the entire survey. Nearly every ACT team leader believed ACT teams have a role in identifying and managing the medical co-morbidities of their clientele. ACT teams report participation in many primary care activities. ACT teams are providing a substantial amount of primary and preventive services to their population. The survey suggests standardization of physical health identification, management or referral processes within ACT teams may result in improved quality of medical care. ACT teams are in a unique position to improve physical health care by virtue of having medically trained staff and frequent, close contact with their clients.
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DEFF Research Database (Denmark)
Scarpaci, Joseph L.
Primary medical care in Chile: accessibility under military rule [Front Cover] [Front Matter] [Title Page] Contents Tables Figures Preface Chapter 1: Introduction Chapter 2: The Restructuring of Medical Care Financing in Chile Chapter 3: Inflation and Medical Care Accessibility Chapter 4: Help......-Seeking Behavior of the Urban Poor Chapter 5: Spatial Organization and Medical Care Accessibility Chapter 6: Conclusion...
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Primary care in a new era: disillusion and dissolution?.
Sandy, Lewis G; Schroeder, Steven A
2003-02-04
The current dilemmas in primary care stem from 1) the unintended consequences of forces thought to promote primary care and 2) the "disruptive technologies of care" that attack the very function and concept of primary care itself. This paper suggests that these forces, in combination with "tiering" in the health insurance market, could lead to the dissolution of primary care as a single concept, to be replaced by alignment of clinicians by economic niche. Evidence already exists in the marketplace for both tiering of health insurance benefits and corresponding practice changes within primary care. In the future, primary care for the top tier will cater to the affluent as "full-service brokers" and will be delivered by a wide variety of clinicians. The middle tier will continue to grapple with tensions created by patient demand and bureaucratic systems but will remain most closely aligned to primary care as a concept. The lower tier will become increasingly concerned with community health and social justice. Each primary care specialty will adapt in a unique way to a tiered world, with general internal medicine facing the most challenges. Given this forecast for the future, those concerned about primary care should focus less on workforce issues and more on macro health care financing and organization issues (such as Medicare reform); appropriate training models; and the development of a conception of primary care that emphasizes values and ethos, not just function.
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Siika, A M; Ayuo, P O; Sidle, Mwangi J E; Wools-Kaloustian, K; Kimaiyo, S N; Tierney, W M
2008-11-01
To determine admissions diagnosis and outcomes of HIV-infected patients attending AMPATH ambulatory HIV-care clinics. Prospective cohort study. Academic Model for Prevention and Treatment of HIV/ AIDS (AMPATH) ambulatory HIV-care clinic in western Kenya. Between January 2005 and December 2006, 495 HIV-infected patients enrolled in AMPATH were admitted. Median age at admission was 38 years (range: 19-74), 62% females, 375 (76%) initiated cART a median 56 days (range: 1-1288) before admission. Majority (53%) had pre-admission CD4 counts 200 cells/ml. Common admissions diagnoses were: tuberculosis (27%); pneumonia (15%); meningitis (11%); diarrhoea (11%); malaria (6%); severe anaemia (4%); and toxoplasmosis (3%). Deaths occurred in 147 (30%) patients who enrolled at AMPATH a median 44 days (range: 1-711) before admission and died a median 41 days (range: 1-713) after initiating cART. Tuberculosis (27%) and meningitis (14%) were the most common diagnoses in the deceased. Median admission duration was six days (range: 1-30) for deceased patients and eight days (range: 1-44) for survivors (P=0.0024). Deceased patients enrolled in AMPATH or initiated cART more recently, had lower CD4 counts and were more frequently lost to follow-up than survivors (P<0.05 for each comparison). Initiation of cART before admission and clinic appointment adherence were independent predictors of survival. Although high mortality rate is seen in HIV-infected in-patients, those initiating cART before admission were more likely to survive.
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Olsen, Margaret A; Tian, Fang; Wallace, Anna E; Nickel, Katelin B; Warren, David K; Fraser, Victoria J; Selvam, Nandini; Hamilton, Barton H
2017-02-01
To determine the impact of surgical site infections (SSIs) on health care costs following common ambulatory surgical procedures throughout the cost distribution. Data on costs of SSIs following ambulatory surgery are sparse, particularly variation beyond just mean costs. We performed a retrospective cohort study of persons undergoing cholecystectomy, breast-conserving surgery, anterior cruciate ligament reconstruction, and hernia repair from December 31, 2004 to December 31, 2010 using commercial insurer claims data. SSIs within 90 days post-procedure were identified; infections during a hospitalization or requiring surgery were considered serious. We used quantile regression, controlling for patient, operative, and postoperative factors to examine the impact of SSIs on 180-day health care costs throughout the cost distribution. The incidence of serious and nonserious SSIs was 0.8% and 0.2%, respectively, after 21,062 anterior cruciate ligament reconstruction, 0.5% and 0.3% after 57,750 cholecystectomy, 0.6% and 0.5% after 60,681 hernia, and 0.8% and 0.8% after 42,489 breast-conserving surgery procedures. Serious SSIs were associated with significantly higher costs than nonserious SSIs for all 4 procedures throughout the cost distribution. The attributable cost of serious SSIs increased for both cholecystectomy and hernia repair as the quantile of total costs increased ($38,410 for cholecystectomy with serious SSI vs no SSI at the 70th percentile of costs, up to $89,371 at the 90th percentile). SSIs, particularly serious infections resulting in hospitalization or surgical treatment, were associated with significantly increased health care costs after 4 common surgical procedures. Quantile regression illustrated the differential effect of serious SSIs on health care costs at the upper end of the cost distribution.
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Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care
Berenson, Robert A.; Schoenbaum, Stephen C.; Gardner, Laurence B.
2007-01-01
Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed. PMID:17356977
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Schmidt, Karen L.; Lingler, Jennifer H.; Schulz, Richard
2009-01-01
Objective Primary care visits of patients with Alzheimer’s disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual’s verbal participation in these triadic interactions. Methods To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed. Results PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver’s own verbal participation. Conclusion Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less. Practice Implications Encouraging verbal participation by AD patients and their caregivers may increase the AD patient’s active role and caregiver satisfaction with primary care visits. PMID:19395224
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Primary Care Practice: Uncertainty and Surprise
Crabtree, Benjamin F.
I will focus my comments on uncertainty and surprise in primary care practices. I am a medical anthropologist by training, and have been a full-time researcher in family medicine for close to twenty years. In this talk I want to look at primary care practices as complex systems, particularly taking the perspective of translating evidence into practice. I am going to discuss briefly the challenges we have in primary care, and in medicine in general, of translating new evidence into the everyday care of patients. To do this, I will look at two studies that we have conducted on family practices, then think about how practices can be best characterized as complex adaptive systems. Finally, I will focus on the implications of this portrayal for disseminating new knowledge into practice.
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Professional flash continuous glucose monitoring as a supplement to A1C in primary care.
Hirsch, Irl B
2017-11-01
Decreasing glycated hemoglobin (A1C) is the primary goal of current diabetes management due to intervention studies in type 1 and type 2 diabetes associating levels <7.0% (53 mmol/mol) with lower complication risk. Strategic self-monitoring of blood glucose (SMBG) is also recommended to achieve greater time in range, with fewer extremes of hypo- or hyperglycemia. Unlike A1C, SMBG can distinguish among fasting, prandial, and postprandial hyperglycemia; uncover glycemic variability, including potentially dangerous hypoglycemia; and provide feedback to patients about the effects of behavior and medication on glycemic control. However, it has the drawback of capturing only static glucose readings and users are often dependent on time-pressed clinicians to interpret numerous data points. A novel flash continuous glucose monitoring (FCGM) device used for a single 2-week period with a readily interpretable data report know as the ambulatory glucose profile (AGP) has the potential to overcome limitations of conventional technologies, with less cost and greater convenience. This review summarizes the rationale for using intermittent FCGM as a supplement to A1C in primary care, and provides a stepwise approach to interpreting the AGP visual display for efficient individualized therapy.
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Fazel, Maryam T; Bagalagel, Alaa; Lee, Jeannie K; Martin, Jennifer R; Slack, Marion K
2017-10-01
To conduct a comprehensive systematic review and meta-analyses examining the impact of pharmacist interventions as part of health care teams on diabetes therapeutic outcomes in ambulatory care settings. PubMed/MEDLINE, EMBASE, Cochrane Library, International Pharmaceutical Abstracts, Web of Science, Scopus, WHO's Global Health Library, ClinicalTrials.gov , and Google Scholar were searched (1995 to February 2017). Search terms included pharmacist, team, and diabetes. Full-text articles published in English with comparative designs, including randomized controlled trials, nonrandomized controlled trials, and pretest-posttest studies evaluating hemoglobin A 1C (A1C), were assessed. Two reviewers independently screened for study inclusion and extracted data. Quality of the studies was assessed using tools developed based on the framework of the Cochrane Collaboration's recommendations. A total of 1908 studies were identified from the literature and reference searches; 42 studies were included in the systematic review (n = 10 860) and 35 in the meta-analyses (n = 7417). Mean age ranged from 42 to 73 years, and 8% to 100% were male. The overall standardized mean difference (SMD) for A1C for pharmacist care versus comparison was 0.57 ( P 83%), indicating functional differences among the studies. No publication bias was detected. Pharmacists' interventions as part of the patient's health care team improved diabetes therapeutic outcomes, substantiating the important role of pharmacists in team-based diabetes management.
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Martínez, M A; García-Puig, J; Martín, J C; Guallar-Castillón, P; Aguirre de Cárcer, A; Torre, A; Armada, E; Nevado, A; Madero, R S
1999-03-01
Most of the previous studies on white coat hypertension were performed in hypertension clinics or academic settings and included relatively small series of patients. Consequently, the prevalence of white coat hypertension in primary care settings and the clinical and epidemiologic characteristics of this subgroup of patients are not well known. We performed this study to estimate the frequency of white coat hypertension in a population of mildly to moderately hypertensive subjects attended in a primary care setting and to examine possible epidemiologic and clinical factors that may identify these patients. Patients included in the study underwent clinical interview, measurement of clinic blood pressure (BP) on three visits, determination of serum lipids, glucose, uric acid, and urinary albumin excretion, 24-h ambulatory BP monitoring, and M-mode and Doppler echocardiography. Patients were classified as white coat hypertensives if their daytime ambulatory BP were < 135/85 mm Hg. We studied 345 patients, 136 (39%) of whom were diagnosed with white coat hypertension. The frequency of white coat hypertension was inversely proportional to the severity of clinic BP values. The diagnosis of white coat hypertension was independently associated with female gender and low educational level. Left ventricular mass index and urinary albumin excretion were lower in the white-coat hypertensive group compared with the group with sustained hypertension. Our results show that a high proportion of patients with mild to moderate hypertension attended in a primary care setting have white coat hypertension. Some clinical characteristics may be helpful in the identification of this group of subjects. White coat hypertensives show less target-organ damage than sustained hypertensive patients.
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COMMUNITY MEDICINE & PRIMARY HEALTH CARE
African Journals Online (AJOL)
Journal of Community Medicine and Primary Health Care. ... Ladoke Akintola University of Technology, PMB 4400, Osogbo, Osun State. ... weak management and poor adherence to the basic infrastructure e.g. primary, secondary and tertiary.
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Society for Ambulatory Anesthesia
... SAMBA Link Digital Newsletter Educational Bibliography Research IARS/Anesthesia & Analgesia SCOR About SCOR Sponsor SAMBA Meetings Affinity Sponsor Program We Represent Ambulatory and Office-Based Anesthesia The Society for Ambulatory Anesthesia provides educational opportunities, ...
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The strength of primary care in Europe: an international comparative study.
Kringos, Dionne; Boerma, Wienke; Bourgueil, Yann; Cartier, Thomas; Dedeu, Toni; Hasvold, Toralf; Hutchinson, Allen; Lember, Margus; Oleszczyk, Marek; Rotar Pavlic, Danica; Svab, Igor; Tedeschi, Paolo; Wilm, Stefan; Wilson, Andrew; Windak, Adam; Van der Zee, Jouke; Groenewegen, Peter
2013-11-01
A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking. Evaluation of strength of primary care in Europe. International comparative cross-sectional study performed in 2009-2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey. Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts' consultations. Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries. Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.
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National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections.
Hersh, Adam L; Chambers, Henry F; Maselli, Judith H; Gonzales, Ralph
2008-07-28
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as a common cause of skin and soft-tissue infections (SSTIs) in the United States. It is unknown whether this development has affected the national rate of visits to primary care practices and emergency departments (EDs) and whether changes in antibiotic prescribing have occurred. We examined visits by patients with SSTIs to physician offices, hospital outpatient departments, and EDs using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1997 to 2005. We estimated annual visit rates for all SSTIs and a subset classified as abscess/cellulitis. For abscess/cellulitis visits, we examined trends in characteristics of patients and clinical settings and in antibiotic prescribing. Overall rate of visits for SSTIs increased from 32.1 to 48.1 visits per 1000 population (50%; P = .003 for trend), reaching 14.2 million by 2005. More than 95% of this change was attributable to visits for abscess/cellulitis, which increased from 17.3 to 32.5 visits per 1000 population (88% increase; P trend). The largest relative increases occurred in EDs (especially in high safety-net-status EDs and in the South), among black patients, and among patients younger than 18 years. Use of antibiotics recommended for CA-MRSA increased from 7% to 28% of visits (P < .001) during the study period. Independent predictors of treatment with these antibiotics included being younger than 45 years, living in the South, and an ED setting. The incidence of SSTIs has rapidly increased nationwide in the CA-MRSA era and appears to disproportionately affect certain populations. Although physicians are beginning to modify antibiotic prescribing practices, opportunities for improvement exist, targeting physicians caring for patients who are at high risk.
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Larach, Marilyn Green; Dirksen, Sharon J Hirshey; Belani, Kumar G; Brandom, Barbara W; Metz, Keith M; Policastro, Michael A; Rosenberg, Henry; Valedon, Arnaldo; Watson, Charles B
2012-01-01
Volatile anesthetics and/or succinylcholine may trigger a potentially lethal malignant hyperthermia (MH) event requiring critical care crisis management. If the MH triggering anesthetic is given in an ambulatory surgical center (ASC), then the patient will need to be transferred to a receiving hospital. Before May 2010, there was no clinical guide regarding the development of a specific transfer plan for MH patients in an ASC. MECHANISM BY WHICH THE STATEMENT WAS GENERATED: A consensual process lasting 18 months among 13 representatives of the Malignant Hyperthermia Association of the United States, the Ambulatory Surgery Foundation, the Society for Ambulatory Anesthesia, the Society for Academic Emergency Medicine, and the National Association of Emergency Medical Technicians led to the creation of this guide. EVIDENCE FOR THE STATEMENT: Most of the guide is based on the clinical experience and scientific expertise of the 13 representatives. The list of representatives appears in Appendix 1. The recommendation that IV dantrolene should be initiated pending transfer is also supported by clinical research demonstrating that the likelihood of significant MH complications doubles for every 30-minute delay in dantrolene administration (Anesth Analg 2010;110:498-507). This guide includes a list of potential clinical problems and therapeutic interventions to assist each ASC in the development of its own unique MH transfer plan. Points to consider include receiving health care facility capabilities, indicators of patient stability and necessary report data, transport team considerations and capabilities, implementation of transfer decisions, and coordination of communication among the ASC, the receiving hospital, and the transport team. See Appendix 2 for the guide.
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African Journals Online (AJOL)
Claire van Deventer
Keywords: child HIV, doctor involvement, primary health care, quality improvement ... expertise increased, PHC facilities are now expected to be able to .... organised patient documentation were revisited. .... Review: what can we learn from quality ... South Pacific: Review of evidence and lessons from an innovative.
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COMMUNITY MEDICINE & PRIMARY HEALTH CARE
African Journals Online (AJOL)
Client Satisfaction with Antenatal Care Services in Primary Health Care. Centres in Sabon ... important information about how well clinicians and the population of women within child bearing. 8 ..... model. Health and Quality of Life outcomes.
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The european primary care monitor: structure, process and outcome indicators
Directory of Open Access Journals (Sweden)
Wilson Andrew
2010-10-01
Full Text Available Abstract Background Scientific research has provided evidence on benefits of well developed primary care systems. The relevance of some of this research for the European situation is limited. There is currently a lack of up to date comprehensive and comparable information on variation in development of primary care, and a lack of knowledge of structures and strategies conducive to strengthening primary care in Europe. The EC funded project Primary Health Care Activity Monitor for Europe (PHAMEU aims to fill this gap by developing a Primary Care Monitoring System (PC Monitor for application in 31 European countries. This article describes the development of the indicators of the PC Monitor, which will make it possible to create an alternative model for holistic analyses of primary care. Methods A systematic review of the primary care literature published between 2003 and July 2008 was carried out. This resulted in an overview of: (1 the dimensions of primary care and their relevance to outcomes at (primary health system level; (2 essential features per dimension; (3 applied indicators to measure the features of primary care dimensions. The indicators were evaluated by the project team against criteria of relevance, precision, flexibility, and discriminating power. The resulting indicator set was evaluated on its suitability for Europe-wide comparison of primary care systems by a panel of primary care experts from various European countries (representing a variety of primary care systems. Results The developed PC Monitor approaches primary care in Europe as a multidimensional concept. It describes the key dimensions of primary care systems at three levels: structure, process, and outcome level. On structure level, it includes indicators for governance, economic conditions, and workforce development. On process level, indicators describe access, comprehensiveness, continuity, and coordination of primary care services. On outcome level, indicators
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[Primary care in the United Kingdom].
Sánchez-Sagrado, T
2016-03-01
The inadequate planning of health professionals in Spain has boosted the way out of doctors overseas. The United Kingdom is one of the countries chosen by Spanish doctors to develop their job. The National Health Service is a health system similar to the Spanish one. Health care services are financing mainly through taxes. The right to health care is linked to the citizen condition. The provision of health care is a mix-up of public and private enterprises. Primary Care is much closed to Spanish Primary Care. Doctors are "self-employed like" professionals. They can set their surgeries in a free area previously designed by the government. They have the right to make their own team and to manage their own budget. Medical salary is linked to professional capability and curriculum vitae. The main role of a General Practitioner is the prevention. Team work and coordination within primary and specialised care is more developed than in Spain. The access to diagnostic tests and to the specialist is controlled through waiting lists. General Practitioners work as gate-keepers. Patients may choose freely their doctor and consultations and hospital care are free at the point of use. Within the United Kingdom there are also health regions with problems due to inequalities to access and to treatment. There is a training path and the access to it is by Curricula. The number of training jobs is regulated by the local needs. Continuing education is compulsory and strictly regulated local and nationally. The National Health Service was the example for the Spanish health reform in 1986. While Spanish Primary health care is of quality, the efficiency of the health system would improve if staff in Primary Care settings were managed in a similar way to the British's. Copyright © 2015 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
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Teh, Benjamin W; Brown, Christine; Joyce, Trish; Worth, Leon J; Slavin, Monica A; Thursky, Karin A
2018-03-01
Neutropenic fever (NF) is a common complication of cancer chemotherapy. Patients at low risk of medical complications from NF can be identified using a validated risk assessment and managed in an outpatient setting. This is a new model of care for Australia. This study described the implementation of a sustainable ambulatory program for NF at a tertiary cancer centre over a 12-month period. Peter MacCallum Cancer Centre introduced an ambulatory care program in 2014, which identified low-risk NF patients, promoted early de-escalation to oral antibiotics, and early discharge to a nurse-led ambulatory program. Patients prospectively enrolled in the ambulatory program were compared with a historical-matched cohort of patients from 2011 for analysis. Patient demographics, clinical variables (cancer type, recent chemotherapy, treatment intent, site of presentation) and outcomes were collected and compared. Total cost of inpatient admissions was determined from diagnosis-related group (DRG) codes and applied to both the prospective and historical cohorts to allow comparisons. Twenty-five patients were managed in the first year of this program with a reduction in hospital median length of stay from 4.0 to 1.1 days and admission cost from Australian dollars ($AUD) 8580 to $AUD2360 compared to the historical cohort. Offsetting salary costs, the ambulatory program had a net cost benefit of $AUD 71895. Readmission for fever was infrequent (8.0%), and no deaths were reported. Of relevance to hospitals providing cancer care, feasibility, safety, and cost benefits of an ambulatory program for low-risk NF patients have been demonstrated.
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77 FR 50546 - Agency Information Collection: (PACT Patient Experiences Survey); Comment Request
2012-08-21
... Primary Care sites. This initiative supports the VHA's Universal Health Care Services Plan to redesign VHA... Health Administration Ambulatory Primary Care sites. The medical home provides accessible, coordinated... used by the VAAAHS PACT Demonstration Laboratory and the Ambulatory Care Service to evaluate the...
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Improving Health Care Management in Primary Care for Homeless People: A Literature Review
Abcaya, Julien; Ștefan, Diana-Elena; Calvet-Montredon, Céline; Gentile, Stéphanie
2018-01-01
Background: Homeless people have poorer health status than the general population. They need complex care management, because of associated medical troubles (somatic and psychiatric) and social difficulties. We aimed to describe the main characteristics of the primary care programs that take care of homeless people, and to identify which could be most relevant. Methods: We performed a literature review that included articles which described and evaluated primary care programs for homeless people. Results: Most of the programs presented a team-based approach, multidisciplinary and/or integrated care. They often proposed co-located services between somatic health services, mental health services and social support services. They also tried to answer to the specific needs of homeless people. Some characteristics of these programs were associated with significant positive outcomes: tailored primary care organizations, clinic orientation, multidisciplinary team-based models which included primary care physicians and clinic nurses, integration of social support, and engagement in the community’s health. Conclusions: Primary health care programs that aimed at taking care of the homeless people should emphasize a multidisciplinary approach and should consider an integrated (mental, somatic and social) care model. PMID:29439403
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Integrated primary care in Germany: the road ahead
Directory of Open Access Journals (Sweden)
Sophia Schlette
2009-04-01
Full Text Available Problem statement: Health care delivery in Germany is highly fragmented, resulting in poor vertical and horizontal integration and a system that is focused on curing acute illness or single diseases instead of managing patients with more complex or chronic conditions, or managing the health of determined populations. While it is now widely accepted that a strong primary care system can help improve coordination and responsiveness in health care, primary care has so far not played this role in the German system. Primary care physicians traditionally do not have a gatekeeper function; patients can freely choose and directly access both primary and secondary care providers, making coordination and cooperation within and across sectors difficult. Description of policy development: Since 2000, driven by the political leadership and initiative of the Federal Ministry of Health, the German Bundestag has passed several laws enabling new forms of care aimed to improve care coordination and to strengthen primary care as a key function in the German health care system. These include on the contractual side integrated care contracts, and on the delivery side disease management programmes, medical care centres, gatekeeping and ‘community medicine nurses’. Conclusion and discussion: Recent policy reforms improved framework conditions for new forms of care. There is a clear commitment by the government and the introduction of selective contracting and financial incentives for stronger cooperation constitute major drivers for change. First evaluations, especially of disease management programmes, indicate that the new forms of care improve coordination and outcomes. Yet the process of strengthening primary care as a lever for better care coordination has only just begun. Future reforms need to address other structural barriers for change such as fragmented funding streams, inadequate payment systems, the lack of standardized IT systems and trans
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Integrated primary care in Germany: the road ahead.
Schlette, Sophia; Lisac, Melanie; Blum, Kerstin
2009-04-20
Health care delivery in Germany is highly fragmented, resulting in poor vertical and horizontal integration and a system that is focused on curing acute illness or single diseases instead of managing patients with more complex or chronic conditions, or managing the health of determined populations. While it is now widely accepted that a strong primary care system can help improve coordination and responsiveness in health care, primary care has so far not played this role in the German system. Primary care physicians traditionally do not have a gatekeeper function; patients can freely choose and directly access both primary and secondary care providers, making coordination and cooperation within and across sectors difficult. Since 2000, driven by the political leadership and initiative of the Federal Ministry of Health, the German Bundestag has passed several laws enabling new forms of care aimed to improve care coordination and to strengthen primary care as a key function in the German health care system. These include on the contractual side integrated care contracts, and on the delivery side disease management programmes, medical care centres, gatekeeping and 'community medicine nurses'. Recent policy reforms improved framework conditions for new forms of care. There is a clear commitment by the government and the introduction of selective contracting and financial incentives for stronger cooperation constitute major drivers for change. First evaluations, especially of disease management programmes, indicate that the new forms of care improve coordination and outcomes. Yet the process of strengthening primary care as a lever for better care coordination has only just begun. Future reforms need to address other structural barriers for change such as fragmented funding streams, inadequate payment systems, the lack of standardized IT systems and trans-sectoral education and training of providers.
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Copp, Hillary L; Shapiro, Daniel J; Hersh, Adam L
2011-06-01
The goal of this study was to investigate patterns of ambulatory antibiotic use and to identify factors associated with broad-spectrum antibiotic prescribing for pediatric urinary tract infections (UTIs). We examined antibiotics prescribed for UTIs for children aged younger than 18 years from 1998 to 2007 using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Amoxicillin-clavulanate, quinolones, macrolides, and second- and third-generation cephalosporins were classified as broad-spectrum antibiotics. We evaluated trends in broad-spectrum antibiotic prescribing patterns and performed multivariable logistic regression to identify factors associated with broad-spectrum antibiotic use. Antibiotics were prescribed for 70% of pediatric UTI visits. Trimethoprim-sulfamethoxazole was the most commonly prescribed antibiotic (49% of visits). Broad-spectrum antibiotics were prescribed one third of the time. There was no increase in overall use of broad-spectrum antibiotics (P = .67); however, third-generation cephalosporin use doubled from 12% to 25% (P = .02). Children younger than 2 years old (odds ratio: 6.4 [95% confidence interval: 2.2-18.7, compared with children 13-17 years old]), females (odds ratio: 3.6 [95% confidence interval: 1.6-8.5]), and temperature ≥ 100.4°F (odds ratio: 2.9 [95% confidence interval: 1.0-8.6]) were independent predictors of broad-spectrum antibiotic prescribing. Race, physician specialty, region, and insurance status were not associated with antibiotic selection. Ambulatory care physicians commonly prescribe broad-spectrum antibiotics for the treatment of pediatric UTIs, especially for febrile infants in whom complicated infections are more likely. The doubling in use of third-generation cephalosporins suggests that opportunities exist to promote more judicious antibiotic prescribing because most pediatric UTIs are susceptible to narrower alternatives.
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Allegheny County Primary Care Access
Allegheny County / City of Pittsburgh / Western PA Regional Data Center — The data on health care facilities includes the name and location of all the hospitals and primary care facilities in Allegheny County. The current listing of...
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Gruen, Russell L; Knox, Stephanie; Britt, Helena; Bailie, Ross S
2004-01-01
Background The interface between primary care and specialist medical services is an important domain for health services research and policy. Of particular concern is optimising specialist services and the organisation of the specialist workforce to meet the needs and demands for specialist care, particularly those generated by referral from primary care. However, differences in the disease classification and reporting of the work of primary and specialist surgical sectors hamper such research. This paper describes the development of a bridging classification for use in the study of potential surgical problems in primary care settings, and for classifying referrals to surgical specialties. Methods A three stage process was undertaken, which involved: (1) defining the categories of surgical disorders from a specialist perspective that were relevant to the specialist-primary care interface; (2) classifying the 'terms' in the International Classification of Primary Care Version 2-Plus (ICPC-2 Plus) to the surgical categories; and (3) using referral data from 303,000 patient encounters in the BEACH study of general practice activity in Australia to define a core set of surgical conditions. Inclusion of terms was based on the probability of specialist referral of patients with such problems, and specialists' perception that they constitute part of normal surgical practice. Results A four-level hierarchy was developed, containing 8, 27 and 79 categories in the first, second and third levels, respectively. These categories classified 2050 ICPC-2 Plus terms that constituted the fourth level, and which covered the spectrum of problems that were managed in primary care and referred to surgical specialists. Conclusion Our method of classifying terms from a primary care classification system to categories delineated by specialists should be applicable to research addressing the interface between primary and specialist care. By describing the process and putting the bridging
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Primary health care in the Southern Mediterranean region.
Weide, M.G.; Fakiri, F. el; Kulu Glasgow, I.; Grielen, S.J.; Zee, J. van der
1998-01-01
This book gives an overview of primary health care in the Southern Mediterranean region. For twelve countries detailed information is provided on the structure and financing of health care, the organisation of primary care (including mother and child health care and immunisation programmes), health
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McDermott, S; Royer, J; Mann, J R; Armour, B S
2018-03-01
Ambulatory care sensitive conditions (ACSCs) can be seen as failure of access or management in primary care settings. Identifying factors associated with ACSCs for individuals with an Intellectual Disability (ID) provide insight into potential interventions. To assess the association between emergency department (ED) ACSC visits and a number of demographic and health characteristics of South Carolina Medicaid members with ID. A retrospective cohort of adults with ID was followed from 2001 to 2011. Using ICD-9-CM codes, four ID subgroups, totalling 14 650 members, were studied. There were 106 919 ED visits, with 21 214 visits (19.8%) classified as ACSC. Of those, 82.9% were treated and released from EDs with costs averaging $578 per visit. People with mild and unspecified ID averaged greater than one ED visit per member year. Those with Down syndrome and other genetic cause ID had the lowest rates of ED visits but the highest percentage of ACSC ED visits that resulted in inpatient hospitalisation (26.6% vs. an average of 16.8% for other subgroups). When compared with other residential types, those residing at home with no health support services had the highest ED visit rate and were most likely to be discharged back to the community following an ED visit (85.2%). Adults residing in a nursing home had lower rates of ED visits but were most likely to be admitted to the hospital (38.9%) following an ED visit. Epilepsy and convulsions were the leading cause (29.6%) of ACSC ED visits across all subgroups and residential settings. Prevention of ACSC ED visits may be possible by targeting adults with ID who live at home without health support services. © 2017 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.
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Integrating mental health into primary care: a global perspective
National Research Council Canada - National Science Library
Funk, Michelle
2008-01-01
... for mental disorders is enormous 4. Primary care for mental health enhances access 5. Primary care for mental health promotes respect of human rights 6. Primary care for mental health is affordab...
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Introducing Pharmaceutical Care to Primary Care in Iceland—An Action Research Study
Directory of Open Access Journals (Sweden)
Anna Bryndis Blondal
2017-04-01
Full Text Available Even though pharmaceutical care is not a new concept in pharmacy, its introduction and development has proved to be challenging. In Iceland, general practitioners are not familiar with pharmaceutical care and additionally no such service is offered in pharmacies or primary care settings. Introducing pharmaceutical care in primary care in Iceland is making great efforts to follow other countries, which are bringing the pharmacist more into patient care. General practitioners are key stakeholders in this endeavor. The aim of this study was to introduce pharmacist-led pharmaceutical care into primary care clinics in Iceland in collaboration with general practitioners by presenting different setting structures. Action research provided the framework for this research. Data was collected from pharmaceutical care interventions, whereby the pharmaceutical care practitioner ensures that each of a patient’s medications is assessed to determine if it is appropriate, effective, safe, and that the patient can take medicine as expected. Sources of data included pharmaceutical care notes on patients, researcher’s notes, meetings, and interviews with general practitioners over the period of the study. The study ran from September 2013 to October 2015. Three separate semi-structured in-depth interviews were conducted with five general practitioners from one primary health care clinic in Iceland at different time points throughout the study. Pharmaceutical care was provided to elderly patients (n = 125 before and between general practitioners’ interviews. The study setting was a primary care clinic in the Reykjavik area and the patients’ homes. Results showed that the GPs’ knowledge about pharmacist competencies as healthcare providers and their potential in patient care increased. GPs would now like to have access to a pharmacist on a daily basis. Direct contact between the pharmacist and GPs is better when working in the same physical space
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Carbone, Paul S; Young, Paul C; Stoddard, Gregory J; Wilkes, Jacob; Trasande, Leonardo
2015-01-01
To compare the prevalence of hospitalizations for ambulatory care sensitive conditions (ACSC) in children with and without autism spectrum disorder (ASD) and to compare inpatient health care utilization (total charges and length of stay) for the same conditions in children with and without ASD. The 2009 Kids' Inpatient Database was used to examine hospitalizations for ACSC in children within 3 cohorts: those with ASD, those with chronic conditions (CC) without ASD, and those with no CC. The proportion of hospitalizations for ACSC in the ASD cohort was 55.9%, compared with 28.2% in the CC cohort and 22.9% in the no-CC cohort (P Hospitalized children with ASD were more likely to be admitted for a mental health condition, epilepsy, constipation, pneumonia, dehydration, vaccine-preventable diseases, underweight, and nutritional deficiencies compared with the no-CC cohort. Compared with the CC cohort, the ASD cohort was more likely to be admitted for mental health conditions, epilepsy, constipation, dehydration, and underweight. Hospitalized children with ASD admitted for mental health conditions had significantly higher total charges and longer LOS compared with the other 2 cohorts. The proportion of potentially preventable hospitalizations is higher in hospitalized children with ASD compared with children without ASD. These data underscore the need to improve outpatient care of children with ASD, especially in the areas of mental health care and seizure management. Future research should focus on understanding the reasons for increased inpatient health care utilization in children with ASD admitted for mental health conditions. Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
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Side effects after ambulatory lumbar iohexol myelography
International Nuclear Information System (INIS)
Sand, T.; Myhr, G.; Stovner, L.J.; Dale, L.G.; Tangerud, A.
1989-01-01
Side effect incidences after ambulatory (22G needle and two h bed rest) and after non-ambulatory (22 and 20G needles and 20 h bed rest) lumbar iohexol myelography have been estimated and compared. Headache incidence was significantly greater in ambulatory (50%, n=107) as compared to nonambulatory myelography (26%, n=58). Headaches in the ambulatory group tended to be of shorter duration and the difference between severe headaches in ambulatory and non-ambulatory groups was not significant. Serious adverse reactions did not occur and none of the ambulatory patients required readmission because of side effects. The headache was predominantly postural and occurred significantly earlier in the ambulatory group. Headache incidence was significantly greater after 20G needle myelography (44%, n=97) as compared to 22G needle iohexol myelography (26%, n=58). The results support the hypothesis that CSF leakage is a major cause of headache after lumbar iohexol myelography. (orig.)
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Gordon, Christopher J; Aggar, Christina; Williams, Anna M; Walker, Lynne; Willcock, Simon M; Bloomfield, Jacqueline
2014-01-01
This debate discusses the potential merits of a New Graduate Nurse Transition to Primary Health Care Program as an untested but potential nursing workforce development and sustainability strategy. Increasingly in Australia, health policy is focusing on the role of general practice and multidisciplinary teams in meeting the service needs of ageing populations in the community. Primary health care nurses who work in general practice are integral members of the multidisciplinary team - but this workforce is ageing and predicted to face increasing shortages in the future. At the same time, Australia is currently experiencing a surplus of and a corresponding lack of employment opportunities for new graduate nurses. This situation is likely to compound workforce shortages in the future. A national nursing workforce plan that addresses supply and demand issues of primary health care nurses is required. Innovative solutions are required to support and retain the current primary health care nursing workforce, whilst building a skilled and sustainable workforce for the future. This debate article discusses the primary health care nursing workforce dilemma currently facing policy makers in Australia and presents an argument for the potential value of a New Graduate Transition to Primary Health Care Program as a workforce development and sustainability strategy. An exploration of factors that may contribute or hinder transition program for new graduates in primary health care implementation is considered. A graduate transition program to primary health care may play an important role in addressing primary health care workforce shortages in the future. There are, however, a number of factors that need to be simultaneously addressed if a skilled and sustainable workforce for the future is to be realised. The development of a transition program to primary health care should be based on a number of core principles and be subjected to both a summative and cost
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COMMUNITY MEDICINE & PRIMARY HEALTH CARE
African Journals Online (AJOL)
ajiboro
2Department of Community Medicine & Primary Care, Faculty of Clinical Sciences, ... It may result from road traffic accident, near saving basic principles in emergency care that even drowning, electric ... (4.3%) at place of work, 8 (11.4%) at.
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Valentijn, Pim P; Schepman, Sanneke M; Opheij, Wilfrid; Bruijnzeels, Marc A
2013-01-01
Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care. The search method involved a combination of electronic database searches, hand searches of reference lists (snowball method) and contacting researchers in the field. The process of synthesizing the literature was iterative, to relate the concepts of primary care and integrated care. First, we identified the general principles of primary care and integrated care. Second, we connected the dimensions of integrated care and the principles of primary care. Finally, to improve content validity we held several meetings with researchers in the field to develop and refine our conceptual framework. The conceptual framework combines the functions of primary care with the dimensions of integrated care. Person-focused and population-based care serve as guiding principles for achieving integration across the care continuum. Integration plays complementary roles on the micro (clinical integration), meso (professional and organisational integration) and macro (system integration) level. Functional and normative integration ensure connectivity between the levels. The presented conceptual framework is a first step to achieve a better understanding of the inter-relationships among the dimensions of integrated care from a primary care perspective.
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Initiatives to Enhance Primary Care Delivery
Directory of Open Access Journals (Sweden)
Jan L. Losby
2015-01-01
Full Text Available Objectives: Increasing demands on primary care providers have created a need for systems-level initiatives to improve primary care delivery. The purpose of this article is to describe and present outcomes for 2 such initiatives: the Pennsylvania Academy of Family Physicians’ Residency Program Collaborative (RPC and the St Johnsbury Vermont Community Health Team (CHT. Methods: Researchers conducted case studies of the initiatives using mixed methods, including secondary analysis of program and electronic health record data, systematic document review, and interviews. Results: The RPC is a learning collaborative that teaches quality improvement and patient centeredness to primary care providers, residents, clinical support staff, and administrative staff in residency programs. Results show that participation in a higher number of live learning sessions resulted in a significant increase in patient-centered medical home recognition attainment and significant improvements in performance in diabetic process measures including eye examinations (14.3%, P = .004, eye referrals (13.82%, P = .013, foot examinations (15.73%, P = .003, smoking cessation (15.83%, P = .012, and self-management goals (25.45%, P = .001. As a community-clinical linkages model, CHT involves primary care practices, community health workers (CHWs, and community partners. Results suggest that CHT members successfully work together to coordinate comprehensive care for the individuals they serve. Further, individuals exposed to CHWs experienced increased stability in access to health insurance ( P = .001 and prescription drugs ( P = .000 and the need for health education counseling ( P = .000. Conclusion: Findings from this study indicate that these 2 system-level strategies have the promise to improve primary care delivery. Additional research can determine the extent to which these strategies can improve other health outcomes.
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Directory of Open Access Journals (Sweden)
Tsima BM
2016-08-01
Full Text Available Billy M Tsima,1 Vincent Setlhare,1 Oathokwa Nkomazana2 1Department of Family Medicine and Public Health, 2Department of Surgery, Faculty of Medicine, University of Botswana, Gaborone, Botswana Background: Botswana’s health care system is based on a primary care model. Various national guidelines exist for specific diseases. However, most of the guidelines address management at a tertiary level and often appear nonapplicable for the limited resources in primary care facilities. An integrated symptom-based guideline was developed so as to translate the Botswana national guidelines to those applicable in primary care. The Botswana Primary Care Guideline (BPCG integrates the care of communicable diseases, including HIV/AIDS and noncommunicable diseases, by frontline primary health care workers.Methods: The Department of Family Medicine, Faculty of Medicine, University of Botswana, together with guideline developers from the Knowledge Translation Unit (University of Cape Town collaborated with the Ministry of Health to develop the guideline. Stakeholder groups were set up to review specific content of the guideline to ensure compliance with Botswana government policy and the essential drug list.Results: Participants included clinicians, academics, patient advocacy groups, and policymakers from different disciplines, both private and public. Drug-related issues were identified as necessary for implementing recommendations of the guideline. There was consensus by working groups for updating the essential drug list for primary care and expansion of prescribing rights of trained nurse prescribers in primary care within their scope of practice. An integrated guideline incorporating common symptoms of diseases seen in the Botswana primary care setting was developed.Conclusion: The development of the BPCG took a broad consultative approach with buy in from relevant stakeholders. It is anticipated that implementation of the BPCG will translate into better
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Bezzina, Andrew J; Smith, Peter B; Cromwell, David; Eagar, Kathy
2005-01-01
To review the definition of 'primary care' and 'inappropriate' patients in ED and develop a generally acceptable working definition of a 'primary care' presentation in ED. A Medline review of articles on primary care in ED and the definitions used. A total of 34 reviewed papers contained a proposed definition or comment on the definition for potential 'primary care', 'general practice', or 'inappropriate' patients in ED. A representative definition was developed premised on the common factors in these papers: low urgency/acuity--triage categories four or five in the Australasian Triage Scale, self-referred--by definition, patients referred by general practitioner/community primary medical services are not primary care cases because a primary care service has referred them on, presenting for a new episode of care (i.e. not a planned return because planned returns are not self-referred), unlikely to be admitted (in the opinion of Emergency Nurse interviewers) or ultimately not admitted. This definition can be applied either prospectively or retrospectively, depending on the purpose. Appropriateness must be considered in light of a legitimate role for ED in primary care and the balance of resources between primary care and emergency medicine in local settings.
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Norsidah, A M; Yahya, N; Adeeb, N; Lim, A L
2001-03-01
Ambulatory or day care surgery is still in its infancy in this part of the world. Our newly built university affiliated hospital started its Day Surgery Centre in February 1998. It is the first multidisciplinary ambulatory surgery centre in a teaching hospital in the country. It caters for Orthopaedic surgery, Urology, Plastic surgery, Otorhinolaryngology, General surgery, Paediatric surgery and Ophthalmology. We have done 2,604 cases and our unanticipated admission rate is less than 2%. There has been no major morbidity or mortality. The problems of setting up a multidisciplinary ambulatory centre in a teaching hospital are discussed.
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Challenges in referral communication between VHA primary care and specialty care.
Zuchowski, Jessica L; Rose, Danielle E; Hamilton, Alison B; Stockdale, Susan E; Meredith, Lisa S; Yano, Elizabeth M; Rubenstein, Lisa V; Cordasco, Kristina M
2015-03-01
Poor communication between primary care providers (PCPs) and specialists is a significant problem and a detriment to effective care coordination. Inconsistency in the quality of primary-specialty communication persists even in environments with integrated delivery systems and electronic medical records (EMRs), such as the Veterans Health Administration (VHA). The purpose of this study was to measure ease of communication and to characterize communication challenges perceived by PCPs and primary care personnel in the VHA, with a particular focus on challenges associated with referral communication. The study utilized a convergent mixed-methods design: online cross-sectional survey measuring PCP-reported ease of communication with specialists, and semi-structured interviews characterizing primary-specialty communication challenges. 191 VHA PCPs from one regional network were surveyed (54% response rate), and 41 VHA PCPs and primary care staff were interviewed. PCP-reported ease of communication mean score (survey) and recurring themes in participant descriptions of primary-specialty referral communication (interviews) were analyzed. Among PCPs, ease-of-communication ratings were highest for women's health and mental health (mean score of 2.3 on a scale of 1-3 in both), and lowest for cardiothoracic surgery and neurology (mean scores of 1.3 and 1.6, respectively). Primary care personnel experienced challenges communicating with specialists via the EMR system, including difficulty in communicating special requests for appointments within a certain time frame and frequent rejection of referral requests due to rigid informational requirements. When faced with these challenges, PCPs reported using strategies such as telephone and e-mail contact with specialists with whom they had established relationships, as well as the use of an EMR-based referral innovation called "eConsults" as an alternative to a traditional referral. Primary-specialty communication is a continuing
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Patient evaluations of primary care.
Schäfer, W.L.A.; Boerma, W.G.W.; Schellevis, F.G.; Groenewegen, P.P.
2012-01-01
Background: So far, studies about people’s appreciation of primary care services has shown that patient satisfaction seems to be lower in health care systems with regulated access to specialist services by gate keeping. Nevertheless, international comparative research about patients’ expectations
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COMMUNITY HEALTH & PRIMARY HEALTH CARE
African Journals Online (AJOL)
the_monk
Journal of Community Medicine and Primary Health Care. 26 (1) 12-20 .... large proportions of the population work in the poor people use health care services far less than. 19 ... hypertension, cancers and road traffic accidents) below 1 dollar ...
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Improving adherence to the Epic Beacon ambulatory workflow.
Chackunkal, Ellen; Dhanapal Vogel, Vishnuprabha; Grycki, Meredith; Kostoff, Diana
2017-06-01
Computerized physician order entry has been shown to significantly improve chemotherapy safety by reducing the number of prescribing errors. Epic's Beacon Oncology Information System of computerized physician order entry and electronic medication administration was implemented in Henry Ford Health System's ambulatory oncology infusion centers on 9 November 2013. Since that time, compliance to the infusion workflow had not been assessed. The objective of this study was to optimize the current workflow and improve the compliance to this workflow in the ambulatory oncology setting. This study was a retrospective, quasi-experimental study which analyzed the composite workflow compliance rate of patient encounters from 9 to 23 November 2014. Based on this analysis, an intervention was identified and implemented in February 2015 to improve workflow compliance. The primary endpoint was to compare the composite compliance rate to the Beacon workflow before and after a pharmacy-initiated intervention. The intervention, which was education of infusion center staff, was initiated by ambulatory-based, oncology pharmacists and implemented by a multi-disciplinary team of pharmacists and nurses. The composite compliance rate was then reassessed for patient encounters from 2 to 13 March 2015 in order to analyze the effects of the determined intervention on compliance. The initial analysis in November 2014 revealed a composite compliance rate of 38%, and data analysis after the intervention revealed a statistically significant increase in the composite compliance rate to 83% ( p < 0.001). This study supports a pharmacist-initiated educational intervention can improve compliance to an ambulatory, oncology infusion workflow.
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Hospitalisations and costs relating to ambulatory care sensitive conditions in Ireland.
LENUS (Irish Health Repository)
Sheridan, A
2012-03-08
BACKGROUND: Ambulatory care sensitive conditions (ACSCs) are conditions for which the provision of timely and effective outpatient care can reduce the risks of hospitalisation by preventing, controlling or managing a chronic disease or condition. AIMS: The aims of this study were to report on ACSCs in Ireland, and to provide a baseline for future reference. METHODS: Using HIPE, via Health Atlas Ireland, inpatient discharges classified as ACSCs using definitions from the Victorian ACSC study were extracted for the years 2005-2008. Direct methods of standardisation allowed comparison of rates using the EU standard population as a comparison for national data, and national population as comparison for county data. Costs were estimated using diagnosis-related groups. RESULTS: The directly age-standardised discharge rate for ACSC-related discharges increased slightly, but non-significantly, from 15.40 per 1,000 population in 2005 to 15.75 per 1,000 population in 2008. The number of discharges increased (9.5%) from 63,619 in 2005 to 69,664 in 2008, with the estimated associated hospital costs increasing (31.5%) from
267.8 million in 2005 to 352.2 million in 2008. Across the country, there was considerable variation in the discharge rates for the Top-10 ACSCs for the years 2005-2008. Significantly lower rates of hospitalisation were observed in more urban areas including Cork, Dublin and Galway. The most common ACSC in 2008 was diabetes with complications (29.8%). CONCLUSIONS: The variation in rates observed indicates the scope of reducing hospitalisations and associated costs for ACSCs, across both adult\\'s and children\\'s services and particularly in relation to diabetes complications. -
Primary prevention of chronic obstructive pulmonary disease in primary care.
van der Molen, Thys; Schokker, Siebrig
2009-12-01
Chronic obstructive pulmonary disease (COPD) is a prevalent disease, with cigarette smoking being the main risk factor. Prevention is crucial in the fight against COPD. Whereas primary prevention is targeted on whole populations, patient populations are the focus of primary care; therefore, prevention in this setting is mainly aimed at preventing further deterioration of the disease in patients who present with the first signs of disease (secondary prevention). Prevention of COPD in primary care requires detection of COPD at an early stage. An accurate definition of COPD is crucial in this identification process. The benefits of detecting new patients with COPD should be determined before recommending screening and case-finding programs in primary care. No evidence is available that screening by spirometry results in significant health gains. Effective treatment options in patients with mild disease are lacking. Smoking cessation is the cornerstone of COPD prevention. Because cigarette smoking is not only a major cause of COPD but is also a major cause of many other diseases, a decline in tobacco smoking would result in substantial health benefits.
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De Regge, Melissa; De Groote, Hélène; Trybou, Jeroen; Gemmel, Paul; Brugada, Pedro
2017-04-01
Health care organizations are constantly looking for ways to establish a differential advantage to attract customers. To this end, service quality has become an important differentiator in the strategy of health care organizations. In this study, we compared the service quality and patient experience in an ambulatory care setting of a physician-owned specialized facility with that of a general hospital. A comparative case study with a mixed method design was employed. Data were gathered through a survey on health service quality and patient experience, completed with observations, walkthroughs, and photographic material. Service quality and patient experiences are high in both the investigated health care facilities. A significant distinction can be made between the two facilities in terms of interpersonal quality (p = 0.001) and environmental quality (P ≤ 0.001), in favor of the medical center. The difference in environmental quality is also indicated by the scores given by participants who had been in both facilities. Qualitative analysis showed higher administrative quality in the medical center. Environmental quality and patient experience can predict the interpersonal quality; for environmental quality, interpersonal quality and age are significant predictors. Service quality and patient experiences are high in both facilities. The medical center has higher service quality for interpersonal and environmental service quality and is more process-centered.
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Occupational Therapy and Primary Care: Updates and Trends
Mroz, Tracy M.; Fogelberg, Donald J.; Leland, Natalie E.
2018-01-01
As our health care system continues to change, so do the opportunities for occupational therapy. This article provides an update to a 2012 Health Policy Perspectives on this topic. We identify new initiatives and opportunities in primary care, explore common challenges to integrating occupational therapy in primary care environments, and highlight international works that can support our efforts. We conclude by discussing next steps for occupational therapy practitioners in order to continue to progress our efforts in primary care. PMID:29689169
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Fibromyalgia: management strategies for primary care providers.
Arnold, L M; Gebke, K B; Choy, E H S
2016-02-01
Fibromyalgia (FM), a chronic disorder defined by widespread pain, often accompanied by fatigue and sleep disturbance, affects up to one in 20 patients in primary care. Although most patients with FM are managed in primary care, diagnosis and treatment continue to present a challenge, and patients are often referred to specialists. Furthermore, the lack of a clear patient pathway often results in patients being passed from specialist to specialist, exhaustive investigations, prescription of multiple drugs to treat different symptoms, delays in diagnosis, increased disability and increased healthcare resource utilisation. We will discuss the current and evolving understanding of FM, and recommend improvements in the management and treatment of FM, highlighting the role of the primary care physician, and the place of the medical home in FM management. We reviewed the epidemiology, pathophysiology and management of FM by searching PubMed and references from relevant articles, and selected articles on the basis of quality, relevance to the illness and importance in illustrating current management pathways and the potential for future improvements. The implementation of a framework for chronic pain management in primary care would limit unnecessary, time-consuming, and costly tests, reduce diagnostic delay and improve patient outcomes. The patient-centred medical home (PCMH), a management framework that has been successfully implemented in other chronic diseases, might improve the care of patients with FM in primary care, by bringing together a team of professionals with a range of skills and training. Although there remain several barriers to overcome, implementation of a PCMH would allow patients with FM, like those with other chronic conditions, to be successfully managed in the primary care setting. © 2016 John Wiley & Sons Ltd.
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Directory of Open Access Journals (Sweden)
Heather L. Maracle
2012-01-01
Full Text Available This study explored primary care providers' (PCPs experiences with the practice of pharmaceutical care-based medication therapy management (MTM. Qualitative, semi-structured interviews were conducted with six PCPs who have experiences working with MTM pharmacists for at least three years. The first author conducted the interviews that were audio-taped, transcribed, and coded independently. The codes were then harmonized via discussion and consensus with the other authors. Data were analyzed for themes using the hermeneutic-phenomenological method as proposed by Max van Manen. Three men and three women were interviewed. On average, the interviewees have worked with MTM pharmacists for seven years. The six (6 themes uncovered from the interviews included: (1 "MTM is just part of our team approach to the practice of medicine": MTM as an integral part of PCPs' practices; (2 "Frankly it's education for the patient but it's also education for me": MTM services as a source of education; (3 "It's not exactly just the pharmacist that passes out the medicines at the pharmacy": The MTM practitioner is different from the dispensing pharmacist; (4 "So, less reactive, cleaning up the mess, and more proactive and catching things before they become so involved": MTM services as preventative health care efforts; (5"I think that time is the big thing": MTM pharmacists spend more time with patients; (6 "There's an access piece, there's an availability piece, there's a finance piece": MTM services are underutilized at the clinics. In conclusion, PCPs value having MTM pharmacists as part of their team in ambulatory clinics. MTM pharmacists are considered an important source of education to patients as well as to providers as they are seen as having a unique body of knowledge äóñmedication expertise. All PCPs highly treasure the time and education provided by the MTM pharmacists, their ability to manage and adjust patients' medications, and their capability to
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Directory of Open Access Journals (Sweden)
Heather L. Maracle, Pharm.D.
2012-01-01
Full Text Available This study explored primary care providers’ (PCPs experiences with the practice of pharmaceutical care-based medication therapy management (MTM. Qualitative, semi-structured interviews were conducted with six PCPs who have experiences working with MTM pharmacists for at least three years. The first author conducted the interviews that were audio-taped, transcribed, and coded independently. The codes were then harmonized via discussion and consensus with the other authors. Data were analyzed for themes using the hermeneutic-phenomenological method as proposed by Max van Manen. Three men and three women were interviewed. On average, the interviewees have worked with MTM pharmacists for seven years. The six (6 themes uncovered from the interviews included: (1 “MTM is just part of our team approach to the practice of medicine”: MTM as an integral part of PCPs’ practices; (2 “Frankly it’s education for the patient but it’s also education for me”: MTM services as a source of education; (3 “It’s not exactly just the pharmacist that passes out the medicines at the pharmacy”: The MTM practitioner is different from the dispensing pharmacist; (4 “So, less reactive, cleaning up the mess, and more proactive and catching things before they become so involved”: MTM services as preventative health care efforts; (5“I think that time is the big thing”: MTM pharmacists spend more time with patients; (6 “There’s an access piece, there’s an availability piece, there’s a finance piece”: MTM services are underutilized at the clinics. In conclusion, PCPs value having MTM pharmacists as part of their team in ambulatory clinics. MTM pharmacists are considered an important source of education to patients as well as to providers as they are seen as having a unique body of knowledge –medication expertise. All PCPs highly treasure the time and education provided by the MTM pharmacists, their ability to manage and adjust patients
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76 FR 61103 - Medicare Program; Comprehensive Primary Care Initiative
2011-10-03
...] Medicare Program; Comprehensive Primary Care Initiative AGENCY: Centers for Medicare & Medicaid Services... organizations to participate in the Comprehensive Primary Care initiative (CPC), a multipayer model designed to... the Comprehensive Primary Care initiative or the application process. SUPPLEMENTARY INFORMATION: I...
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Ambulatory heart rate is underestimated when measured by an Ambulatory Blood Pressure device
Vrijkotte, T.G.M.; de Geus, E.J.C.
1999-01-01
Objective: To test the validity of ambulatory heart rate (HR) assessment with a cuff ambulatory blood pressure (ABP) monitor. Design: Cross-instrument comparison of HR measured intermittently by a cuff ABP monitor (SpaceLabs, Redmond, Washington, USA), with HR derived from continuous
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Ambulatory heart rate is underestimated when measured by an ambulatory blood pressure device
Vrijkotte, T. G.; de Geus, E. J.
2001-01-01
To test the validity of ambulatory heart rate (HR) assessment with a cuff ambulatory blood pressure (ABP) monitor. Cross-instrument comparison of HR measured intermittently by a cuff ABP monitor (SpaceLabs, Redmond, Washington, USA), with HR derived from continuous electrocardiogram (ECG) recordings
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Ambulatory heart rate is underestimated when measured by an ambulatory blood pressure device
Vrijkotte, T.G.M.; de Geus, E.J.C.
2001-01-01
Objective: To test the validity of ambulatory heart rate (HR) assessment with a cuff ambulatory blood pressure (ABP) monitor. Design: Cross-instrument comparison of HR measured intermittently by a cuff ABP monitor (SpaceLabs, Redmond, Washington, USA), with HR derived from continuous
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Nursing Practice in Primary Care and Patients' Experience of Care.
Borgès Da Silva, Roxane; Brault, Isabelle; Pineault, Raynald; Chouinard, Maud-Christine; Prud'homme, Alexandre; D'Amour, Danielle
2018-01-01
Nurses are identified as a key provider in the management of patients in primary care. The objective of this study was to evaluate patients' experience of care in primary care as it pertained to the nursing role. The aim was to test the hypothesis that, in primary health care organizations (PHCOs) where patients are systematically followed by a nurse, and where nursing competencies are therefore optimally used, patients' experience of care is better. Based on a cross-sectional analysis combining organizational and experience of care surveys, we built 2 groups of PHCOs. The first group of PHCOs reported having a nurse who systematically followed patients. The second group had a nurse who performed a variety of activities but did not systematically follow patients. Five indicators of care were constructed based on patient questionnaires. Bivariate and multivariate linear mixed models with random intercepts and with patients nested within were used to analyze the experience of care indicators in both groups. Bivariate analyses revealed a better patient experience of care in PHCOs where a nurse systematically followed patients than in those where a nurse performed other activities. In multivariate analyses that included adjustment variables related to PHCOs and patients, the accessibility indicator was found to be higher. Results indicated that systematic follow-up of patients by nurses improved patients' experience of care in terms of accessibility. Using nurses' scope of practice to its full potential is a promising avenue for enhancing both patients' experience of care and health services efficiency.
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[Quality Indicators of Primary Health Care Facilities in Austria].
Semlitsch, Thomas; Abuzahra, Muna; Stigler, Florian; Jeitler, Klaus; Posch, Nicole; Siebenhofer, Andrea
2017-07-11
Background The strengthening of primary health care is one major goal of the current national health reform in Austria. In this context, a new interdisciplinary concept was developed in 2014 that defines structures and requirements for future primary health care facilities. Objective The aim of this project was the development of quality indicators for the evaluation of the scheduled primary health care facilities in Austria, which are in accordance with the new Austrian concept. Methods We used the RAND/NPCRDC method for the development and selection of the quality indicators. We conducted systematic literature searches for existing measures in international databases for quality indicators as well as in bibliographic databases. All retrieved measures were evaluated and rated by an expert panel in a 2-step process regarding relevance and feasibility. Results Overall, the literature searches yielded 281 potentially relevant quality indicators, which were summarized to 65 different quality measures for primary health care. Out of these, the panel rated and accepted 30 measures as relevant and feasible for use in Austria. Five of these indicators were structure measures, 14 were process measures and the remaining 11 were outcome measures. Based on the Austrian primary health care concept, the final set of quality indicators was grouped in the 5 following domains: Access to primary health care (5), quality of care (15), continuity of care (5), coordination of care (4), and safety (1). Conclusion This set of quality measures largely covers the four defined functions of primary health care. It enables standardized evaluation of primary health care facilities in Austria regarding the implementation of the Austrian primary health care concept as well as improvement in healthcare of the population. © Georg Thieme Verlag KG Stuttgart · New York.
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Coates, Allan L; Graham, Brian L; McFadden, Robin G; McParland, Colm; Moosa, Dilshad; Provencher, Steeve; Road, Jeremy
2013-01-01
Canadian Thoracic Society (CTS) clinical guidelines for asthma and chronic obstructive pulmonary disease (COPD) specify that spirometry should be used to diagnose these diseases. Given the burden of asthma and COPD, most people with these diseases will be diagnosed in the primary care setting. The present CTS position statement was developed to provide guidance on key factors affecting the quality of spirometry testing in the primary care setting. The present statement may also be used to inform and guide the accreditation process for spirometry in each province. Although many of the principles discussed are equally applicable to pulmonary function laboratories and interpretation of tests by respirologists, they are held to a higher standard and are outside the scope of the present statement. PMID:23457669
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Improving Quality of Care in Primary Health-Care Facilities in Rural Nigeria
Ugo, Okoli; Ezinne, Eze-Ajoku; Modupe, Oludipe; Nicole, Spieker; Winifred, Ekezie; Kelechi, Ohiri
2016-01-01
Background: Nigeria has a high population density but a weak health-care system. To improve the quality of care, 3 organizations carried out a quality improvement pilot intervention at the primary health-care level in selected rural areas. Objective: To assess the change in quality of care in primary health-care facilities in rural Nigeria following the provision of technical governance support and to document the successes and challenges encountered. Method: A total of 6 states were selected...
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Care guides: an examination of occupational conflict and role relationships in primary care.
Wholey, Douglas R; White, Katie M; Adair, Richard; Christianson, Jon B; Lee, Suhna; Elumba, Deborah
2013-01-01
Improving the efficiency and effectiveness of primary care treatment of patients with chronic illness is an important goal in reforming the U.S. health care system. Reducing occupational conflicts and creating interdependent primary care teams is crucial for the effective functioning of new models being developed to reorganize chronic care. Occupational conflict, role interdependence, and resistance to change in a proof-of-concept pilot test of one such model that uses a new kind of employee in the primary care office, a "care guide," were analyzed. Care guides are lay individuals who help chronic disease patients and their providers achieve standard health goals. The aim of this study was to examine the development of occupational boundaries, interdependence of care guides and primary care team members, and acceptance by clinic employees of this new kind of health worker. A mixed methods, pilot study was conducted using qualitative analysis; clinic, provider, and patient surveys; administrative data; and multivariate analysis. Qualitative analysis examined the emergence of the care guide role. Administrative data and surveys were used to examine patterns of interdependence between care guides, physicians, team members, and clinic staff; obtain physician evaluations of the care guide role; and evaluate the effect of care guides on patient perceptions of care coordination and follow-up. Evaluation of implementation of the care guide model showed that (a) the care guide scope of practice was clearly defined; (b) interdependent relationships between care guides and providers were formed; (c) relational triads consisting of patient, care guide, and physician were created; (d) patients and providers were supported in managing chronic disease; and (e) resistance to this model among traditional employees was minimized. The feasibility of implementing a new care model for chronic disease management in the primary care setting, identifying factors associated with a positive
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Measuring progress towards a primary care-led NHS.
Miller, P; Craig, N; Scott, A; Walker, A; Hanlon, P
1999-07-01
The push towards a 'primary care-led' National Health Service (NHS) has far-reaching implications for the future structure of the NHS. The policy involves both a growing emphasis on the role of primary care practitioners in the commissioning of health services, and a change from hospital to primary and community settings for a range of services and procedures. Although the terminology has changed, this emphasis remains in the recent Scottish Health Service White Paper and its English counterpart. To consider three questions in relation to this policy goal. First, does the evidence base support the changes? Secondly, what is the scale of the changes that have occurred? Thirdly, what are the barriers to the development of a primary care-led NHS? Programme budgets were compiled to assess changes over time in the balance of NHS resource allocation with respect to primary and secondary care. Total NHS revenue expenditure for the 15 Scottish health boards was grouped into four blocks or 'programmes': primary care, secondary care, community services, and a residual. The study period was 1991/2 to 1995/6. Expenditure data were supplied by the Scottish Office. Ambiguity of definitions and the absence of good data cause methodological difficulties in evaluating the scale and the appropriateness of the shift. The data that are available suggest that, at the aggregate level, there have been changes over time in the balance of resource allocation between care settings: relative investment into primary care has increased. It would appear that this investment is relatively small and from growth money rather than a 'shift' from secondary care. In addition, the impact of GP-led commissioning is variable but limited. General practitioners' (GPs') attitudes to the policy suggest that progress towards a primary care-led NHS will continue to be patchy. The limited shift to date, alongside evidence of ambivalent attitudes to the shift on the part of GPs, suggest that this is a policy
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Ambulatory Care after Acute Kidney Injury: An Opportunity to Improve Patient Outcomes
Directory of Open Access Journals (Sweden)
Samuel A. Silver
2015-10-01
Full Text Available Purpose of review: Acute kidney injury (AKI is an increasingly common problem among hospitalized patients. Patients who survive an AKI-associated hospitalization are at higher risk of de novo and worsening chronic kidney disease, end-stage kidney disease, cardiovascular disease, and death. For hospitalized patients with dialysis-requiring AKI, outpatient follow-up with a nephrologist within 90 days of hospital discharge has been associated with enhanced survival. However, most patients who survive an AKI episode do not receive any follow-up nephrology care. This narrative review describes the experience of two new clinical programs to care for AKI patients after hospital discharge: the Acute Kidney Injury Follow-up Clinic for adults (St. Michael's Hospital and University Health Network, Toronto, Canada and the AKI Survivor Clinic for children (Cincinnati Children's Hospital, USA. Sources of information: MEDLINE, PubMed, ISI Web of Science Findings: These two ambulatory clinics have been in existence for close to two (adult and four (pediatric years, and were developed separately and independently in different populations and health systems. The components of both clinics are described, including the target population, referral process, medical interventions, patient education activities, and follow-up schedule. Common elements include targeting patients with KDIGO stage 2 or 3 AKI, regular audits of the inpatient nephrology census to track eligible patients, medication reconciliation, and education on the long-term consequences of AKI. Limitations: Despite the theoretical benefits of post-AKI follow-up and the clinic components described, there is no high quality evidence to prove that the interventions implemented in these clinics will reduce morbidity or mortality. Therefore, we also present a plan to evaluate the adult AKI Follow-up Clinic in order to determine if it can improve clinical outcomes compared to patients with AKI who do not
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Journal of Community Medicine and Primary Health Care
African Journals Online (AJOL)
Journal of Community Medicine and Primary Health Care. ... environmental health, clinical care, health planning and management, health policy, health ... non-communicable diseases within the Primary Health Care system in the Federal ... Assessment of occupational hazards, health problems and safety practices of petrol ...
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Tan, Lee; Carr, Julia; Reidy, Johanna
2012-03-30
This paper provides New Zealand evidence on the effectiveness of primary care investment, measured through the Capital and Coast District Health Board's (DHB) Primary Health Care Framework. The Framework was developed in 2002/2003 to guide funding decisions at a DHB level, and to provide a transparent basis for evaluation of the implementation of the Primary Health Care Strategy in this district. The Framework used a mixed method approach; analysis was based on quantitative and qualitative data. This article demonstrates the link between investment in primary health care, increased access to primary care for high-need populations, workforce redistribution, and improved health outcomes. Over the study period, ambulatory sensitive hospitalisations and emergency department use reduced for enrolled populations and the District's immunisation coverage improved markedly. Funding and contracting which enhanced both 'mainstream' and 'niche' providers combined with community-based health initiatives resulted in a measurable impact on a range of health indicators and inequalities. Maori primary care providers improved access for Maori but also for their enrolled populations of Pacific and Other ethnicity. Growth and redistribution of primary care workforce was observed, improving the availability of general practitioners, nurses, and community workers in poorer communities.
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Medical Assistant-based care management for high risk patients in small primary care practices
DEFF Research Database (Denmark)
Freund, Tobias; Peters-Klimm, Frank; Boyd, Cynthia M.
2016-01-01
Background: Patients with multiple chronic conditions are at high risk of potentially avoidable hospital admissions, which may be reduced by care coordination and self-management support. Medical assistants are an increasingly available resource for patient care in primary care practices. Objective......: To determine whether protocol-based care management delivered by medical assistants improves patient care in patients at high risk of future hospitalization in primary care. Design: Two-year cluster randomized clinical trial. Setting: 115 primary care practices in Germany. Patients: 2,076 patients with type 2......, and monitoring delivered by medical assistants with usual care. Measurements: All-cause hospitalizations at 12 months (primary outcome) and quality of life scores (Short Form 12 Health Questionnaire [SF-12] and the Euroqol instrument [EQ-5D]). Results: Included patients had, on average, four co-occurring chronic...
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Koslov, Steven; Trowbridge, Elizabeth; Kamnetz, Sandra; Kraft, Sally; Grossman, Jeffrey; Pandhi, Nancy
2016-09-01
Primary care is considered the foundation of an effective health care system. However, primary care departments at academic health centers have numerous challenges to overcome when trying to achieve the Triple Aim. As part of an organizational initiative to redesign primary care at a large academic health center, departments of internal medicine, general pediatrics and adolescent medicine, and family medicine worked together to comprehensively redesign primary care. This article describes the process of aligning these three primary care departments: defining panel size, developing a common primary care job description, redesigning the primary care compensation plan, redesigning the care model, and developing standardized staffing. Prior to the initiative, the rate of patient satisfaction was 85%, anticoagulation measurement 65%, pneumococcal vaccination 85%, breast cancer screening 79%, and colorectal cancer screening 69%. These rates all improved to 87%, 75%, 88%, 80%, and 80% respectively. Themes around key challenges to departmental integration are identified: (1) implementing effective communication strategies; (2) addressing specialty differences in primary care delivery; (3) working within resource limitations; and (4) developing long-term sustainability. Primary care in this large academic health center was transformed through developing a united primary care leadership team that bridged individual departments to create and adopt a common vision and solutions to shared problems. Our collaboration has achieved improvements across patient satisfaction, clinical safety metrics, and publicly-reported preventive care outcomes. The description of this experience may be useful for other academic health centers or other non-integrated delivery systems undertaking primary care practice transformation. Copyright © 2015 Elsevier Inc. All rights reserved.
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The myth of standardized workflow in primary care.
Holman, G Talley; Beasley, John W; Karsh, Ben-Tzion; Stone, Jamie A; Smith, Paul D; Wetterneck, Tosha B
2016-01-01
Primary care efficiency and quality are essential for the nation's health. The demands on primary care physicians (PCPs) are increasing as healthcare becomes more complex. A more complete understanding of PCP workflow variation is needed to guide future healthcare redesigns. This analysis evaluates workflow variation in terms of the sequence of tasks performed during patient visits. Two patient visits from 10 PCPs from 10 different United States Midwestern primary care clinics were analyzed to determine physician workflow. Tasks and the progressive sequence of those tasks were observed, documented, and coded by task category using a PCP task list. Variations in the sequence and prevalence of tasks at each stage of the primary care visit were assessed considering the physician, the patient, the visit's progression, and the presence of an electronic health record (EHR) at the clinic. PCP workflow during patient visits varies significantly, even for an individual physician, with no single or even common workflow pattern being present. The prevalence of specific tasks shifts significantly as primary care visits progress to their conclusion but, notably, PCPs collect patient information throughout the visit. PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a "dance" between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice. Future healthcare redesigns should support a wide variety of task sequences to deliver high-quality primary care. The development of tools such as electronic health records must be based on the realities of primary care visits if they are to successfully support a PCP's mental and physical work, resulting in effective, safe, and efficient primary care. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
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Carel, R S
1982-04-01
The cost-effectiveness of a computerized ECG interpretation system in an ambulatory health care organization has been evaluated in comparison with a conventional (manual) system. The automated system was shown to be more cost-effective at a minimum load of 2,500 patients/month. At larger monthly loads an even greater cost-effectiveness was found, the average cost/ECG being about $2. In the manual system the cost/unit is practically independent of patient load. This is primarily due to the fact that 87% of the cost/ECG is attributable to wages and fees of highly trained personnel. In the automated system, on the other hand, the cost/ECG is heavily dependent on examinee load. This is due to the relatively large impact of equipment depreciation on fixed (and total) cost. Utilization of a computer-assisted system leads to marked reduction in cardiologists' interpretation time, substantially shorter turnaround time (of unconfirmed reports), and potential provision of simultaneous service at several remotely located "heart stations."
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Environmental factors associated with primary care access among urban older adults.
Ryvicker, Miriam; Gallo, William T; Fahs, Marianne C
2012-09-01
Disparities in primary care access and quality impede optimal chronic illness prevention and management for older adults. Although research has shown associations between neighborhood attributes and health, little is known about how these factors - in particular, the primary care infrastructure - inform older adults' primary care use. Using geographic data on primary care physician supply and surveys from 1260 senior center attendees in New York City, we examined factors that facilitate and hinder primary care use for individuals living in service areas with different supply levels. Supply quartiles varied in primary care use (visit within the past 12 months), racial and socio-economic composition, and perceived neighborhood safety and social cohesion. Primary care use did not differ significantly after controlling for compositional factors. Individuals who used a community clinic or hospital outpatient department for most of their care were less likely to have had a primary care visit than those who used a private doctor's office. Stratified multivariate models showed that within the lowest-supply quartile, public transit users had a higher odds of primary care use than non-transit users. Moreover, a higher score on the perceived neighborhood social cohesion scale was associated with a higher odds of primary care use. Within the second-lowest quartile, nonwhites had a lower odds of primary care use compared to whites. Different patterns of disadvantage in primary care access exist that may be associated with - but not fully explained by - local primary care supply. In lower-supply areas, racial disparities and inadequate primary care infrastructure hinder access to care. However, accessibility and elder-friendliness of public transit, as well as efforts to improve social cohesion and support, may facilitate primary care access for individuals living in low-supply areas. Copyright © 2012 Elsevier Ltd. All rights reserved.
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Models for Primary Eye Care Services in India
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Vasundhra Misra
2015-01-01
In the current situation, an integrated health care system with primary eye care promoted by government of India is apparently the best answer. This model is both cost effective and practical for the prevention and control of blindness among the underprivileged population. Other models functioning with the newer technology of tele-ophthalmology or mobile clinics also add to the positive outcome in providing primary eye care services. This review highlights the strengths and weaknesses of various models presently functioning in the country with the idea of providing useful inputs for eye care providers and enabling them to identify and adopt an appropriate model for primary eye care services.
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National Ambulatory Antibiotic Prescribing Patterns for Pediatric Urinary Tract Infection, 1998–2007
Shapiro, Daniel J.; Hersh, Adam L.
2011-01-01
OBJECTIVE: The goal of this study was to investigate patterns of ambulatory antibiotic use and to identify factors associated with broad-spectrum antibiotic prescribing for pediatric urinary tract infections (UTIs). METHODS: We examined antibiotics prescribed for UTIs for children aged younger than 18 years from 1998 to 2007 using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Amoxicillin-clavulanate, quinolones, macrolides, and second- and third-generation cephalosporins were classified as broad-spectrum antibiotics. We evaluated trends in broad-spectrum antibiotic prescribing patterns and performed multivariable logistic regression to identify factors associated with broad-spectrum antibiotic use. RESULTS: Antibiotics were prescribed for 70% of pediatric UTI visits. Trimethoprim-sulfamethoxazole was the most commonly prescribed antibiotic (49% of visits). Broad-spectrum antibiotics were prescribed one third of the time. There was no increase in overall use of broad-spectrum antibiotics (P = .67); however, third-generation cephalosporin use doubled from 12% to 25% (P = .02). Children younger than 2 years old (odds ratio: 6.4 [95% confidence interval: 2.2–18.7, compared with children 13–17 years old]), females (odds ratio: 3.6 [95% confidence interval: 1.6–8.5]), and temperature ≥100.4°F (odds ratio: 2.9 [95% confidence interval: 1.0–8.6]) were independent predictors of broad-spectrum antibiotic prescribing. Race, physician specialty, region, and insurance status were not associated with antibiotic selection. CONCLUSIONS: Ambulatory care physicians commonly prescribe broad-spectrum antibiotics for the treatment of pediatric UTIs, especially for febrile infants in whom complicated infections are more likely. The doubling in use of third-generation cephalosporins suggests that opportunities exist to promote more judicious antibiotic prescribing because most pediatric UTIs are susceptible to narrower
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Directory of Open Access Journals (Sweden)
Anwar Dudekula
Full Text Available Nonalcoholic fatty liver disease (NALFD is a leading cause of liver disease. Weight loss improves clinical features of NAFLD; however, maintenance of weight loss outside of investigational protocols is poor. The goals of this study were to characterize patterns and clinical predictors of long-term weight loss in ambulatory patients with NAFLD.We retrospectively reviewed 924 non-cirrhotic patients with NAFLD presenting to a liver clinic from May 1st 2007 to April 30th 2013. Overweight and obese patients were counseled on lifestyle modifications for weight loss as per USPSTF guidelines. The primary outcome was percent weight change between the first and last recorded visits: % weight change = (weightinitial - weightfinal/(weightinitial. Baseline BMI and percent BMI change were secondary measures. Predictors of weight loss were determined using logistic regression.The mean baseline BMI was 33.3±6.6 kg/m2, and the mean follow-up duration was 17.3±17.6 months. Most patients with NAFLD were in either overweight (26.1% or class I obesity (30.5% categories at baseline, while the prevalence of underweight and class III obesity was lower (0.2% and 15.4%, respectively. Overall, there was no change in mean weight or BMI during the follow-up period, and only 183 patients (19.8% lost at least 5% body weight during the follow up period. Independent predictors of weight loss included number of clinic visits and baseline BMI, and patients with higher baseline BMI required more clinic visits to lose weight.Weight loss is largely unsuccessful in NAFLD patients in the ambulatory care setting. Frequent clinical encounters are associated with weight reduction, especially among individuals with high baseline BMI. Future studies are required to define effective weight loss strategies in NAFLD patients.
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Nathan, Lisa M.; Shi, Quihu; Plewniak, Kari; Zhang, Charles; Nsabimana, Damien; Sklar, Marc; Mutimura, Eugene; Merkatz, Irwin R.; Einstein, Mark H.; Anastos, Kathryn
2015-01-01
To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of ≥3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB (p = 0.007), however distance lived to ANC site did not predict ≥3 ANC visits (p = 0.81). Neither decentralization of ambulatory reproductive healthcare (p = 0.10) nor intrapartum care (p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive ≥3 ANC visits (p < 0.001). Receiving <3 ANC visits was associated with a 3.98 times greater odds of not having SAB (p = 0.001). No increase in adverse outcomes was found with decentralization of ambulatory reproductive health care or intrapartum care. The factors that predict utilization of physically accessible services in rural Africa are complex. Decentralization of services may be one strategy to increase rates of SAB and ANC utilization, but selection biases may have precluded accurate analysis. Efforts to increase ANC utilization may be a worthwhile investment to increase SAB. PMID:25652061
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Primary care performance in Dominica
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James Macinko
2015-02-01
Full Text Available Objective. To document the structure and functions of primary care (PC in the country of Dominica using the Primary Care Assessment Tools (PCAT, a set of questionnaires that evaluate PC functions. Methods. This cross-sectional study combined data from two surveys. The systems PCAT (S-PCAT survey gathered national-level data from key informants about health system characteristics and PC performance. The provider version (P-PCAT survey collected data on PC performance from health providers (nurses and physicians at all PC facilities in the country. Provider-level data were aggregated to obtain national and district-level results for PC domains scored from 0.00 (worst to 1.00 (best. Results. From the systems perspective, results showed several knowledge gaps in PC policy, financing, and structure. Key informants gave “Good” (adequate ratings for “first-contact” care (0.74, continuity of care (0.77, comprehensive care (0.70, and coordinated care (0.78; middling scores for family-centered care and community-oriented care (0.65; and low scores for access to care (0.57. PC providers assessed access to care (which included “first-contact” care, in the P-PCAT surveys (0.84, continuity of care (0.86, information systems (0.84, family-centered care (0.92, and community-oriented care (0.85 as “Very Good”; comprehensive care as “Good” (0.79; and coordinated care as “Reasonable” (0.68. Overall, the scores for the country's health districts were good, although the ratings varied by specific PC domain. Conclusions. The assessments described here were carried out with relatively little expense and have provided important inputs into strategic planning, strategies for improving PC, and identification of priority areas for further investigation. This two-staged approach could be adapted and used in other countries.
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Taking Innovation To Scale In Primary Care Practices: The Functions Of Health Care Extension
Ono, Sarah S.; Crabtree, Benjamin F.; Hemler, Jennifer R.; Balasubramanian, Bijal A.; Edwards, Samuel T.; Green, Larry A.; Kaufman, Arthur; Solberg, Leif I.; Miller, William L.; Woodson, Tanisha Tate; Sweeney, Shannon M.; Cohen, Deborah J.
2018-01-01
Health care extension is an approach to providing external support to primary care practices with the aim of diffusing innovation. EvidenceNOW was launched to rapidly disseminate and implement evidence-based guidelines for cardiovascular preventive care in the primary care setting. Seven regional grantee cooperatives provided the foundational elements of health care extension—technological and quality improvement support, practice capacity building, and linking with community resources—to more than two hundred primary care practices in each region. This article describes how the cooperatives varied in their approaches to extension and provides early empirical evidence that health care extension is a feasible and potentially useful approach for providing quality improvement support to primary care practices. With investment, health care extension may be an effective platform for federal and state quality improvement efforts to create economies of scale and provide practices with more robust and coordinated support services. PMID:29401016
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Kipp, Ryan; Young, Natasha; Barnett, Anne; Kopp, Douglas; Leal, Miguel A; Eckhardt, Lee L; Teelin, Thomas; Hoffmayer, Kurt S; Wright, Jennifer; Field, Michael
2017-09-01
Implantable loop recorder (ILR) insertion has historically been performed in a surgical environment such as the electrophysiology (EP) lab. The newest generation loop recorder (Medtronic Reveal LINQ™, Minneapolis, MN, USA) is injectable with potential for implantation in a non-EP lab setting by advanced practice providers (APPs) facilitating improved workflow and resource utilization. We report the safety and efficacy of injectable ILR placement in the ambulatory care setting by APPs. A retrospective review was performed including all patients referred for injectable ILR placement from March 2014 to November 2015. All device placement procedures were performed in an ambulatory care setting using the standard manufacturer deployment kit with sterile technique and local anesthetic following a single dose of intravenous antibiotics. Acute procedural success and complication rates following injectable ILR placement in the ambulatory setting were reviewed. During the study period, 125 injectable ILRs were implanted. Acute procedural success with adequate sensing (R-waves ≥ 0.2 mV) occurred in 100% of patients. There were no acute procedural complications. Subacute complications occurred in two patients (1.6% of implantations), including one possible infection treated with oral antibiotics and one device removal due to pain at the implant site. In this retrospective single-center study, implantation of injectable ILR in an ambulatory care setting by APPs following a single dose of intravenous antibiotics and standard manufacturer technique yielded a low complication rate with high acute procedural success. Use of this implantation strategy may improve EP lab workflow while providing a safe and effective technique for device placement. © 2017 Wiley Periodicals, Inc.
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Directory of Open Access Journals (Sweden)
Liddy Clare
2009-06-01
Full Text Available Abstract Background The growing prevalence of diabetes and heightened awareness of the benefits of early and intensive disease management have increased service demands and expectations not only of primary care physicians but also of diabetes specialists. While research has addressed issues related to referral into specialist care, much less has been published about the transition from diabetes specialists back to primary care. Understanding the concerns of family physicians related to discharge of diabetes care from specialist centers can support the development of strategies that facilitate this transition and result in broader access to limited specialist services. This study was undertaken to explore primary care physician (PCP perspectives and concerns related to reassuming responsibility for diabetes care after referral to a specialized diabetes center. Methods Qualitative data were collected through three focus groups. Sessions were audio-taped and transcribed verbatim. Data were coded and sorted with themes identified using a constant comparison method. The study was undertaken through the regional academic referral center for adult diabetes care in Ottawa, Canada. Participants included 22 primary care physicians representing a variety of referral frequencies, practice types and settings. Results Participants described facilitators and barriers to successful transition of diabetes care at the provider, patient and systems level. Major facilitators included clear communication of a detailed, structured plan of care, ongoing access to specialist services for advice or re-referral, continuing education and mentoring for PCPs. Identified provider barriers were gaps in PCP knowledge and confidence related to diabetes treatment, excessive workload and competing time demands. Systems deterrents included reimbursement policies for health professionals and inadequate funding for diabetes medications and supplies. At the PCP-patient interface
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Freed, Christopher R; Hansberry, Shantisha T; Arrieta, Martha I
2013-09-01
To examine a local primary health care infrastructure and the reality of primary health care from the perspective of residents of a small, urban community in the southern United States. Data derive from 13 semi-structured focus groups, plus three semi-structured interviews, and were analyzed inductively consistent with a grounded theory approach. Structural barriers to the local primary health care infrastructure include transportation, clinic and appointment wait time, and co-payments and health insurance. Hidden barriers consist of knowledge about local health care services, non-physician gatekeepers, and fear of medical care. Community residents have used home remedies and the emergency department at the local academic medical center to manage these structural and hidden barriers. Findings might not generalize to primary health care infrastructures in other communities, respondent perspectives can be biased, and the data are subject to various interpretations and conceptual and thematic frameworks. Nevertheless, the structural and hidden barriers to the local primary health care infrastructure have considerably diminished the autonomy community residents have been able to exercise over their decisions about primary health care, ultimately suggesting that efforts concerned with increasing the access of medically underserved groups to primary health care in local communities should recognize the centrality and significance of power. This study addresses a gap in the sociological literature regarding the impact of specific barriers to primary health care among medically underserved groups.
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The Influence of Ambulatory Aid on Lower-Extremity Muscle Activation During Gait.
Sanders, Michael; Bowden, Anton E; Baker, Spencer; Jensen, Ryan; Nichols, McKenzie; Seeley, Matthew K
2018-05-10
Foot and ankle injuries are common and often require a nonweight-bearing period of immobilization for the involved leg. This nonweight-bearing period usually results in muscle atrophy for the involved leg. There is a dearth of objective data describing muscle activation for different ambulatory aids that are used during the aforementioned nonweight-bearing period. To compare activation amplitudes for 4 leg muscles during (1) able-bodied gait and (2) ambulation involving 3 different ambulatory aids that can be used during the acute phase of foot and ankle injury care. Within-subject, repeated measures. University biomechanics laboratory. Sixteen able-bodied individuals (7 females and 9 males). Each participant performed able-bodied gait and ambulation using 3 different ambulatory aids (traditional axillary crutches, knee scooter, and a novel lower-leg prosthesis). Muscle activation amplitude quantified via mean surface electromyography amplitude throughout the stance phase of ambulation. Numerous statistical differences (P < .05) existed for muscle activation amplitude between the 4 observed muscles, 3 ambulatory aids, and able-bodied gait. For the involved leg, comparing the 3 ambulatory aids: (1) knee scooter ambulation resulted in the greatest vastus lateralis activation, (2) ambulation using the novel prosthesis and traditional crutches resulted in greater biceps femoris activation than knee scooter ambulation, and (3) ambulation using the novel prosthesis resulted in the greatest gastrocnemius activation (P < .05). Generally speaking, muscle activation amplitudes were most similar to able-bodied gait when subjects were ambulating using the knee scooter or novel prosthesis. Type of ambulatory aid influences muscle activation amplitude. Traditional axillary crutches appear to be less likely to mitigate muscle atrophy during the nonweighting, immobilization period that often follows foot or ankle injuries. Researchers and clinicians should consider
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DSM-IV hypochondriasis in primary care.
Escobar, J I; Gara, M; Waitzkin, H; Silver, R C; Holman, A; Compton, W
1998-05-01
The object of this study was to assess the prevalence and correlates of the DSM-IV diagnosis of hypochondriasis in a primary care setting. A large sample (N = 1456) of primary care users was given a structured interview to make diagnoses of mood, anxiety, and somatoform disorders and estimate levels of disability. The prevalence of hypochondriasis (DSM-IV) was about 3%. Patients with this disorder had higher levels of medically unexplained symptoms (abridged somatization) and were more impaired in their physical functioning than patients without the disorder. Of the various psychopathologies examined, major depressive syndromes were the most frequent among patients with hypochondriasis. Interestingly, unlike somatization disorder, hypochondriasis was not related to any demographic factor. Hypochondriasis is a relatively rare condition in primary care that is largely separable from somatization disorder but seems closely intertwined with the more severe depressive syndromes.
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Rauenzahn, Sherri L; Schmidt, Susanne; Aduba, Ifeoma O; Jones, Jessica T; Ali, Nazneen; Tenner, Laura L
2017-04-01
Research in palliative care demonstrates improvements in overall survival, quality of life, symptom management, and reductions in the cost of care. Despite the American Society of Clinical Oncology recommendation for early concurrent palliative care in patients with advanced cancer and high symptom burden, integrating palliative services is challenging. Our aims were to quantitatively describe the palliative referral rates and symptom burden in a South Texas cancer center and establish a palliative referral system by implementing the Edmonton Symptom Assessment Scale (ESAS). As part of our Plan-Do-Study-Act process, all staff received an educational overview of the ESAS tool and consultation ordering process. The ESAS form was then implemented across five ambulatory oncology clinics to assess symptom burden and changes therein longitudinally. Referral rates and symptom assessment scores were tracked as metrics for quality improvement. On average, one patient per month was referred before implementation of the intervention compared with 10 patients per month after implementation across all clinics. In five sample clinics, 607 patients completed the initial assessment, and 430 follow-up forms were collected over 5 months, resulting in a total of 1,037 scores collected in REDCap. The mean ESAS score for initial patient visits was 20.0 (standard deviation, 18.1), and referred patients had an initial mean score of 39.0 (standard deviation, 19.0). This project highlights the low palliative care consultation rate, high symptom burden of oncology patients, and underuse of services by oncologists despite improvements with the introduction of a symptom assessment form and referral system.
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Reinventing your primary care practice: becoming an MDCEO™
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Conard SE
2013-03-01
Full Text Available Scott E Conard,1 Maureen Reni Courtney21ACAP Health, Dallas, 2College of Nursing, University of Texas, Arlington, TX, USAAbstract: Primary care medicine in the United States is undergoing a revolutionary shift. Primary care providers and their staff have an extraordinary chance to create and participate in exciting new approaches to care. New strategies will require courage, flexibility, and openness to change by every member of the practice team, especially the lead clinician who is most often the physician, but can also be the nurse practitioner or physician's assistant. Providers must first recognize their need to alter their fundamental identity to incorporate a new kind of leadership role—that of the MDCEO™ (i.e., the individual clinician who leads the practice to ensure that quality, service, and financial systems are developed and effectively managed. This paper provides a practical vision and rationale for the required transition in primary care, pointing the way for how to achieve new practice effectiveness through new leadership roles. It also provides a model to evaluate the status of a primary care practice. The authors have extensive experience in working with primary care providers to radically evolve their clinical practices to become MDCEOs™. The MDCEO™ will articulate the vision and strategy for the practice, define and foster the practice culture, and create and facilitate team development and overall high level functioning. Each member of the team can then begin to lead their part of the practice: a 21st century population-oriented, purpose-based practice resulting in increased quality of care, improved patient outcomes, greater financial success, and enhanced peace of mind.Keywords: primary health care organization and administration, health care reform, leadership, patient-centered care
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Wysong, Ashley; Linos, Eleni; Hernandez-Boussard, Tina; Arron, Sarah T; Gladstone, Hayes; Tang, Jean Y
2013-04-01
The rising incidence of nonmelanoma skin cancer (NMSC) is well documented, but data are limited on the number of visits and treatment patterns of NMSC in the outpatient setting. To evaluate practice and treatment patterns of NMSC in the United States over the last decade and to characterize differences according to sex, age, race, insurance type, and physician specialty. Adults with an International Classification of Diseases, Ninth Revision, diagnosis of NMSC were included in this cross-sectional survey study of the National Ambulatory Medical Care Survey between 1995 and 2007. Primary outcomes included population-adjusted NMSC visit rates and odds ratios of receiving a procedure for NMSC using logistic regression. Rates of NMSC visits increased between 1995 and 2007. The number of visits was significantly higher in men, particularly those aged 65 and older. Fifty-nine percent of NMSC visits were associated with a procedure, and the individuals associated with that visit were more likely to be male, to be seen by a dermatologist, and to have private-pay insurance. Nonmelanoma skin cancer visit rates increased from 1995 to 2007 and were higher in men than women. Visits to a dermatologist are more likely to be associated with a procedure for NMSC, and there may be discrepancies in treatment patterns based on insurance type and sex. © 2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.
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Francis, Nick A; Ridd, Matthew J; Thomas-Jones, Emma; Butler, Christopher C; Hood, Kerenza; Shepherd, Victoria; Marwick, Charis A; Huang, Chao; Longo, Mirella; Wootton, Mandy; Sullivan, Frank
2017-03-01
Eczema may flare because of bacterial infection, but evidence supporting antibiotic treatment is of low quality. We aimed to determine the effect of oral and topical antibiotics in addition to topical emollient and corticosteroids in children with clinically infected eczema. We employed a 3-arm, blinded, randomized controlled trial in UK ambulatory care. Children with clinical, non-severely infected eczema were randomized to receive oral and topical placebos (control), oral antibiotic (flucloxacillin) and topical placebo, or topical antibiotic (fusidic acid) and oral placebo, for 1 week. We compared Patient Oriented Eczema Measure (POEM) scores at 2 weeks using analysis of covariance (ANCOVA). We randomized 113 children (40 to control, 36 to oral antibiotic, and 37 to topical antibiotic). Mean (SD) baseline Patient Oriented Eczema Measure scores were 13.4 (5.1) for the control group, 14.6 (5.3) for the oral antibiotic group, and 16.9 (5.5) for the topical antibiotic group. At baseline, 104 children (93%) had 1 or more of the following findings: weeping, crusting, pustules, or painful skin. Mean (SD) POEM scores at 2 weeks were 6.2 (6.0) for control, 8.3 (7.3) for the oral antibiotic group, and 9.3 (6.2) for the topical antibiotic group. Controlling for baseline POEM score, neither oral nor topical antibiotics produced a significant difference in mean (95% CI) POEM scores (1.5 [-1.4 to 4.4] and 1.5 [-1.6 to 4.5] respectively). There were no significant differences in adverse effects and no serious adverse events. We found rapid resolution in response to topical steroid and emollient treatment and ruled out a clinically meaningful benefit from the addition of either oral or topical antibiotics. Children seen in ambulatory care with mild clinically infected eczema do not need treatment with antibiotics. © 2017 Annals of Family Medicine, Inc.
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Team-based primary care: The medical assistant perspective.
Sheridan, Bethany; Chien, Alyna T; Peters, Antoinette S; Rosenthal, Meredith B; Brooks, Joanna Veazey; Singer, Sara J
Team-based care has the potential to improve primary care quality and efficiency. In this model, medical assistants (MAs) take a more central role in patient care and population health management. MAs' traditionally low status may give them a unique view on changing organizational dynamics and teamwork. However, little empirical work exists on how team-based organizational designs affect the experiences of low-status health care workers like MAs. The aim of this study was to describe how team-based primary care affects the experiences of MAs. A secondary aim was to explore variation in these experiences. In late 2014, the authors interviewed 30 MAs from nine primary care practices transitioning to team-based care. Interviews addressed job responsibilities, teamwork, implementation, job satisfaction, and learning. Data were analyzed using a thematic networks approach. Interviews also included closed-ended questions about workload and job satisfaction. Most MAs reported both a higher workload (73%) and a greater job satisfaction (86%) under team-based primary care. Interview data surfaced four mechanisms for these results, which suggested more fulfilling work and greater respect for the MA role: (a) relationships with colleagues, (b) involvement with patients, (c) sense of control, and (d) sense of efficacy. Facilitators and barriers to these positive changes also emerged. Team-based care can provide low-status health care workers with more fulfilling work and strengthen relationships across status lines. The extent of this positive impact may depend on supporting factors at the organization, team, and individual worker levels. To maximize the benefits of team-based care, primary care leaders should recognize the larger role that MAs play under this model and support them as increasingly valuable team members. Contingent on organizational conditions, practices may find MAs who are willing to manage the increased workload that often accompanies team-based care.
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Care interrupted: Poverty, in-migration, and primary care in rural resource towns.
Rice, Kathleen; Webster, Fiona
2017-10-01
Internationally, rural people have poorer health outcomes relative to their urban counterparts, and primary care providers face particular challenges in rural and remote regions. Drawing on ethnographic fieldnotes and 14 open-ended qualitative interviews with care providers and chronic pain patients in two remote resource communities in Northern Ontario, Canada, this article examines the challenges involved in providing and receiving primary care for complex chronic conditions in these communities. Both towns struggle with high unemployment in the aftermath of industry closure, and are characterized by an abundance of affordable housing. Many of the challenges that care providers face and that patients experience are well-documented in Canadian and international literature on rural and remote health, and health care in resource towns (e.g. lack of specialized care, difficulty with recruitment and retention of care providers, heavy workload for existing care providers). However, our study also documents the recent in-migration of low-income, largely working-age people with complex chronic conditions who are drawn to the region by the low cost of housing. We discuss the ways in which the needs of these in-migrants compound existing challenges to rural primary care provision. To our knowledge, our study is the first to document both this migration trend, and the implications of this for primary care. In the interest of patient health and care provider well-being, existing health and social services will likely need to be expanded to meet the needs of these in-migrants. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.
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Comparing Homeless Persons’ Care Experiences in Tailored Versus Nontailored Primary Care Programs
Holt, Cheryl L.; Steward, Jocelyn L.; Jones, Richard N.; Roth, David L.; Stringfellow, Erin; Gordon, Adam J.; Kim, Theresa W.; Austin, Erika L.; Henry, Stephen Randal; Kay Johnson, N.; Shanette Granstaff, U.; O’Connell, James J.; Golden, Joya F.; Young, Alexander S.; Davis, Lori L.; Pollio, David E.
2013-01-01
Objectives. We compared homeless patients’ experiences of care in health care organizations that differed in their degree of primary care design service tailoring. Methods. We surveyed homeless-experienced patients (either recently or currently homeless) at 3 Veterans Affairs (VA) mainstream primary care settings in Pennsylvania and Alabama, a homeless-tailored VA clinic in California, and a highly tailored non-VA Health Care for the Homeless Program in Massachusetts (January 2011-March 2012). We developed a survey, the “Primary Care Quality-Homeless Survey," to reflect the concerns and aspirations of homeless patients. Results. Mean scores at the tailored non-VA site were superior to those from the 3 mainstream VA sites (P < .001). Adjusting for patient characteristics, these differences remained significant for subscales assessing the patient–clinician relationship (P < .001) and perceptions of cooperation among providers (P = .004). There were 1.5- to 3-fold increased odds of an unfavorable experience in the domains of the patient–clinician relationship, cooperation, and access or coordination for the mainstream VA sites compared with the tailored non-VA site; the tailored VA site attained intermediate results. Conclusions. Tailored primary care service design was associated with a superior service experience for patients who experienced homelessness. PMID:24148052
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DEFF Research Database (Denmark)
Thomsen, Linda Aagaard; Winterstein, Almut G; Søndergaard, Birthe
2007-01-01
studies, health services research, and follow-up studies. Additional articles were found in the reference sections of retrieved articles. STUDY SELECTION AND DATA EXTRACTION: Peer-reviewed articles assessing pADEs in ambulatory care, with detailed descriptions/frequency distributions of (1) ADE....../pADE incidence, (2) clinical outcomes, (3) associated drug groups, and/or (4) underlying medication errors were included. Study country, year and design, sample size, follow-up time, ADE/pADE identification method, proportion of ADEs/pADEs and ADEs/pADEs requiring hospital admission, and frequency distribution......-months, and the pADE incidence was 5.6 per 1000 person-months (1.1-10.1). The median ADE preventability rate was 21% (11-38%). The median incidence of ADEs requiring hospital admission was 0.45 (0.10-13.1) per 1000 person-months, and the median incidence of pADEs requiring hospital admission was 4.5 per 1000 person...
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Embracing a diversified future for US primary care.
Hoff, Timothy
2013-01-01
Although less focused upon given the current emphasis on the patient-centered medical home innovation, the future for US primary care is arguably one that will be characterized by diversity in service delivery structures and personnel. The drivers of this diversity include increased patient demand requiring a larger number of primary care access points; the need for lower-cost delivery structures that can flourish in a low-margin business model; greater interest in primary care delivery by retailers and hospitals that see their involvement as a means to enhance their core business goals; the increased desire by non-physician providers to gain work independence; and a growing cadre of younger PCPs whose career and job preferences leave them open to working in a variety of different settings and structures. A key issue to ask of a more diversified primary care system is whether or not it will be characterized by competition or cooperation. While a competitive system would not be unexpected given historical and current trends, such a system would likely stunt the prospects for a full revitalization of US primary care. However, there is reason to believe that a cooperative system is possible and would be advantageous, given the mutual dependencies that already exist among primary care stakeholders, and additional steps that could be taken to enhance such dependencies even more into the future.
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Work-Related Depression in Primary Care Teams in Brazil.
da Silva, Andréa Tenório Correia; Lopes, Claudia de Souza; Susser, Ezra; Menezes, Paulo Rossi
2016-11-01
To identify work-related factors associated with depressive symptoms and probable major depression in primary care teams. Cross-sectional study among primary care teams (community health workers, nursing assistants, nurses, and physicians) in the city of São Paulo, Brazil (2011-2012; n = 2940), to assess depressive symptoms and probable major depression and their associations with job strain and other work-related conditions. Community health workers presented higher prevalence of probable major depression (18%) than other primary care workers. Higher odds ratios for depressive symptoms or probable major depression were associated with longer duration of employment in primary care; having a passive, active, or high-strain job; lack of supervisor feedback regarding performance; and low social support from colleagues and supervisors. Observed levels of job-related depression can endanger the sustainability of primary care programs. Public Health implications. Strategies are needed to deliver care to primary care workers with depression, facilitating diagnosis and access to treatment, particularly in low- and middle-income countries. Preventive interventions can include training managers to provide feedback and creating strategies to increase job autonomy and social support at work.
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COMMUNITY HEALTH & PRIMARY HEALTH CARE
African Journals Online (AJOL)
adedamla
Background: The well-being of women and children is one of the major determinants ... The Sample for the study were women recruited from 11 primary health care ... respondents educational level and knowledge of preconception care (X =24.76, ... single adult or married couple) are in an optimal state .... The major site for.
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Gill, James M; Klinkman, Michael S; Chen, Ying Xia
2010-01-01
Because comorbid depression can complicate medical conditions (eg, diabetes), physicians may treat depression more aggressively in patients who have these conditions. This study examined whether primary care physicians prescribe antidepressant medications more often and in higher doses for persons with medical comorbidities. This secondary data analysis of electronic health record data was conducted in the Centricity Health Care User Research Network (CHURN), a national network of ambulatory practices that use a common outpatient electronic health record. Participants included 209 family medicine and general internal medicine providers in 40 primary care CHURN offices in 17 US states. Patients included adults with a new episode of depression that had been diagnosed during the period October 2006 through July 2007 (n = 1513). Prescription of antidepressant medication and doses of antidepressant medication were compared for patients with and without 6 comorbid conditions: diabetes, coronary heart disease, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, and cancer. 20.7% of patients had at least one medical comorbidity whereas 5.8% had multiple comorbidities. Overall, 77% of depressed patients were prescribed antidepressant medication. After controlling for age and sex, patients with multiple comorbidities were less likely to be prescribed medication (adjusted odds ratio, 0.58; 95% CI, 0.35-0.96), but there was no significant difference by individual comorbidities. Patients with cerebrovascular disease were less likely to be prescribed a full dose of medication (adjusted odds ratio, 0.26; 95% CI, 0.08-0.88), but there were no differences for other comorbidities or for multiple comorbidities, and there was no difference for any comorbidities in the prescription of minimally effective doses. Patients with new episodes of depression who present to a primary care practice are not treated more aggressively if they have medical
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Funk, Russell J; Owen-Smith, Jason; Landon, Bruce E; Birkmeyer, John D; Hollingsworth, John M
2017-02-01
To develop and compare methods for identifying natural alignments between ambulatory surgery centers (ASCs) and hospitals that anchor local health systems. Using all-payer data from Florida's State Ambulatory Surgery and Inpatient Databases (2005-2009), we developed 3 methods for identifying alignments between ASCS and hospitals. The first, a geographic proximity approach, used spatial data to assign an ASC to its nearest hospital neighbor. The second, a predominant affiliation approach, assigned an ASC to the hospital with which it shared a plurality of surgeons. The third, a network community approach, linked an ASC with a larger group of hospitals held together by naturally occurring physician networks. We compared each method in terms of its ability to capture meaningful and stable affiliations and its administrative simplicity. Although the proximity approach was simplest to implement and produced the most durable alignments, ASC surgeon's loyalty to the assigned hospital was low with this method. The predominant affiliation and network community approaches performed better and nearly equivalently on these metrics, capturing more meaningful affiliations between ASCs and hospitals. However, the latter's alignments were least durable, and it was complex to administer. We describe 3 methods for identifying natural alignments between ASCs and hospitals, each with strengths and weaknesses. These methods will help health system managers identify ASCs with which to partner. Moreover, health services researchers and policy analysts can use them to study broader communities of surgical care.
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Dsm-iv hypochondriasis in primary care
Escobar, JI; Gara, M; Waitzkin, H; Silver, RC; Holman, A; Compton, W
1998-01-01
The object of this study was to assess the prevalence and correlates of the DSM-IV diagnosis of hypochondriasis in a primary care setting. A large sample (N = 1456) of primary care users was given a structured interview to make diagnoses of mood, anxiety, and somatoform disorders and estimate levels of disability. The prevalence of hypochondriasis (DSM-IV) was about 3%. Patients with this disorder had higher levels of medically unexplained symptoms (abridged somatization) and were more impair...
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Fincher, Ruth-Marie E.; And Others
1992-01-01
This study identified factors in graduating medical students' choice of primary versus nonprimary care specialty. Subjects were 509 students at the Medical College of Georgia in 1988-90. Students could be classified by such factors as desire for longitudinal patient care opportunities, monetary rewards, perception of lifestyle, and perception of…
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Directory of Open Access Journals (Sweden)
Wisnivesky Juan
2011-09-01
Full Text Available Abstract Background Clinical prediction rules (CPRs represent well-validated but underutilized evidence-based medicine tools at the point-of-care. To date, an inability to integrate these rules into an electronic health record (EHR has been a major limitation and we are not aware of a study demonstrating the use of CPR's in an ambulatory EHR setting. The integrated clinical prediction rule (iCPR trial integrates two CPR's in an EHR and assesses both the usability and the effect on evidence-based practice in the primary care setting. Methods A multi-disciplinary design team was assembled to develop a prototype iCPR for validated streptococcal pharyngitis and bacterial pneumonia CPRs. The iCPR tool was built as an active Clinical Decision Support (CDS tool that can be triggered by user action during typical workflow. Using the EHR CDS toolkit, the iCPR risk score calculator was linked to tailored ordered sets, documentation, and patient instructions. The team subsequently conducted two levels of 'real world' usability testing with eight providers per group. Usability data were used to refine and create a production tool. Participating primary care providers (n = 149 were randomized and intervention providers were trained in the use of the new iCPR tool. Rates of iCPR tool triggering in the intervention and control (simulated groups are monitored and subsequent use of the various components of the iCPR tool among intervention encounters is also tracked. The primary outcome is the difference in antibiotic prescribing rates (strep and pneumonia iCPR's encounters and chest x-rays (pneumonia iCPR only between intervention and control providers. Discussion Using iterative usability testing and development paired with provider training, the iCPR CDS tool leverages user-centered design principles to overcome pervasive underutilization of EBM and support evidence-based practice at the point-of-care. The ongoing trial will determine if this collaborative
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Collaboration of midwives in primary care midwifery practices with other maternity care providers.
Warmelink, J Catja; Wiegers, Therese A; de Cock, T Paul; Klomp, Trudy; Hutton, Eileen K
2017-12-01
Inter-professional collaboration is considered essential in effective maternity care. National projects are being undertaken to enhance inter-professional relationships and improve communication between all maternity care providers in order to improve the quality of maternity care in the Netherlands. However, little is known about primary care midwives' satisfaction with collaboration with other maternity care providers, such as general practitioners, maternity care assistance organisations (MCAO), maternity care assistants (MCA), obstetricians, clinical midwives and paediatricians. More insight is needed into the professional working relations of primary care midwives in the Netherlands before major changes are made OBJECTIVE: To assess how satisfied primary care midwives are with collaboration with other maternity care providers and to assess the relationship between their 'satisfaction with collaboration' and personal and work-related characteristics of the midwives, their attitudes towards their work and collaboration characteristics (accessibility). The aim of this study was to provide insight into the professional working relations of primary care midwives in the Netherlands. Our descriptive cross-sectional study is part of the DELIVER study. Ninety nine midwives completed a written questionnaire in May 2010. A Friedman ANOVA test assessed differences in satisfaction with collaboration with six groups of maternity care providers. Bivariate analyses were carried out to assess the relationship between satisfaction with collaboration and personal and work-related characteristics of the midwives, their attitudes towards their work and collaboration characteristics. Satisfaction experienced by primary care midwives when collaborating with the different maternity care providers varies within and between primary and secondary/tertiary care. Interactions with non-physicians (clinical midwives and MCA(O)) are ranked consistently higher on satisfaction compared with
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Family-centred care delivery: comparing models of primary care service delivery in Ontario.
Mayo-Bruinsma, Liesha; Hogg, William; Taljaard, Monica; Dahrouge, Simone
2013-11-01
To determine whether models of primary care service delivery differ in their provision of family-centred care (FCC) and to identify practice characteristics associated with FCC. Cross-sectional study. Primary care practices in Ontario (ie, 35 salaried community health centres, 35 fee-for-service practices, 32 capitation-based health service organizations, and 35 blended remuneration family health networks) that belong to 4 models of primary care service delivery. A total of 137 practices, 363 providers, and 5144 patients. Measures of FCC in patient and provider surveys were based on the Primary Care Assessment Tool. Statistical analyses were conducted using linear mixed regression models and generalized estimating equations. Patient-reported FCC scores were high and did not vary significantly by primary care model. Larger panel size in a practice was associated with lower odds of patients reporting FCC. Provider-reported FCC scores were significantly higher in community health centres than in family health networks (P = .035). A larger number of nurse practitioners and clinical services on-site were both associated with higher FCC scores, while scores decreased as the number of family physicians in a practice increased and if practices were more rural. Based on provider and patient reports, primary care reform strategies that encourage larger practices and more patients per family physician might compromise the provision of FCC, while strategies that encourage multidisciplinary practices and a range of services might increase FCC.
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Financial incentive schemes in primary care
Directory of Open Access Journals (Sweden)
Gillam S
2015-09-01
Full Text Available Stephen Gillam Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK Abstract: Pay-for-performance (P4P schemes have become increasingly common in primary care, and this article reviews their impact. It is based primarily on existing systematic reviews. The evidence suggests that P4P schemes can change health professionals' behavior and improve recorded disease management of those clinical processes that are incentivized. P4P may narrow inequalities in performance comparing deprived with nondeprived areas. However, such schemes have unintended consequences. Whether P4P improves the patient experience, the outcomes of care or population health is less clear. These practical uncertainties mirror the ethical concerns of many clinicians that a reductionist approach to managing markers of chronic disease runs counter to the humanitarian values of family practice. The variation in P4P schemes between countries reflects different historical and organizational contexts. With so much uncertainty regarding the effects of P4P, policy makers are well advised to proceed carefully with the implementation of such schemes until and unless clearer evidence for their cost–benefit emerges. Keywords: financial incentives, pay for performance, quality improvement, primary care
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International Nuclear Information System (INIS)
Nguyen, Thanh Vân France; Bosset, Jean-François; Monnier, Alain; Fournier, Jacqueline; Perrin, Valérie; Baumann, Cédric; Brédart, Anne; Mercier, Mariette
2011-01-01
The aim of this study was to identify factors associated with satisfaction with care in cancer patients undergoing ambulatory treatment. We investigated associations between patients' baseline clinical and socio-demographic characteristics, as well as self-reported quality of life, and satisfaction with care. Patients undergoing ambulatory chemotherapy or radiotherapy in 2 centres in France were invited, at the beginning of their treatment, to complete the OUT-PATSAT35, a 35 item and 13 scale questionnaire evaluating perception of doctors, nurses and aspects of care organisation. Additionally, for each patient, socio-demographic variables, clinical characteristics and self-reported quality of life using the EORTC QLQ-C30 questionnaire were recorded. Among 692 patients included between January 2005 and December 2006, only 6 were non-responders. By multivariate analysis, poor perceived global health strongly predicted dissatisfaction with care (p < 0.0001). Patients treated by radiotherapy (vs patients treated by chemotherapy) reported lower levels of satisfaction with doctors' technical and interpersonal skills, information provided by caregivers, and waiting times. Patients with primary head and neck cancer (vs other localisations), and those living alone were less satisfied with information provided by doctors, and younger patients (< 55 years) were less satisfied with doctors' availability. A number of clinical of socio-demographic factors were significantly associated with different scales of the satisfaction questionnaire. However, the main determinant was the patient's global health status, underlining the importance of measuring and adjusting for self-perceived health status when evaluating satisfaction. Further analyses are currently ongoing to determine the responsiveness of the OUT-PATSAT35 questionnaire to changes over time
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Assessment of primary care services and perceived barriers to care in persons with disabilities.
Harrington, Amanda L; Hirsch, Mark A; Hammond, Flora M; Norton, H James; Bockenek, William L
2009-10-01
To determine what percentage of persons with disabilities have a primary care provider, participate in routine screening and health maintenance examinations, and identify perceived physical or physician barriers to receiving care. A total of 344 surveys, consisting of 66 questions, were collected from adults with disabilities receiving care at an outpatient rehabilitation clinic. A total of 89.5% (95% CI 86.3%-92.8%) of participants reported having a primary care physician. Younger persons (P brain injury (P use, and safety with relationships at home ranged from 26.6% to 37.5% compared with screening for depression, diet, exercise, and smoking (64.5%-70%). Completion rates of age- and gender-appropriate health maintenance examinations ranged from 42.4% to 90%. A total of 2.67% of participants reported problems with physical access at their physician's office, and 36.4% (95% CI 30.8%-42.1%) of participants reported having to teach their primary care physician about their disability. Most persons with disabilities have a primary care physician. In general, completion rates for routine screening and health maintenance examinations were high. Perceived deficits in primary care physicians' knowledge of disability issues seem more prevalent than physical barriers to care.
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Primary care research conducted in networks: getting down to business.
Mold, James W
2012-01-01
This seventh annual practice-based research theme issue of the Journal of the American Board of Family Medicine highlights primary care research conducted in practice-based research networks (PBRNs). The issue includes discussion of (1) theoretical and methodological research, (2) health care research (studies addressing primary care processes), (3) clinical research (studies addressing the impact of primary care on patients), and (4) health systems research (studies of health system issues impacting primary care including the quality improvement process). We had a noticeable increase in submissions from PBRN collaborations, that is, studies that involved multiple networks. As PBRNs cooperate to recruit larger and more diverse patient samples, greater generalizability and applicability of findings lead to improved primary care processes.
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Borderline personality disorder in the primary care setting.
Dubovsky, Amelia N; Kiefer, Meghan M
2014-09-01
Borderline personality disorder is estimated to be present in approximately 6% of outpatient primary care settings. However, the time and energy spent on this population can greatly exceed what primary care doctors are able to spend. This article gives an overview of borderline personality disorder, including the clinical characteristics, epidemiology, and comorbidities, as well as pharmacologic and most important behavioral management. It is our hope that, with improved understanding of the disorder and skills for managing this population, caring for patients with the disorder can be more satisfying and less taxing for both primary care doctors and their patients. Copyright © 2014 Elsevier Inc. All rights reserved.
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Third sector primary health care in New Zealand.
Crampton, P; Dowell, A C; Bowers, S
2000-03-24
To describe key organisational characteristics of selected third sector (non-profit and non-government) primary health care organisations. Data were collected, in 1997 and 1998, from 15 third sector primary care organisations that were members of a network of third sector primary care providers, Health Care Aotearoa (HCA). Data were collected by face-to-face interviews of managers and key informants using a semi-structured interview schedule, and from practice computer information systems. Overall the populations served were young: only 4% of patients were aged 65 years or older, and the ethnicity profile was highly atypical, with 21.8% European, 36% Maori, 22.7% Pacific Island, 12% other, and 7.5% not stated. Community services card holding rates were higher than recorded in other studies, and registered patients tended to live in highly deprived areas. HCA organisations had high patient to doctor ratios, in general over 2000:1, and there were significant differences in management structures between HCA practices and more traditional general practice. Third sector organisations provide services for populations that are disadvantaged in many respects. It is likely that New Zealand will continue to develop a diverse range of primary care organisational arrangements. Effort is now required to measure quality and effectiveness of services provided by different primary care organisations serving comparable populations.
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Identification of early childhood caries in primary care settings.
Nicolae, Alexandra; Levin, Leo; Wong, Peter D; Dave, Malini G; Taras, Jillian; Mistry, Chetna; Ford-Jones, Elizabeth L; Wong, Michele; Schroth, Robert J
2018-04-01
Early childhood caries (ECC) is the most common chronic disease affecting young children in Canada. ECC may lead to pain and infection, compromised general health, decreased quality of life and increased risk for dental caries in primary and permanent teeth. A multidisciplinary approach to prevent and identify dental disease is recommended by dental and medical national organizations. Young children visit primary care providers at regular intervals from an early age. These encounters provide an ideal opportunity for primary care providers to educate clients about their children's oral health and its importance for general health. We designed an office-based oral health screening guide to help primary care providers identify ECC, a dental referral form to facilitate dental care access and an oral health education resource to raise parental awareness. These resources were reviewed and trialled with a small number of primary care providers.
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Primary care practice organization influences colorectal cancer screening performance.
Yano, Elizabeth M; Soban, Lynn M; Parkerton, Patricia H; Etzioni, David A
2007-06-01
To identify primary care practice characteristics associated with colorectal cancer (CRC) screening performance, controlling for patient-level factors. Primary care director survey (1999-2000) of 155 VA primary care clinics linked with 38,818 eligible patients' sociodemographics, utilization, and CRC screening experience using centralized administrative and chart-review data (2001). Practices were characterized by degrees of centralization (e.g., authority over operations, staffing, outside-practice influence); resources (e.g., sufficiency of nonphysician staffing, space, clinical support arrangements); and complexity (e.g., facility size, academic status, managed care penetration), adjusting for patient-level covariates and contextual factors. Chart-based evidence of CRC screening through direct colonoscopy, sigmoidoscopy, or consecutive fecal occult blood tests, eliminating cases with documented histories of CRC, polyps, or inflammatory bowel disease. After adjusting for sociodemographic characteristics and health care utilization, patients were significantly more likely to be screened for CRC if their primary care practices had greater autonomy over the internal structure of care delivery (pmanagement and referral procedures are associated with significantly lower CRC screening performance. Competition with hospital resource demands may impinge on the degree of internal organization of their affiliated primary care practices.
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Valentijn, P.P.; Schepman, S.M.; Opheij, W.; Bruijnzeels, M.A.
2013-01-01
Introduction: Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to
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Job satisfaction of primary care team members and quality of care.
Mohr, David C; Young, Gary J; Meterko, Mark; Stolzmann, Kelly L; White, Bert
2011-01-01
In recent years, hospitals and payers have increased their efforts to improve the quality of patient care by encouraging provider adherence to evidence-based practices. Although the individual provider is certainly essential in the delivery of appropriate care, a team perspective is important when examining variation in quality. In the present study, the authors modeled the relationship between a measure of aggregate job satisfaction for members of primary care teams and objective measures of quality based on process indicators and intermediate outcomes. Multilevel analyses indicated that aggregate job satisfaction ratings were associated with higher values on both types of quality measures. Team-level job satisfaction ratings are a potentially important marker for the effectiveness of primary care teams in managing patient care.
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Van Groenestijn, Annerieke C; Schröder, Carin D; Kruitwagen-Van Reenen, Esther T; Van Den Berg, Leonard H; Visser-Meily, Johanna M A
2017-11-01
The aim of this study was to assess the prevalence of participation restrictions in ambulatory patients with amyotrophic lateral sclerosis (ALS) and to identify physical and psychological contributory factors. In this cross-sectional study, self-reported participation restrictions of 72 ambulatory ALS patients were assessed using the social health status dimension (SIPSOC) of the Sickness Impact Profile (SIP-68). Associations between SIPSOC and physical functioning, psychological factors, and demographic factors were analyzed using hierarchical regression analyses. Ninety-two percent of the patients reported participation restrictions; 54.9% could be explained by physical functioning; psychological factors accounted for 8.1% of the variance. Lung capacity, functional mobility, fatigue, and helplessness were independently associated with participation restrictions. Ambulatory ALS patients have participation restrictions, which may be influenced if early ALS care is directed toward lung capacity, functional mobility, fatigue, and feelings of helplessness. Muscle Nerve 56: 912-918, 2017. © 2017 Wiley Periodicals, Inc.
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Diverticular Disease in the Primary Care Setting.
Wensaas, Knut-Arne; Hungin, Amrit Pali
2016-10-01
Diverticular disease is a chronic and common condition, and yet the impact of diverticular disease in primary care is largely unknown. The diagnosis of diverticular disease relies on the demonstration of diverticula in the colon, and the necessary investigations are often not available in primary care. The specificity and sensitivity of symptoms, clinical signs and laboratory tests alone are generally low and consequently the diagnostic process will be characterized by uncertainty. Also, the criteria for symptomatic uncomplicated diverticular disease in the absence of macroscopic inflammation are not clearly defined. Therefore both the prevalence of diverticular disease and the incidence of diverticulitis in primary care are unknown. Current recommendations for treatment and follow-up of patients with acute diverticulitis are based on studies where the diagnosis has been verified by computerized tomography. The results cannot be directly transferred to primary care where the diagnosis has to rely on the interpretation of symptoms and signs. Therefore, one must allow for greater diagnostic uncertainty, and safety netting in the event of unexpected development of the condition is an important aspect of the management of diverticulitis in primary care. The highest prevalence of diverticular disease is found among older patients, where multimorbidity and polypharmacy is common. The challenge is to remember the possible contribution of diverticular disease to the patient's overall condition and to foresee its implications in terms of advice and treatment in relation to other diseases.
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Time providing care outside visits in a home-based primary care program.
Pedowitz, Elizabeth J; Ornstein, Katherine A; Farber, Jeffrey; DeCherrie, Linda V
2014-06-01
To assess how much time physicians in a large home-based primary care (HBPC) program spend providing care outside of home visits. Unreimbursed time and patient and provider-related factors that may contribute to that time were considered. Mount Sinai Visiting Doctors (MSVD) providers filled out research forms for every interaction involving care provision outside of home visits. Data collected included length of interaction, mode, nature, and with whom the interaction was for 3 weeks. MSVD, an academic home-visit program in Manhattan, New York. All primary care physicians (PCPs) in MSVD (n = 14) agreed to participate. Time data were analyzed using a comprehensive estimate and conservative estimates to quantify unbillable time. Data on 1,151 interactions for 537 patients were collected. An average 8.2 h/wk was spent providing nonhome visit care for a full-time provider. Using the most conservative estimates, 3.6 h/wk was estimated to be unreimbursed per full-time provider. No significant differences in interaction times were found between patients with and without dementia, new and established patients, and primary-panel and covered patients. Home-based primary care providers spend substantial time providing care outside home visits, much of which goes unrecognized in the current reimbursement system. These findings may help guide practice development and creation of new payment systems for HBPC and similar models of care. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.
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Fernald, Douglas; Hamer, Mika; James, Kathy; Tutt, Brandon; West, David
2015-01-01
Family medicine and internal medicine physicians order diagnostic laboratory tests for nearly one-third of patient encounters in an average week, yet among medical errors in primary care, an estimated 15% to 54% are attributed to laboratory testing processes. From a practice improvement perspective, we (1) describe the need for laboratory testing process quality improvements from the perspective of primary care practices, and (2) describe the approaches and resources needed to implement laboratory testing process quality improvements in practice. We applied practice observations, process mapping, and interviews with primary care practices in the Shared Networks of Colorado Ambulatory Practices and Partners (SNOCAP)-affiliated practice-based research networks that field-tested in 2013 a laboratory testing process improvement toolkit. From the data collected in each of the 22 participating practices, common testing quality issues included, but were not limited to, 3 main testing process steps: laboratory test preparation, test tracking, and patient notification. Three overarching qualitative themes emerged: practices readily acknowledge multiple laboratory testing process problems; practices know that they need help addressing the issues; and practices face challenges with finding patient-centered solutions compatible with practice priorities and available resources. While practices were able to get started with guidance and a toolkit to improve laboratory testing processes, most did not seem able to achieve their quality improvement aims unassisted. Providing specific guidance tools with practice facilitation or other rapid-cycle quality improvement support may be an effective approach to improve common laboratory testing issues in primary care. © Copyright 2015 by the American Board of Family Medicine.
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Optimizing the Primary Prevention of Type-2 Diabetes in Primary Health Care
2017-08-18
Interprofessional Relations; Primary Health Care/Organization & Administration; Diabetes Mellitus, Type 2/Prevention & Control; Primary Prevention/Methods; Risk Reduction Behavior; Randomized Controlled Trial; Life Style
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Directory of Open Access Journals (Sweden)
Sandipan Bhattacharjee
2018-01-01
Full Text Available Little is known regarding depression treatment patterns and predictors among older adults with comorbid Parkinson's disease and depression (dPD in the United States (US. The objective of this study was to assess the patterns and predictors of depression treatment among older adults with dPD in the US. We adopted a cross-sectional study design by pooling multiple-year data (2005–2011 from the National Ambulatory Medical Care Survey (NAMCS and the outpatient department of the National Hospital Ambulatory Medical Care Survey (NHAMCS. The final study sample consisted of visits by older adults with dPD. Depression treatment was defined as antidepressant use with or without psychotherapy. To identify predictors of depression treatment, multivariate logistic regression analysis was conducted adjusting for predisposing, enabling, and need factors. Individuals with dPD and polypharmacy were 74% more likely to receive depression treatment (odds ratio = 1.743, 95% CI 1.376–2.209, while dPD subjects with comorbid chronic conditions were 44% less likely (odds ratio = 0.559, 95% CI 0.396–0.790 to receive depression treatment. Approximately six out of ten older adults with PD and depression received depression treatment. Treatment options for dPD are underutilized in routine clinical practice, and further research should explore how overall medical complexity presents a barrier to depression treatment.
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Physical Profiling Performance of Air Force Primary Care Providers
2017-08-09
AFRL-SA-WP-TR-2017-0014 Physical Profiling Performance of Air Force Primary Care Providers Anthony P. Tvaryanas1; William P...COVERED (From – To) September 2016 – January 2017 4. TITLE AND SUBTITLE Physical Profiling Performance of Air Force Primary Care Providers...encounter with their primary care team. An independent medical standards subject matter expert (SME) reviewed encounters in the electronic health record
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Managed care and the delivery of primary care to the elderly and the chronically ill.
Wholey, D R; Burns, L R; Lavizzo-Mourey, R
1998-06-01
To analyze primary care staffing in HMOs and to review the literature on primary care organization and performance in managed care organizations, with an emphasis on the delivery of primary care to the elderly and chronically ill. Analysis of primary care staffing: InterStudy HMO census data on primary care (n = 1,956) and specialist (n = 1,777) physician staffing levels from 1991 through 1995. Primary care organization and performance for the chronically ill and elderly were analyzed using a review of published research. For the staffing-level models, the number of primary care and specialist physicians per 100,000 enrollees was regressed on HMO characteristics (HMO type [group, staff, network, mixed], HMO enrollment, federal qualification, profit status, national affiliation) and community characteristics (per capita income, population density, service area size, HMO competition). For the review of organization and performance, literature published was summarized in a tabular format. The analysis of physician staffing shows that group and staff HMOs have fewer primary care and specialist physicians per 100,000 enrollees than do network and mixed HMOs, which have fewer than IPAs. Larger HMOs use fewer physicians per 100,000 enrollees than smaller HMOs. Federally qualified HMOs have fewer primary care and specialist physicians per 100,000 enrollees. For-profit, nationally affiliated, and Blue Cross HMOs have more primary care and specialist physicians than do local HMOs. HMOs in areas with high per capita income have more PCPs per 100,000 and a greater proportion of PCPs in the panel. HMO penetration decreases the use of specialists, but the number of HMOs increases the use of primary care and specialist physicians in highly competitive markets. Under very competitive conditions, HMOs appear to compete by increasing access to both PCPs and specialists, with a greater emphasis on access to specialists. The review of research on HMO performance suggests that access
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Cinema Sessions in Primary Care
Directory of Open Access Journals (Sweden)
Francisco Ignacio MORETA-VELAYOS
2016-04-01
Full Text Available For a long time films have been used in teaching and at various levels of professional training and more specifically in the medical area. In this case, through the description of a project developed in a Primary Care Health Center, we intend to justify the use of movies as a tool that could ease, the sometimes difficult task of continued education among Primary Care professionals. We propose different aspects of everyday practice in which cinema can be potentially useful, as well as the way to include it in the Plan of Continued Education of the Centre and its accreditation.Films and issues discussed in each session, and the project evaluation, are detailed.
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Electronic consultation system demonstrates educational benefit for primary care providers.
Kwok, Jonas; Olayiwola, J Nwando; Knox, Margae; Murphy, Elizabeth J; Tuot, Delphine S
2017-01-01
Background Electronic consultation systems allow primary care providers to receive timely speciality expertise via iterative electronic communication. The use of such systems is expanding across the USA with well-documented high levels of user satisfaction. We characterise the educational impact for primary care providers of a long-standing integrated electronic consultation and referral system. Methods Primary care providers' perceptions of the educational value inherent to electronic consultation system communication and the impact on their ability to manage common speciality clinical conditions and questions were examined by electronic survey using five-point Likert scales. Differences in primary care providers' perceptions were examined overall and by primary care providers' speciality, provider type and years of experience. Results Among 221 primary care provider participants (35% response rate), 83.9% agreed or strongly agreed that the integrated electronic consultation and referral system provided educational value. There were no significant differences in educational value reported by provider type (attending physician, mid-level provider, or trainee physician), primary care providers' speciality, or years of experience. Perceived benefit of the electronic consultation and referral system in clinical management appeared stronger for laboratory-based conditions (i.e. subclinical hypothyroidism) than more diffuse conditions (i.e. abdominal pain). Nurse practitioners/physician assistants and trainee physicians were more likely to report improved abilities to manage specific clinical conditions when using the electronic consultation and/or referral system than were attending physicians, as were primary care providers with ≤10 years experience, versus those with >20 years of experience. Conclusions Primary care providers report overwhelmingly positive perceptions of the educational value of an integrated electronic consultation and referral system. Nurse
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Assessment and management of suicide risk in primary care.
Saini, Pooja; While, David; Chantler, Khatidja; Windfuhr, Kirsten; Kapur, Navneet
2014-01-01
Risk assessment and management of suicidal patients is emphasized as a key component of care in specialist mental health services, but these issues are relatively unexplored in primary care services. To examine risk assessment and management in primary and secondary care in a clinical sample of individuals who were in contact with mental health services and died by suicide. Data collection from clinical proformas, case records, and semistructured face-to-face interviews with general practitioners. Primary and secondary care data were available for 198 of the 336 cases (59%). The overall agreement in the rating of risk between services was poor (overall κ = .127, p = .10). Depression, care setting (after discharge), suicidal ideation at last contact, and a history of self-harm were associated with a rating of higher risk. Suicide prevention policies were available in 25% of primary care practices, and 33% of staff received training in suicide risk assessments. Risk is difficult to predict, but the variation in risk assessment between professional groups may reflect poor communication. Further research is required to understand this. There appears to be a relative lack of suicide risk assessment training in primary care.
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Mazzaglia, Giampiero; Lapi, Francesco; Silvestri, Caterina; Roti, Lorenzo; Giustini, Saffi Ettore; Buiatti, Eva
2009-01-01
Reforms introduced in the last decade in Italian general practice, have contributed to the changing role of primary care physicians (PCPs) within the Italian National Health Service, with potential difficulties adapting that may lead to job stress and dissatisfaction. The present study aims to compare job satisfaction and stress levels of PCPs working in primary healthcare teams (PHCTs) with those for practitioners operating in single ambulatory offices, and to assess potential associations with aspects of job and practice management. A postal survey was conducted between January and March 2005 among PCPs working in Tuscany. Data were collected by using a structured questionnaire containing questions concerning personal, professional, job and practice characteristics. The Warr-Cook-Wall scale and the Cooper test were used to assess job satisfaction and stress, respectively. From 3043 PCPs, a response rate of 45.2% was achieved. Significant differences were found between PHCT physicians and solo practitioners in several aspects of their job. Physicians working in PHCTs appeared more satisfied in some aspects of their practice such as organisation, whereas they were less satisfied about workload and interaction with other healthcare providers. Multivariate modelling showed relevant aspects of dissatisfaction and stress, particularly the difficulties of collaboration with other healthcare providers, and access to specialised services. Reform strategies aimed at improving the quality of care among PCPs needs to take into account the contextual determinants of physician satisfaction and stress, and should highlight programmes that might be pursued to improve the integration of PCPs within the Italian National Health System.
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Olry de Labry Lima, Antonio; Moya Garrido, María Natividad; Espín Balbino, Jaime
2014-04-01
Realise a review of studies of economic evaluation about the ambulatory monitoring of capillary glucose (AMGC) in diabetic type II persons. A review of the literature was conducted, in MedLine, various websites, referenced paper and provided by expert's persons. Five studies concluded that the AMGC was a cost-effective strategic, of this papers use Kaiser Permanente data base, its make that these studies could be considered a solely one study. The rest of the papers did not find difference in the AMGC use. The use of AMGC has an uncertainty efficiency. More studies are needed. Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
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Understanding performance management in primary care.
Rogan, Lisa; Boaden, Ruth
2017-02-13
Purpose Principal-agent theory (PAT) has been used to understand relationships among different professional groups and explain performance management between organisations, but is rarely used for research within primary care. The purpose of this paper is to explore whether PAT can be used to attain a better understanding of performance management in primary care. Design/methodology/approach Purposive sampling was used to identify a range of general practices in the North-west of England. Interviews were carried out with directors, managers and clinicians in commissioning and regional performance management organisations and within general practices, and the data analysed using matrix analysis techniques to produce a case study of performance management. Findings There are various elements of the principal-agent framework that can be applied in primary care. Goal alignment is relevant, but can only be achieved through clear, strategic direction and consistent interpretation of objectives at all levels. There is confusion between performance measurement and performance management and a tendency to focus on things that are easy to measure whilst omitting aspects of care that are more difficult to capture. Appropriate use of incentives, good communication, clinical engagement, ownership and trust affect the degree to which information asymmetry is overcome and goal alignment achieved. Achieving the right balance between accountability and clinical autonomy is important to ensure governance and financial balance without stifling innovation. Originality/value The principal-agent theoretical framework can be used to attain a better understanding of performance management in primary care; although it is likely that only partial goal alignment will be achieved, dependent on the extent and level of alignment of a range of factors.
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Odusola, Aina O; Stronks, Karien; Hendriks, Marleen E; Schultsz, Constance; Akande, Tanimola; Osibogun, Akin; van Weert, Henk; Haafkens, Joke A
2016-01-01
Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA) that can be modified through timely and long-term treatment in primary care. We explored perspectives of primary care staff and health insurance managers on enablers and barriers for implementing high-quality hypertension care, in the context of a community-based health insurance programme in rural Nigeria. Qualitative study using semi-structured individual interviews with primary care staff (n = 11) and health insurance managers (n=4). Data were analysed using standard qualitative techniques. Both stakeholder groups perceived health insurance as an important facilitator for implementing high-quality hypertension care because it covered costs of care for patients and provided essential resources and incentives to clinics: guidelines, staff training, medications, and diagnostic equipment. Perceived inhibitors included the following: high staff workload; administrative challenges at facilities; discordance between healthcare provider and insurer on how health insurance and provider payment methods work; and insufficient fit between some guideline recommendations and tools for patient education and characteristics/needs of the local patient population. Perceived strategies to address inhibitors included the following: task-shifting; adequate provider payment benchmarking; good provider-insurer relationships; automated administration systems; and tailoring guidelines/patient education. By providing insights into perspectives of primary care providers and health insurance managers, this study offers information on potential strategies for implementing high-quality hypertension care for insured patients in SSA.
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Bhattacharjee, Sandipan; Vadiei, Nina; Goldstone, Lisa; Alrabiah, Ziyad; Sherman, Scott J.
2018-01-01
Little is known regarding depression treatment patterns and predictors among older adults with comorbid Parkinson's disease and depression (dPD) in the United States (US). The objective of this study was to assess the patterns and predictors of depression treatment among older adults with dPD in the US. We adopted a cross-sectional study design by pooling multiple-year data (2005–2011) from the National Ambulatory Medical Care Survey (NAMCS) and the outpatient department of the National Hospi...
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Ranstad, Karin; Midlöv, Patrik; Halling, Anders
2017-06-09
Socioeconomic status and geographical factors are associated with health and use of healthcare. Well-performing primary care contributes to better health and more adequate healthcare. In a primary care system based on patient's choice of practice, this choice (listing) is a key to understand the system. To explore the relationship between population and practices in a primary care system based on listing. Cross-sectional population-based study. Logistic regressions of the associations between active listing in primary care, income, education, distances to healthcare and geographical location, adjusting for multimorbidity, age, sex and type of primary care practice. Population over 15 years (n=123 168) in a Swedish county, Blekinge (151 731 inhabitants), in year 2007, actively or passively listed in primary care. The proportion of actively listed was 68%. Actively listed in primary care on 31 December 2007. Highest ORs for active listing in the model including all factors according to income had quartile two and three with OR 0.70 (95% CI 0.69 to 0.70), and those according to education less than 9 years of education had OR 0.70 (95% CI 0.68 to 0.70). Best odds for geographical factors in the same model had municipality C with OR 0.85 (95% CI 0.85 to 0.86) for active listing. Akaike's Information Criterion (AIC) was 124 801 for a model including municipality, multimorbidity, age, sex and type of practice and including all factors gave AIC 123 934. Higher income, shorter education, shorter distance to primary care or longer distance to hospital is associated with active listing in primary care.Multimorbidity, age, geographical location and type of primary care practice are more important to active listing in primary care than socioeconomic status and distance to healthcare. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
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Which features of primary care affect unscheduled secondary care use? A systematic review.
Huntley, Alyson; Lasserson, Daniel; Wye, Lesley; Morris, Richard; Checkland, Kath; England, Helen; Salisbury, Chris; Purdy, Sarah
2014-05-23
To conduct a systematic review to identify studies that describe factors and interventions at primary care practice level that impact on levels of utilisation of unscheduled secondary care. Observational studies at primary care practice level. Studies included people of any age of either sex living in Organisation for Economic Co-operation and Development (OECD) countries with any health condition. The primary outcome measure was unscheduled secondary care as measured by emergency department attendance and emergency hospital admissions. 48 papers were identified describing potential influencing features on emergency department visits (n=24 studies) and emergency admissions (n=22 studies). Patient factors associated with both outcomes were increased age, reduced socioeconomic status, lower educational attainment, chronic disease and multimorbidity. Features of primary care affecting unscheduled secondary care were more complex. Being able to see the same healthcare professional reduced unscheduled secondary care. Generally, better access was associated with reduced unscheduled care in the USA. Proximity to healthcare provision influenced patterns of use. Evidence relating to quality of care was limited and mixed. The majority of research was from different healthcare systems and limited in the extent to which it can inform policy. However, there is evidence that continuity of care is associated with reduced emergency department attendance and emergency hospital admissions. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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Suicidality in primary care patients with somatoform disorders
Wiborg, J.F.; Gieseler, D.; Fabisch, A.B.; Voigt, K.; Lautenbach, A.; Lowe, B.
2013-01-01
Objective To examine rates of suicidality in primary care patients with somatoform disorders and to identify factors that might help to understand and manage active suicidal ideation in these patients. Methods We conducted a cross-sectional study screening 1645 primary care patients. In total, 142
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Directory of Open Access Journals (Sweden)
Verbakel Jan Y
2013-01-01
Full Text Available Abstract Background Diagnosing serious infections in children is challenging, because of the low incidence of such infections and their non-specific presentation early in the course of illness. Prediction rules are promoted as a means to improve recognition of serious infections. A recent systematic review identified seven clinical prediction rules, of which only one had been prospectively validated, calling into question their appropriateness for clinical practice. We aimed to examine the diagnostic accuracy of these rules in multiple ambulatory care populations in Europe. Methods Four clinical prediction rules and two national guidelines, based on signs and symptoms, were validated retrospectively in seven individual patient datasets from primary care and emergency departments, comprising 11,023 children from the UK, the Netherlands, and Belgium. The accuracy of each rule was tested, with pre-test and post-test probabilities displayed using dumbbell plots, with serious infection settings stratified as low prevalence (LP; 20% . In LP and IP settings, sensitivity should be >90% for effective ruling out infection. Results In LP settings, a five-stage decision tree and a pneumonia rule had sensitivities of >90% (at a negative likelihood ratio (NLR of Conclusions None of the clinical prediction rules examined in this study provided perfect diagnostic accuracy. In LP or IP settings, prediction rules and evidence-based guidelines had high sensitivity, providing promising rule-out value for serious infections in these datasets, although all had a percentage of residual uncertainty. Additional clinical assessment or testing such as point-of-care laboratory tests may be needed to increase clinical certainty. None of the prediction rules identified seemed to be valuable for HP settings such as emergency departments.
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Does quality influence utilization of primary health care? Evidence from Haiti.
Gage, Anna D; Leslie, Hannah H; Bitton, Asaf; Jerome, J Gregory; Joseph, Jean Paul; Thermidor, Roody; Kruk, Margaret E
2018-06-20
Expanding coverage of primary healthcare services such as antenatal care and vaccinations is a global health priority; however, many Haitians do not utilize these services. One reason may be that the population avoids low quality health facilities. We examined how facility infrastructure and the quality of primary health care service delivery were associated with community utilization of primary health care services in Haiti. We constructed two composite measures of quality for all Haitian facilities using the 2013 Service Provision Assessment survey. We geographically linked population clusters from the Demographic and Health Surveys to nearby facilities offering primary health care services. We assessed the cross-sectional association between quality and utilization of four primary care services: antenatal care, postnatal care, vaccinations and sick child care, as well as one more complex service: facility delivery. Facilities performed poorly on both measures of quality, scoring 0.55 and 0.58 out of 1 on infrastructure and service delivery quality respectively. In rural areas, utilization of several primary cares services (antenatal care, postnatal care, and vaccination) was associated with both infrastructure and quality of service delivery, with stronger associations for service delivery. Facility delivery was associated with infrastructure quality, and there was no association for sick child care. In urban areas, care utilization was not associated with either quality measure. Poor quality of care may deter utilization of beneficial primary health care services in rural areas of Haiti. Improving health service quality may offer an opportunity not only to improve health outcomes for patients, but also to expand coverage of key primary health care services.
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Mental health care roles of non-medical primary health and social care services.
Mitchell, Penny
2009-02-01
Changes in patterns of delivery of mental health care over several decades are putting pressure on primary health and social care services to increase their involvement. Mental health policy in countries like the UK, Australia and New Zealand recognises the need for these services to make a greater contribution and calls for increased intersectoral collaboration. In Australia, most investment to date has focused on the development and integration of specialist mental health services and primary medical care, and evaluation research suggests some progress. Substantial inadequacies remain, however, in the comprehensiveness and continuity of care received by people affected by mental health problems, particularly in relation to social and psychosocial interventions. Very little research has examined the nature of the roles that non-medical primary health and social care services actually or potentially play in mental health care. Lack of information about these roles could have inhibited development of service improvement initiatives targeting these services. The present paper reports the results of an exploratory study that examined the mental health care roles of 41 diverse non-medical primary health and social care services in the state of Victoria, Australia. Data were collected in 2004 using a purposive sampling strategy. A novel method of surveying providers was employed whereby respondents within each agency worked as a group to complete a structured survey that collected quantitative and qualitative data simultaneously. This paper reports results of quantitative analyses including a tentative principal components analysis that examined the structure of roles. Non-medical primary health and social care services are currently performing a wide variety of mental health care roles and they aspire to increase their involvement in this work. However, these providers do not favour approaches involving selective targeting of clients with mental disorders.
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Odusola, A.O.; Stronks, K.; Hendriks, M.E.; Schultsz, C.; Akande, T.; Osibogun, A.; van Weert, H.; Haafkens, J.A.
2016-01-01
Background: Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA) that can be modified through timely and long-term treatment in primary care. Objective: We explored perspectives of primary care staff and health insurance managers on enablers and
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Odusola, Aina O.; Stronks, Karien; Hendriks, Marleen E.; Schultsz, Constance; Akande, Tanimola; Osibogun, Akin; Weert, Henk van; Haafkens, Joke A.
2016-01-01
Background Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA) that can be modified through timely and long-term treatment in primary care. Objective We explored perspectives of primary care staff and health insurance managers on enablers and
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Factors shaping intersectoral action in primary health care services.
Anaf, Julia; Baum, Fran; Freeman, Toby; Labonte, Ron; Javanparast, Sara; Jolley, Gwyn; Lawless, Angela; Bentley, Michael
2014-12-01
To examine case studies of good practice in intersectoral action for health as one part of evaluating comprehensive primary health care in six sites in South Australia and the Northern Territory. Interviews with primary health care workers, collaborating agency staff and service users (Total N=33); augmented by relevant documents from the services and collaborating partners. The value of intersectoral action for health and the importance of partner relationships to primary health care services were both strongly endorsed. Factors facilitating intersectoral action included sufficient human and financial resources, diverse backgrounds and skills and the personal rewards that sustain commitment. Key constraining factors were financial and time limitations, and a political and policy context which has become less supportive of intersectoral action; including changes to primary health care. While intersectoral action is an effective way for primary health care services to address social determinants of health, commitment to social justice and to adopting a social view of health are constrained by a broader health service now largely reinforcing a biomedical model. Effective organisational practices and policies are needed to address social determinants of health in primary health care and to provide a supportive context for workers engaging in intersectoral action. © 2014 Public Health Association of Australia.
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Bleijenberg, N.; Ten Dam, V.H.; Drubbel, I.; Numans, M.E.; De Wit, N.J.; Schuurmans, M.J.
2013-01-01
Purpose: Care for older patients in primary care is currently reactive, fragmented, and time consuming. An innovative structured and proactive primary care program (U-CARE) has been developed to preserve physical functioning and enhance quality of life of frail older people. This study describes in
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Implementation of primary health care - package or process ...
African Journals Online (AJOL)
After establishing the commitment of the government to comprehensive primary health care (PHC), the Department of Health and provinces are now faced with the challenge of implementation. An important response has come with the recent proposed'core package of primary health care services'.' After consultation with ...
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Ambulatory thyroidectomy: A multistate study of revisits and complications
Orosco, RK; Lin, HW; Bhattacharyya, N
2015-01-01
© 2015 American Academy of Otolaryngology - Head and Neck Surgery Foundation. Objective. Determine rates and reasons for revisits after ambulatory adult thyroidectomy. Study Design. Cross-sectional analysis of multistate ambulatory surgery and hospital databases. Setting. Ambulatory surgery data from the State Ambulatory Surgery Databases of California, Florida, Iowa, and New York for calendar years 2010 and 2011. Subjects and Methods. Ambulatory thyroidectomy cases were linked to state ambul...
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Patient safety culture in primary care
Verbakel, N.J.
2015-01-01
Background A constructive patient safety culture is a main prerequisite for patient safety and improvement initiatives. Until now, patient safety culture (PSC) research was mainly focused on hospital care, however, it is of equal importance in primary care. Measuring PSC informs practices on their
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Multimorbidity and quality of preventive care in Swiss university primary care cohorts.
Directory of Open Access Journals (Sweden)
Sven Streit
Full Text Available Caring for patients with multimorbidity is common for generalists, although such patients are often excluded from clinical trials, and thus such trials lack of generalizability. Data on the association between multimorbidity and preventive care are limited. We aimed to assess whether comorbidity number, severity and type were associated with preventive care among patients receiving care in Swiss University primary care settings.We examined a retrospective cohort composed of a random sample of 1,002 patients aged 50-80 years attending four Swiss university primary care settings. Multimorbidity was defined according to the literature and the Charlson index. We assessed the quality of preventive care and cardiovascular preventive care with RAND's Quality Assessment Tool indicators. Aggregate scores of quality of provided care were calculated by taking into account the number of eligible patients for each indicator.Participants (mean age 63.5 years, 44% women had a mean of 2.6 (SD 1.9 comorbidities and 67.5% had 2 or more comorbidities. The mean Charlson index was 1.8 (SD 1.9. Overall, participants received 69% of recommended preventive care and 84% of cardiovascular preventive care. Quality of care was not associated with higher numbers of comorbidities, both for preventive care and for cardiovascular preventive care. Results were similar in analyses using the Charlson index and after adjusting for age, gender, occupation, center and number of visits. Some patients may receive less preventive care including those with dementia (47% and those with schizophrenia (35%.In Swiss university primary care settings, two thirds of patients had 2 or more comorbidities. The receipt of preventive and cardiovascular preventive care was not affected by comorbidity count or severity, although patients with certain comorbidities may receive lower levels of preventive care.
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Directory of Open Access Journals (Sweden)
Dookie Sunitha
2012-07-01
Full Text Available Abstract Background The rhetoric of primary health care philosophy in the district health system is widely cited as a fundamental component of the health transformation process in post-apartheid South Africa. Despite South Africa’s progress and attempts at implementing primary health care, various factors still limit its success. Discussion Inconsistencies and poor understanding of primary care and primary health care raises unrealistic expectations in service delivery and health outcomes, and blame is apportioned when expectations are not met. It is important for all health practitioners to consider the contextual influences on health and ill-health and to recognise the role of the underlying determinants of ill-health, namely, social, economic and environmental influences. The primary health care approach provides a strong framework for this delivery but it is not widely applied. There is a need for renewed political and policy commitments toward quality primary health care delivery, re-orientation of health care workers, integration of primary health care activities into other community-based development, improved management skills and effective coordination at all levels of the health system. There should also be optimal capacity building, and skills development in problem-solving, communication, networking and community participation. Summary A well-functioning district health system is required for the re-engineering of primary health care. This strategy requires a strong leadership, a strengthening of the current district heath system and a greater emphasis on health promotion, prevention, and community participation and empowerment.
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Depression in elderly primary health care clinic attendees in Ilorin ...
African Journals Online (AJOL)
Depression in the elderly presenting at primary care settings is usually under- detected by primary care physicians. This study assessed the prevalence of depression and the utility of the Geriatric Depression Scale (Short Form) in detecting depression in elderly patients in primary care populations in Ilorin, Nigeria. This was ...
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[Primary care: A definition of the field to develop research].
Verga-Gérard, A
2018-03-01
Research in the field of primary care has dramatically increased in France in recent years, especially since 2013 with the introduction of primary care as a thematic priority for research proposals launched by the Ministry of Health (Direction générale de l'offre de soins). The RECaP (Research in Clinical Epidemiology and Public Health) network is a French research network supported by Inserm, which recently implemented a specific working group focusing on research in primary care, based on a multidisciplinary approach. Researchers from different specialties participate in this group. The first aim of the group was to reach a common definition of the perimeter and of the panel of healthcare professionals and structures potentially involved in the field of primary care. For this purpose, a selection of different data sets of sources defining primary care was analyzed by the group, each participant collecting a set of sources, from which a synthesis was made and discussed. A definition of primary care at different levels (international, European and French) was summarized. A special attention was given to the French context in order to adapt the perimeter to the characteristics of the French healthcare system, notably by illustrating the different key elements of the definition with the inclusion of primary care actors and the type of practice premises. In conclusion, this work illustrates the diversity of primary care in France and the potential offered for research purposes. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
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Measuring the strength of primary care systems in Europe.
Kringos, D.S.; Boerma, W.G.W.
2009-01-01
Background: The investment in primary care (PC) reforms to improve the overall performance of health care systems has been substantial in Europe. There is however a lack of up to date comparable information to evaluate the development and strength of PC systems. This EU-funded Primary Health Care
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Acceptance of Ambulatory Laparoscopic Cholecystectomy in Central Switzerland.
Widjaja, Sandra P; Fischer, Henning; Brunner, Alexander R; Honigmann, Philipp; Metzger, Jürg
2017-11-01
Currently, most patients undergoing laparoscopic cholecystectomy (LC) in Switzerland are inpatients for 2-3 days. Due to a lack of available hospital beds, we asked whether day-case surgery would be an option for patients in central Switzerland. The questions of acceptability of outpatient LC and factors contributing to the acceptability thus arose. Hundred patients suffering from symptomatic cholecystolithiasis, capable of communicating in German, and between 18 and 65 years old, were included. Patients received a pre-operative questionnaire on medical history and social situation when informed consent on surgery and participation in the study was obtained. Exclusion criteria were patients suffering from acute cholecystitis or any type of cancer; having a BMI >40 kg/m 2 ; needing conversion to open cholecystectomy or an intraoperative drainage; and non-German speakers. Surgery was performed laparoscopically. Both surgeon and patient filled in a postoperative questionnaire. The surgeon's questionnaire listed medical and technical information, and the patients' questionnaire listed medical information, satisfaction with the treatment and willingness to be released on the same day. These data from both questionnaires were grouped into social and medical factors and analysed on their influence upon willingness to accept an ambulatory procedure. No outpatient follow-up apart from checking for readmission to our hospital within 1 month after discharge was performed. Of the 100 participants, one-third was male. More than two-thirds were Swiss citizens. Only one participant was ineligible for rapid release evaluation due to need of a drainage. Among the social factors contributing to the acceptability of ambulatory care, we found nationality to be relevant; Swiss citizens preferred an inpatient procedure, whereas non-Swiss citizens were significantly more willing to return home on the same day. Household size, sex and age did not correlate with a preference for
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Gustafsson, Lars L; Wettermark, Björn; Godman, Brian; Andersén-Karlsson, Eva; Bergman, Ulf; Hasselström, Jan; Hensjö, Lars-Olof; Hjemdahl, Paul; Jägre, Ingrid; Julander, Margaretha; Ringertz, Bo; Schmidt, Daniel; Sjöberg, Susan; Sjöqvist, Folke; Stiller, Carl-Olav; Törnqvist, Elisabeth; Tryselius, Rolf; Vitols, Sigurd; von Bahr, Christer
2011-04-01
The aim was to present and evaluate the impact of a comprehensive strategy over 10 years to select, communicate and achieve adherence to essential drug recommendations (EDR) in ambulatory care in a metropolitan healthcare region. EDRs were issued and launched as a 'Wise List' by the regional Drug and Therapeutics Committee in Stockholm. This study presents the concept by: (i) documenting the process for selecting, communicating and monitoring the impact of the 'Wise List'; (ii) analysing the variation in the number of drug substances recommended between 2000 and 2010; (iii) assessing the attitudes to the 'Wise List' among prescribers and the public; (iv) evaluating the adherence to recommendations between 2003 and 2009. The 'Wise List' consistently contained 200 drug substances for treating common diseases. The drugs were selected based on their efficacy, safety, suitability and cost-effectiveness. The 'Wise List' was known among one-third of a surveyed sample of the public in 2002 after initial marketing campaigns. All surveyed prescribers knew about the concept and 81% found the recommendations trustworthy in 2005. Adherence to recommendations increased from 69% in 1999 to 77% in 2009. In primary care, adherence increased from 83% to 87% from 2003 to 2009. The coefficient of variation (CV%) decreased from 6.1% to 3.8% for 156 healthcare centres between these years. The acceptance of the 'Wise List' in terms of trust among physicians and among the public and increased adherence may be explained by clear criteria for drug recommendations, a comprehensive communication strategy, electronic access to recommendations, continuous medical education and involvement of professional networks and patients.
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Shaheen, Amy; Papp, Klara K; Torre, Dario
2013-01-01
Education in the ambulatory setting should be an integral part of undergraduate medical education. However, previous studies have shown education in this setting has been lacking in medical school. Ambulatory education occurs on some internal medicine clerkships. The extent of this education is unclear. The purpose of this survey was to assess the structure, curriculum, assessment methods, and barriers to implementation of ambulatory education on the internal medicine clerkship. An annual survey of institutional members of the Clerkship Directors in Internal Medicine (CDIM) was done in April 2010. The data were anonymous and descriptive statistics were used to summarize responses. Free text results were analyzed using qualitative techniques. The response rate was 75%. The majority of respondents had a required ambulatory component to the clerkship. Ambulatory experiences distinct from the inpatient internal medicine experience were common (46%). Integration with either the inpatient experiences or other departmental clerkships also occurred. The majority of ambulatory educational experiences were with generalists (74%) and/or subspecialists (45%). The most common assessment tool was the National Board of Medical Examiners (NBME) ambulatory shelf exam. Thematic analysis of the question about how practice based learning was taught elicited four major themes: Not taught; taught in the context of learning evidence based medicine; taught while learning chronic disease management with quality improvement; taught while learning about health care finance. Barriers to implementation included lack of faculty and financial resources. There have been significant increases in the amount of time dedicated to ambulatory internal medicine. The numbers of medical schools with ambulatory internal medicine education has increased. Integration of the ambulatory experiences with other clerkships such as family medicine occurs. Curriculum was varied but difficulties with dissemination
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Renda, Rahime
2018-04-01
Obesity in adults has been related to hypertension and abnormal nocturnal dipping of blood pressure, which are associated with poor cardiovascular and renal outcomes. Here, we aimed to resolve the relationship between the degree of obesity, the severity of hypertension and dipping status on ambulatory blood pressure in obese children. A total 72 patients with primary obesity aged 7 to 18 years (mean: 13.48 ± 3.25) were selected. Patients were divided into three groups based on body mass index (BMİ) Z-score. Diagnosis and staging of ambulatory hypertension based on 24-h blood pressure measurements, obtained from ambulatory blood pressure monitoring. Based on our ambulatory blood pressure data, 35 patients (48.6%) had hypertension, 7 (20%) had ambulatory prehypertension, 21 (60%) had hypertension, and 7 patients (20%) had severe ambulatory hypertension. There was a significant relationship between severity of hypertension and the degree of obesity (p lood pressure results and loads were similar between groups. Diastolic and mean arterial blood pressure levels during the night, diastolic blood pressure loads, and heart rate during the day were significantly higher in Group 3 (p lood pressure at night, mean arterial pressure at night, diastolic blood pressure loads and heart rate at day. Increase in BMI Z-score does not a significant impact on daytime blood pressure and nocturnal dipping status.
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Doricci, Giovanna Cabral; Guanaes-Lorenzi, Carla; Pereira, Maria José Bistafa
2017-06-01
In 2009, the Secretary of State for Health of Sao Paulo created a Program with a view to qualify the primary care in the state. This proposal includes a new job function, namely the articulator of primary care. Due to the scarcity of information about the practice of these new professionals in the scientific literature, this article seeks to analyze how articulators interpret their function and how they describe their daily routines. Thirteen articulators were interviewed. The interviews were duly analyzed by qualitative delineation. The results describe three themes: 1)Roles of the articulator: technical communicator and political advisor; 2) Activities performed to comply with the expected roles, examples being diagnosis of the municipalities, negotiation of proposals, participation in meetings, visits to municipalities; and 3) Challenges of the role, which are configured as challenges to the health reform process, examples being the lack of physical and human resources, activities of professionals in the medical-centered model, among others. The conclusion drawn is that the Program has great potential to provide input for the development and enhancement of Primary Care. Nevertheless, there are a series of challenges to be overcome, namely challenges to the context per se.
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Is primary care access to CT brain examinations effective?
International Nuclear Information System (INIS)
Benamore, R.E.; Wright, D.; Britton, I.
2005-01-01
AIM: Primary care access to CT head examinations could enable common neurological conditions to be managed within primary care. Outcome data from the first 8 years of a local service were used to identify effective referral criteria. METHODS: Primary care head CT results from 1 March 1995 to 31 October 2003 were categorized as normal, incidental or significant findings. Normal reports were cross-referenced for referral to secondary care. Case notes with incidental or significant CT findings were reviewed for secondary care attendance and outcome. RESULTS: Records of 1403/1645 CT head examinations (85%) were available for review. Of these 1403, 951 (67.8%) returned normal findings, 317 (22.6%) incidental findings and 135 (9.6%) significant findings. The commonest indication for referral was investigation of headaches (46.6%). Of the total 533 patients under 50 years of age, 13 (2.4%) yielded significant findings and all 13 showed other features in addition to headache. Of 314 cases presenting with focal neurology, 83 (26.4%) showed significant findings. 314 patients were referred from primary to secondary care. 189 had normal scans and 74 had findings described as incidental. 60% of secondary care referrals were for normal CT scans. In patients with focal neurology, 90 of 314 were referred, allowing 71% to be managed in primary care. Yield was also 0% for headaches, dizziness, visual disturbance or nausea and vomiting. CONCLUSION: Primary care access to CT brain examinations is effective for patients with focal neurology, neurological symptoms or a known malignancy, but not for patients aged less than 50 years, or with uncomplicated headaches, dizziness or diplopia
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Is primary care access to CT brain examinations effective?
Energy Technology Data Exchange (ETDEWEB)
Benamore, R.E. [Department of Radiology, Pilgrim Hospital, Boston (United Kingdom)]. E-mail: rachelbenamore@doctors.org.uk; Wright, D. [Department of Radiology, Pilgrim Hospital, Boston (United Kingdom); Britton, I. [Department of Radiology, Pilgrim Hospital, Boston (United Kingdom)
2005-10-01
AIM: Primary care access to CT head examinations could enable common neurological conditions to be managed within primary care. Outcome data from the first 8 years of a local service were used to identify effective referral criteria. METHODS: Primary care head CT results from 1 March 1995 to 31 October 2003 were categorized as normal, incidental or significant findings. Normal reports were cross-referenced for referral to secondary care. Case notes with incidental or significant CT findings were reviewed for secondary care attendance and outcome. RESULTS: Records of 1403/1645 CT head examinations (85%) were available for review. Of these 1403, 951 (67.8%) returned normal findings, 317 (22.6%) incidental findings and 135 (9.6%) significant findings. The commonest indication for referral was investigation of headaches (46.6%). Of the total 533 patients under 50 years of age, 13 (2.4%) yielded significant findings and all 13 showed other features in addition to headache. Of 314 cases presenting with focal neurology, 83 (26.4%) showed significant findings. 314 patients were referred from primary to secondary care. 189 had normal scans and 74 had findings described as incidental. 60% of secondary care referrals were for normal CT scans. In patients with focal neurology, 90 of 314 were referred, allowing 71% to be managed in primary care. Yield was also 0% for headaches, dizziness, visual disturbance or nausea and vomiting. CONCLUSION: Primary care access to CT brain examinations is effective for patients with focal neurology, neurological symptoms or a known malignancy, but not for patients aged less than 50 years, or with uncomplicated headaches, dizziness or diplopia.
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Directory of Open Access Journals (Sweden)
Aina O. Odusola
2016-02-01
Full Text Available Background: Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA that can be modified through timely and long-term treatment in primary care. Objective: We explored perspectives of primary care staff and health insurance managers on enablers and barriers for implementing high-quality hypertension care, in the context of a community-based health insurance programme in rural Nigeria. Design: Qualitative study using semi-structured individual interviews with primary care staff (n = 11 and health insurance managers (n=4. Data were analysed using standard qualitative techniques. Results: Both stakeholder groups perceived health insurance as an important facilitator for implementing high-quality hypertension care because it covered costs of care for patients and provided essential resources and incentives to clinics: guidelines, staff training, medications, and diagnostic equipment. Perceived inhibitors included the following: high staff workload; administrative challenges at facilities; discordance between healthcare provider and insurer on how health insurance and provider payment methods work; and insufficient fit between some guideline recommendations and tools for patient education and characteristics/needs of the local patient population. Perceived strategies to address inhibitors included the following: task-shifting; adequate provider payment benchmarking; good provider–insurer relationships; automated administration systems; and tailoring guidelines/patient education. Conclusions: By providing insights into perspectives of primary care providers and health insurance managers, this study offers information on potential strategies for implementing high-quality hypertension care for insured patients in SSA.
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Directory of Open Access Journals (Sweden)
Vanessa Bertoglio Comassetto Antunes de Oliveira
2015-02-01
Full Text Available OBJECTIVE To compare the health assistance models of Basic Traditional Units (UBS with the Family Health Strategy (ESF units for presence and extent of attributes of Primary Health Care (APS, specifically in the care of children. METHOD A cross-sectional study of a quantitative approach with families of children attended by the Public Health Service of Colombo, Paraná. The Primary Care Assessment Tool (PCA-Tool was applied to parents of 482 children, 235 ESF units and 247 UBS units covering all primary care units of the municipality, between June and July 2012. The results were analyzed according to the PCA-Tool manual. RESULTS ESF units reached a borderline overall score for primary health care standards. However, they fared better in their attributes of Affiliation, Integration of care coordination, Comprehensiveness, Family Centeredness and Accessibility of use, while the attributes of Community Guidance/Orientation, Coordination of Information Systems, Longitudinality and Access attributes were rated as insufficient for APS. UBS units had low scores on all attributes. CONCLUSION The ESF units are closer to the principles of APS (Primary Health Care, but there is need to review actions of child care aimed at the attributes of APS in both care models, corroborating similar studies from other regions of Brazil.
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Improving Quality of Care in Primary Health-Care Facilities in Rural Nigeria
Ugo, Okoli; Ezinne, Eze-Ajoku; Modupe, Oludipe; Nicole, Spieker; Kelechi, Ohiri
2016-01-01
Background: Nigeria has a high population density but a weak health-care system. To improve the quality of care, 3 organizations carried out a quality improvement pilot intervention at the primary health-care level in selected rural areas. Objective: To assess the change in quality of care in primary health-care facilities in rural Nigeria following the provision of technical governance support and to document the successes and challenges encountered. Method: A total of 6 states were selected across the 6 geopolitical zones of the country. However, assessments were carried out in 40 facilities in only 5 states. Selection was based on location, coverage, and minimum services offered. The facilities were divided randomly into 2 groups. The treatment group received quality-of-care assessment, continuous feedback, and improvement support, whereas the control group received quality assessment and no other support. Data were collected using the SafeCare Healthcare Standards and managed on the SafeCare Data Management System—AfriDB. Eight core areas were assessed at baseline and end line, and compliance to quality health-care standards was compared. Result: Outcomes from 40 facilities were accepted and analyzed. Overall scores increased in the treatment facilities compared to the control facilities, with strong evidence of improvement (t = 5.28, P = .0004) and 11% average improvement, but no clear pattern of improvement emerged in the control group. Conclusion: The study demonstrated governance support and active community involvement offered potential for quality improvement in primary health-care facilities. PMID:28462280
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An Anesthetist’s Experience and the Incidence of Critical Cases in Ambulatory Surgery
Directory of Open Access Journals (Sweden)
R. V. Bolshedvorov
2009-01-01
Full Text Available Objective: to evaluate the impact of experience on the quality of anesthesia in ambulatory surgery. Materials and methods. The authors undertook a study of the role of experience and specialization on the occurrence of complications in ambulatory anesthesia care. By using the internal audit and calculating the frequency of critical cases, they examined the results of the work of two groups of anesthetists: 1 medical beginners after 2-year adjunct practice and 2 one-day hospital specialists having an at least 7-year practice length. Results. In the beginner group, the number of critical cases per operation was twice higher than that in the experienced specialists. The paper shows the detrimental pattern of the residual principle in selecting anesthetists for work at a one-day hospital and provides evidence that specialization is required in the area under discussion. Key words: ambulatory anesthesiology, role of an anesthetist’s experience, critical cases.
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Anesthesia for Ambulatory Pediatric Surgery in Sub-Saharan Africa: A Pilot Study in Burkina Faso.
Kabré, Yvette B; Traoré, Idriss S S; Kaboré, Flavien A R; Ki, Bertille; Traoré, Alain I; Ouédraogo, Isso; Bandré, Emile; Wandaogo, Albert; Ouédraogo, Nazinigouba
2017-02-01
Long surgical wait times and limited hospital capacity are common obstacles to surgical care in many countries in Sub-Saharan Africa (SSA). Introducing ambulatory surgery might contribute to a solution to these problems. The purpose of this study was to evaluate the safety and feasibility of introducing ambulatory surgery into a pediatric hospital in SSA. This is a cross-sectional descriptive study that took place over 6 months. It includes all patients assigned to undergo ambulatory surgery in the Pediatric University Hospital in Ouagadougou, Burkina Faso. Eligibility criteria for the ambulatory surgery program included >1 year of age, American Society of Anesthesiologists (ASA) 1 status, surgery with a low risk of bleeding, lasting anesthesia with halothane. Sixty-five percent also received regional or local anesthesia consisting of caudal block in 79.23% or nerve block in 20.77%. The average duration of surgery was 33 ± 17.47 minutes. No intraoperative complications were noted. All the patients received acetaminophen and a nonsteroidal anti-inflammatory drug in the recovery room. Twelve (11.7%) patients had complications in recovery, principally nausea and vomiting. Eight (7.8%) patients were admitted to the hospital. No serious complications were associated with ambulatory surgery. Its introduction could possibly be a solution to improving pediatric surgical access in low-income countries.
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Exodus of male physicians from primary care drives shift to specialty practice.
Tu, Ha T; O'Malley, Ann S
2007-06-01
An exodus of male physicians from primary care is driving a marked shift in the U.S. physician workforce toward medical-specialty practice, according to a national study by the Center for Studying Health System Change (HSC). Two factors have helped mask the severity of the shift--a growing proportion of female physicians, who disproportionately choose primary care, and continued reliance on international medical graduates (IMGs), who now account for nearly a quarter of all U.S. primary care physicians. Since 1996-97, a 40 percent increase in the female primary care physician supply has helped to offset a 16 percent decline in the male primary care physician supply relative to the U.S. population. At the same time, primary care physicians' incomes have lost ground to both inflation and medical and surgical specialists' incomes. And women in primary care face a 22 percent income gap relative to men, even after accounting for differing characteristics. If real incomes for primary care physicians continue to decline, there is a risk that the migration of male physicians will intensify and that female physicians may begin avoiding primary care--trends that could aggravate a predicted shortage of primary care physicians.
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Management of postmenopausal osteoporosis for primary care.
Miller, P; Lukert, B; Broy, S; Civitelli, R; Fleischmann, R; Gagel, R; Khosla, S; Lucas, M; Maricic, M; Pacifici, R; Recker, R; Sarran, H S; Short, B; Short, M J
1998-01-01
The shift in health care delivery from a subspecialty to primary care system has transferred the responsibility of preventing osteoporotic fractures from specialists in metabolic bone disease to the web of physicians--family practitioners, general internists, pediatricians, and gynecologists--who provide the bulk of primary care. The challenge for this group of physicians is to decrease the rising prevalence of osteoporotic hip and vertebral fractures while operating within the cost parameters. It is the goal of this brief summary to provide primary practitioners with focused guidelines for the management of postmenopausal osteoporosis based on new and exciting developments. Prevention and treatment will change rapidly over the next decade and these advances will require changes in these recommendations. We identified patients at risk for osteoporosis and provided indications for bone mass measurement, criteria for diagnosis of osteoporosis, therapeutic interventions, and biochemical markers of the disease. Prevention and treatment are discussed, including hormone replacement therapy and use of calcitonin, sodium fluoride, bisphosphonates, and serum estrogen receptor modulators. Postmenopausal osteoporosis should no longer be an accepted process of aging. It is both preventable and treatable. Primary care physicians must proactively prevent and treat osteoporosis in their daily practice, and combination therapies are suggested.
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Providing primary health care with non-physicians.
Chen, P C
1984-04-01
The definition of primary health care is basically the same, but the wide variety of concepts as to the form and type of worker required is largely due to variations in economic, demographic, socio-cultural and political factors. Whatever form it takes, in many parts of the developing world, it is increasingly clear that primary health care must be provided by non-physicians. The reasons for this trend are compelling, yet it is surprisingly opposed by the medical profession in many a developing country. Nonetheless, numerous field trials are being conducted in a variety of situations in several countries around the world. Non-physician primary health care workers vary from medical assistants and nurse practitioners to aide-level workers called village mobilizers, village volunteers, village aides and a variety of other names. The functions, limitations and training of such workers will need to be defined, so that an optimal combination of skills, knowledge and attitudes best suited to produce the desired effect on local health problems may be attained. The supervision of such workers by the physician and other health professionals will need to be developed in the spirit of the health team. An example of the use of non-physicians in providing primary health care in Sarawak is outlined.
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2001 survey on primary medical care in Singapore.
Emmanuel, S C; Phua, H P; Cheong, P Y
2004-05-01
The 2001 survey on primary medical care was undertaken to compare updated primary healthcare practices such as workload and working hours in the public and private sectors; determine private and public sector market shares in primary medical care provision; and gather the biographical profile and morbidity profile of patients seeking primary medical care from both sectors in Singapore. This is the third survey in its series, the earlier two having been carried out in 1988 and 1993, respectively. The survey questionnaire was sent out to all the 1480 family doctors in private primary health outpatient practice, the 89 community-based paediatricians in the private sector who were registered with the Singapore Medical Council and also to all 152 family doctors working in the public sector primary medical care clinics. The latter comprised the polyclinics under the two health clusters in Singapore, namely the Singapore Health Services and National Healthcare Group, and to a very much smaller extent, the School Health Service's (SHS) outpatient clinics. The survey was conducted on 21 August 2001, and repeated on 25 September 2001 to enable those who had not responded to the original survey date to participate. Subjects consisted of all outpatients who sought treatment at the private family practice clinics (including the clinics of the community-based paediatricians), and the public sector primary medical care clinics, on the survey day. The response rate from the family doctors in private practice was 36 percent. Owing to the structured administrative organisation of the polyclinics and SHS outpatient clinics, all returns were completed and submitted to the respective headquarters. Response from the community-based paediatricians was poor, so their findings were omitted in the survey analysis. The survey showed that the average daily patient-load of a family doctor in private practice was 33 patients per day, which was lower than the 40 patients a day recorded in 1993
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Consulting Psychiatry within an Integrated Primary Care Model
Schreiter, Elizabeth A. Zeidler; Pandhi, Nancy; Fondow, Meghan D. M.; Thomas, Chantelle; Vonk, Jantina; Reardon, Claudia L.; Serrano, Neftali
2014-01-01
Summary After implementation of an integrated consulting psychiatry model and psychology services within primary care at a federally qualified health center, patients have increased access to needed mental health services, and primary care clinicians receive the support and collaboration needed to meet the psychiatric needs of the population. PMID:24185149
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COMMUNITY MEDICINE & PRIMARY HEALTH CARE
African Journals Online (AJOL)
ajiboro
3Department of Community and Primary Health Care, College of Medicine, University of Lagos, Idiaraba, ... Some of the participants (45.3%) carry out physical exercises such as walking ..... hypertension, continuous effective management of.
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An efficient and effective teaching model for ambulatory education.
Regan-Smith, Martha; Young, William W; Keller, Adam M
2002-07-01
Teaching and learning in the ambulatory setting have been described as inefficient, variable, and unpredictable. A model of ambulatory teaching that was piloted in three settings (1973-1981 in a university-affiliated outpatient clinic in Portland, Oregon, 1996-2000 in a community outpatient clinic, and 2000-2001 in an outpatient clinic serving Dartmouth Medical School's teaching hospital) that combines a system of education and a system of patient care is presented. Fully integrating learners into the office practice using creative scheduling, pre-rotation learning, and learner competence certification enabled the learners to provide care in roles traditionally fulfilled by physicians and nurses. Practice redesign made learners active members of the patient care team by involving them in such tasks as patient intake, histories and physicals, patient education, and monitoring of patient progress between visits. So that learners can be active members of the patient care team on the first day of clinic, pre-training is provided by the clerkship or residency so that they are able to competently provide care in the time available. To assure effective education, teaching and learning times are explicitly scheduled by parallel booking of patients for the learner and the preceptor at the same time. In the pilot settings this teaching model maintained or improved preceptor productivity and on-time efficiency compared with these outcomes of traditional scheduling. The time spent alone with patients, in direct observation by preceptors, and for scheduled case discussion was appreciated by learners. Increased satisfaction was enjoyed by learners, teachers, clinic staff, and patients. Barriers to implementation include too few examining rooms, inability to manipulate patient appointment schedules, and learners' not being present in a teaching clinic all the time.
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Improving Communication About Serious Illness in Primary Care: A Review.
Lakin, Joshua R; Block, Susan D; Billings, J Andrew; Koritsanszky, Luca A; Cunningham, Rebecca; Wichmann, Lisa; Harvey, Doreen; Lamey, Jan; Bernacki, Rachelle E
2016-09-01
The Institute of Medicine recently called for systematic improvements in clinician-led conversations about goals, values, and care preferences for patients with serious and life-threatening illnesses. Studies suggest that these conversations are associated with improved outcomes for patients and their families, enhanced clinician satisfaction, and lower health care costs; however, the role of primary care clinicians in driving conversations about goals and priorities in serious illness is not well defined. To present a review of a structured search of the evidence base about communication in serious illness in primary care. MEDLINE was searched, via PubMed, on January 19, 2016, finding 911 articles; 126 articles were reviewed and selected titles were added from bibliography searches. Review of the literature informed 2 major topic areas: the role of primary care in communication about serious illness and clinician barriers and system failures that interfere with effective communication. Literature regarding the role that primary care plays in communication focused primarily on the ambiguity about whether primary care clinicians or specialists are responsible for initiating conversations, the benefits of primary care clinicians and specialists conducting conversations, and the quantity and quality of discussions. Timely and effective communication about serious illness in primary care is hampered by key clinician barriers, which include deficits in knowledge, skills, and attitudes; discomfort with prognostication; and lack of clarity about the appropriate timing and initiation of conversations. Finally, system failures in coordination, documentation, feedback, and quality improvement contribute to lack of conversations. Clinician and system barriers will challenge primary care clinicians and institutions to meet the needs of patients with serious illness. Ensuring that conversations about goals and values occur at the appropriate time for seriously ill patients will
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Jenkins, Rachel; Othieno, Caleb; Okeyo, Stephen; Aruwa, Julyan; Kingora, James; Jenkins, Ben
2013-09-30
Health system weaknesses in Africa are broadly well known, constraining progress on reducing the burden of both communicable and non-communicable disease (Afr Health Monitor, Special issue, 2011, 14-24), and the key challenges in leadership, governance, health workforce, medical products, vaccines and technologies, information, finance and service delivery have been well described (Int Arch Med, 2008, 1:27). This paper uses focus group methodology to explore health worker perspectives on the challenges posed to integration of mental health into primary care by generic health system weakness. Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 20 health workers drawn from a randomised controlled trial to evaluate the impact of a mental health training programme for primary care, 10 from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training). These focus group discussions suggested that there are a number of generic health system weaknesses in Kenya which impact on the ability of health workers to care for clients with mental health problems and to implement new skills acquired during a mental health continuing professional development training programmes. These weaknesses include the medicine supply, health management information system, district level supervision to primary care clinics, the lack of attention to mental health in the national health sector targets, and especially its absence in district level targets, which results in the exclusion of mental health from such district level supervision as exists, and the lack of awareness in the district management team about mental health. The lack of mental health coverage included in HIV training courses experienced by the health workers was also striking, as was the intensive focus during district supervision on HIV to the detriment of other
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2013-09-13
... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-9953-PN] Health Insurance Exchanges; Application by the Accreditation Association for Ambulatory Health Care To Be... Federal Register announcing the result of our determination. (Health Insurance Exchanges; Application by...
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Primary Care Practice Transformation and the Rise of Consumerism.
Shrank, William H
2017-04-01
Americans are increasingly demanding the same level of service in healthcare that they receive in other services and products that they buy. This rise in consumerism poses challenges for primary care physicians as they attempt to transform their practices to succeed in a value-based reimbursement landscape, where they are rewarded for managing costs and improving the health of populations. In this paper, three examples of consumer-riven trends are described: retail healthcare, direct and concierge care, and home-based diagnostics and care. For each, the intersection of consumer-driven care and the goals of value-based primary care are explored. If the correct payment and connectivity enablers are in place, some examples of consumer-driven care are well-positioned to support primary care physicians in their mission to deliver high-quality, efficient care for the populations they serve. However, concerns about access and equity make other trends less consistent with that mission.
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Health coaching in primary care: a feasibility model for diabetes care.
Liddy, Clare; Johnston, Sharon; Nash, Kate; Ward, Natalie; Irving, Hannah
2014-04-03
Health coaching is a new intervention offering a one-on-one focused self-management support program. This study implemented a health coaching pilot in primary care clinics in Eastern Ontario, Canada to evaluate the feasibility and acceptability of integrating health coaching into primary care for patients who were either at risk for or diagnosed with diabetes. We implemented health coaching in three primary care practices. Patients with diabetes were offered six months of support from their health coach, including an initial face-to-face meeting and follow-up by email, telephone, or face-to-face according to patient preference. Feasibility was assessed through provider focus groups and qualitative data analysis methods. All three sites were able to implement the program. A number of themes emerged from the focus groups, including the importance of physician buy-in, wide variation in understanding and implementing of the health coach role, the significant impact of different systems of team communication, and the significant effect of organizational structure and patient readiness on Health coaches' capacity to perform their role. It is feasible to implement health coaching as an integrated program within small primary care clinics in Canada without adding additional resources into the daily practice. Practices should review their organizational and communication processes to ensure optimal support for health coaches if considering implementing this intervention.
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Advancing primary care to promote equitable health: implications for China
Directory of Open Access Journals (Sweden)
Hung Li-Mei
2012-01-01
Full Text Available Abstract China is a country with vast regional differences and uneven economic development, which have led to widening gaps between the rich and poor in terms of access to healthcare, quality of care, and health outcomes. China's healthcare reform efforts must be tailored to the needs and resources of each region and community. Building and strengthening primary care within the Chinese health care system is one way to effectively address health challenges. This paper begins by outlining the concept of primary care, including key definitions and measurements. Next, results from a number of studies will demonstrate that primary care characteristics are associated with savings in medical costs, improvements in health outcomes and reductions in health disparities. This paper concludes with recommendations for China on successfully incorporating a primary care model into its national health policy, including bolstering the primary care workforce, addressing medical financing structures, recognizing the importance of evidence-based medicine, and looking to case studies from countries that have successfully implemented health reform.
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Oncology in primary health care
International Nuclear Information System (INIS)
Mendoza del Pino, Mario Valentín
2009-01-01
The book O ncology in the primary health care , constitutes an important contribution to the prevention and treatment of cancer, from a very comprehensive assessment. It's a disease that is the second leading cause of death in our country, to much pain and suffering is for the patient and their family. The book has a very useful for basic health equipment approach, since it emphasizes that cancer can be prevented if achieved in the population changes in lifestyle. The book is valued not correct food as responsible for one third of all cancers. Currently important research being developed in relation to psiconeuroinmuno-Endocrinology, who is studying the association between psychological factors and the development of cancer valuing that kept stress and depression reduces the antitumor activity of the immune system; that made programs with encouraging results where the treatment of cancer has joined elements of psychotherapy, immunotherapy and the use of the biotherapy. The focus of the book fills an important place in the primary health care and is an indispensable guide for professionals at this level of care (author)
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Directory of Open Access Journals (Sweden)
Kuo Christina L
2003-05-01
Full Text Available Abstract Background While physicians are key to primary preventive care, their delivery rate is sub-optimal. Assessment of physician beliefs is integral to understanding current behavior and the conceptualization of strategies to increase delivery. Methods A focus group with regional primary care physician (PCP Opinion Leaders was conducted as a formative step towards regional assessment of attitudes and barriers regarding preventive care delivery in primary care. Following the PRECEDE-PROCEED model, the focus group aim was to identify conceptual themes that characterize PCP beliefs and practices regarding preventive care. Seven male and five female PCPs (family medicine, internal medicine participated in the audiotaped discussion of their perceptions and behaviors in delivery of primary preventive care. The transcribed audiotape was qualitatively analyzed using grounded theory methodology. Results The PCPs' own perceived role in daily practice was a significant barrier to primary preventive care. The prevailing PCP model was the "one-stop-shop" physician who could provide anything from primary to tertiary care, but whose provision was dominated by the delivery of immediate diagnoses and treatments, namely secondary care. Conclusions The secondary-tertiary prevention PCP model sustained the expectation of immediacy of corrective action, cure, and satisfaction sought by patients and physicians alike, and, thereby, de-prioritized primary prevention in practice. Multiple barriers beyond the immediate control of PCP must be surmounted for the full integration of primary prevention in primary care practice. However, independent of other barriers, physician cognitive value of primary prevention in practice, a base mediator of physician behavior, will need to be increased to frame the likelihood of such integration.
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Directory of Open Access Journals (Sweden)
Daniele Favaro Ribeiro
2009-12-01
DPAC.Objectives: To describe the elders with end stage renal disease (ESRD undergoing continuous ambulatory peritoneal dialysis (CAPD, their caregivers, and the care the caregivers provide to the elders. Methods: This was a qualitative study with 9 caregivers. Data were collected through oral history. Data analysis consisted of thematic content analysis. Results: The sample consisted of 5 male and 4 female elders and all them were dependent on caregivers to change the dialysis collection bag. The mean age of the participants was 70 years. Among the caregivers, 8 of them were female with a mean age of 41.5 years and they provided 8 hours of care to the elders daily. The main theme emerging from the content analysis was "home care for the elderly undergoing continuous ambulatory peritoneal dialysis." Conclusion: Caregivers need support for the development of knowledge and skills to deal with the elders' demand of care, particularly in regard to the management of CAPD.
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Physician's self-perceived abilities at primary care settings in Indonesia.
Istiono, Wahyudi; Claramita, Mora; Ekawati, Fitriana Murriya; Gayatri, Aghnaa; Sutomo, Adi Heru; Kusnanto, Hari; Graber, Mark Alan
2015-01-01
Southeast Asian countries with better-skilled primary care physicians have been shown to have better health outcomes. However, in Indonesia, there has been a large number of inappropriate referrals, leading to suboptimal health outcomes. This study aimed to examine the reasons underlying the unnecessary referrals as related to Indonesian physicians' standard of abilities. This was a multiple-case study that explored physicians' self-evaluation of their abilities. Self-evaluation questionnaires were constructed from the Indonesian Standards of Physicians Competences of 2006-2012 (ISPC), which is a list of 155 diseases. This study was undertaken in three cities, three towns, and one "border-less developed" area during 2011-2014. The study involved 184 physicians in those seven districts. Data were collected using one-on-one, in-depth interviews, focus group discussions (FGDs), and clinical observations. This study found that primary care physicians in Indonesia felt that they were competent to handle less than one-third of "typical" primary care cases. The reasons were limited understanding of person-centered care principles and limited patient care services to diagnosis and treatment of common biomedical problems. Additionally, physical facilities in primary care settings are lacking. Strengthening primary health care in Indonesia requires upscaling doctors' abilities in managing health problems through more structured graduate education in family medicine, which emphasizes the bio-psycho-socio-cultural background of persons; secondly, standardizing primary care facilities to support physicians' performance is critical. Finally, a strong national health policy that recognizes the essential role of primary care physicians in health outcomes is an urgent need.
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Screening for anxiety, depression, and anxious depression in primary care
DEFF Research Database (Denmark)
Goldberg, David P.; Reed, Geoffrey M.; Robles, Rebeca
2017-01-01
Background In this field study of WHO's revised classification of mental disorders for primary care settings, the ICD-11 PHC, we tested the usefulness of two five-item screening scales for anxiety and depression to be administered in primary care settings. Methods The study was conducted in primary...... in primary care settings. Conclusions The two five-item screening scales for anxiety and depression provide a practical way for PCPs to evaluate the likelihood of mood and anxiety disorders without paper and pencil measures that are not feasible in many settings. These scales may provide substantially...... care settings in four large middle-income countries. Primary care physicians (PCPs) referred individuals who they suspected might be psychologically distressed to the study. Screening scales as well as a structured diagnostic interview, the revised Clinical Interview Schedule (CIS-R), adapted...
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Improving primary care for persons with spinal cord injury: Development of a toolkit to guide care.
Milligan, James; Lee, Joseph; Hillier, Loretta M; Slonim, Karen; Craven, Catharine
2018-05-07
To identify a set of essential components for primary care for patients with spinal cord injury (SCI) for inclusion in a point-of-practice toolkit for primary care practitioners (PCP) and identification of the essential elements of SCI care that are required in primary care and those that should be the focus of specialist care. Modified Delphi consensus process; survey methodology. Primary care. Three family physicians, six specialist physicians, and five inter-disciplinary health professionals completed surveys. Importance of care elements for inclusion in the toolkit (9-point scale: 1 = lowest level of importance, 9 = greatest level of importance) and identification of most responsible physician (family physician, specialist) for completing key categories of care. Open-ended comments were solicited. There was consensus between the respondent groups on the level of importance of various care elements. Mean importance scores were highest for autonomic dysreflexia, pain, and skin care and lowest for preventive care, social issues, and vital signs. Although, there was agreement across all respondents that family physicians should assume responsibility for assessing mental health, there was variability in who should be responsible for other care categories. Comments were related to the need for shared care approaches and capacity building and lack of knowledge and specialized equipment as barriers to optimal care. This study identified important components of SCI care to be included in a point-of-practice toolkit to facilitate primary care for persons with SCI.
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Directory of Open Access Journals (Sweden)
Bailey Kerry A
2010-08-01
Full Text Available Abstract Background Antiretroviral treatment services delivered in hospital settings in Africa increasingly lack capacity to meet demand and are difficult to access by patients. We evaluate the effectiveness of nurse led primary care based antiretroviral treatment by comparison with usual hospital care in a typical rural sub Saharan African setting. Methods We undertook a prospective, controlled evaluation of planned service change in Lubombo, Swaziland. Clinically stable adults with a CD4 count > 100 and on antiretroviral treatment for at least four weeks at the district hospital were assigned to either nurse led primary care based antiretroviral treatment care or usual hospital care. Assignment depended on the location of the nearest primary care clinic. The main outcome measures were clinic attendance and patient experience. Results Those receiving primary care based treatment were less likely to miss an appointment compared with those continuing to receive hospital care (RR 0·37, p p = 0·001. Those receiving primary care based, nurse led care were more likely to be satisfied in the ability of staff to manage their condition (RR 1·23, p = 0·003. There was no significant difference in loss to follow-up or other health related outcomes in modified intention to treat analysis. Multilevel, multivariable regression identified little inter-cluster variation. Conclusions Clinic attendance and patient experience are better with nurse led primary care based antiretroviral treatment care than with hospital care; health related outcomes appear equally good. This evidence supports efforts of the WHO to scale-up universal access to antiretroviral treatment in sub Saharan Africa.
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Integration of depression and primary care: barriers to adoption.
Grazier, Kyle L; Smith, Judith E; Song, Jean; Smiley, Mary L
2014-01-01
Despite the prevailing consensus as to its value, the adoption of integrated care models is not widespread. Thus, the objective of this article it to examine the barriers to the adoption of depression and primary care models in the United States. A literature search focused on peer-reviewed journal literature in Medline and PsycInfo. The search strategy focused on barriers to integrated mental health care services in primary care, and was based on previously existing searches. The search included: MeSH terms combined with targeted keywords; iterative citation searches in Scopus; searches for grey literature (literature not traditionally indexed by commercial publishers) in Google and organization websites, examination of reference lists, and discussions with researchers. Integration of depression care and primary care faces multiple barriers. Patients and families face numerous barriers, linked inextricably to create challenges not easily remedied by any one party, including the following: vulnerable populations with special needs, patient and family factors, medical and mental health comorbidities, provider supply and culture, financing and costs, and organizational issues. An analysis of barriers impeding integration of depression and primary care presents information for future implementation of services.
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COMMUNITY HEALTH & PRIMARY HEALTH CARE
African Journals Online (AJOL)
2Primary Health Care Department, Ikpoba Okha Local Government Area, Benin City, ... selected from each of the ten wards in the LGA using multistage sampling technique. ..... Knowledge of HIV/AIDS Insurance Companies in Lagos State.
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Pediatric Primary Care Providers' Relationships with Mental Health Care Providers: Survey Results
Pidano, Anne E.; Honigfeld, Lisa; Bar-Halpern, Miri; Vivian, James E.
2014-01-01
Background: As many as 20 % of children have diagnosable mental health conditions and nearly all of them receive pediatric primary health care. However, most children with serious mental health concerns do not receive mental health services. This study tested hypotheses that pediatric primary care providers (PPCPs) in relationships with mental…
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Electrocardiogram interpretation and arrhythmia management: a primary and secondary care survey.
Begg, Gordon; Willan, Kathryn; Tyndall, Keith; Pepper, Chris; Tayebjee, Muzahir
2016-05-01
There is increasing desire among service commissioners to treat arrhythmia in primary care. Accurate interpretation of the electrocardiogram (ECG) is fundamental to this. ECG interpretation has previously been shown to vary widely but there is little recent data. To examine the interpretation of ECGs in primary and secondary care. A cross-sectional survey of participants' interpretation of six ECGs and hypothetical management of patients based on those ECGs, at primary care educational events, and a cardiology department in Leeds. A total of 262 primary care clinicians and 20 cardiology clinicians were surveyed via questionnaire. Answers were compared with expert electrophysiologist opinion. In primary care, abnormal ECGs were interpreted as normal by 23% of responders. ST elevation and prolonged QT were incorrectly interpreted as normal by 1% and 22%, respectively. In cardiology, abnormal ECGs were interpreted as normal by 3%. ECG provision and interpretation remains inconsistent in both primary and secondary care. Primary care practitioners are less experienced and less confident with ECG interpretation than cardiologists, and require support in this area. © British Journal of General Practice 2016.
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Ambulatory surgery center market share and rates of outpatient surgery in the elderly.
Hollenbeck, Brent K; Hollingsworth, John M; Dunn, Rodney L; Zaojun Ye; Birkmeyer, John D
2010-12-01
Relative to outpatient surgery in hospital settings, ambulatory surgery centers (ASCs) are more efficient and associated with a lower cost per case. However, these facilities may also spur higher overall procedure utilization and thus lead to greater overall health care costs. The authors used the State Ambulatory Surgery Database from the State of Florida to identify Medicare-aged patients undergoing 4 common ambulatory procedures in 2006, including knee arthroscopy, cystoscopy, cataract removal, and colonoscopy. Hospital service areas (HSAs) were characterized according to ASC market share, that is, the proportion of residents undergoing outpatient surgery in these facilities. The authors then examined relationships between ASC market share and rates of each procedure. Age-adjusted rates of ambulatory surgery ranged from 190.5 cases per 1000 to 320.8 cases per 1000 in HSAs with low and high ASC market shares, respectively (P market share. The greatest difference, both in relative and absolute terms, was observed for patients undergoing cystoscopy. In areas of high ASC market share, the age-adjusted rate of cystoscopy was nearly 3-fold higher than in areas with low ASC market share (34.5 vs 11.9 per 1000 population; P elderly. Whether ASCs are meeting unmet clinical demand or spurring overutilization is not clear.
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Marginal ambulatory teaching cost under varying levels of service utilization.
Panton, D M; Mushlin, A I; Gavett, J W
1980-06-01
The ambulatory component of residency training jointly produces two products, namely, training and patient services. In costing educational programs of this type, two approaches are frequently taken. The first considers the total costs of the educational program, including training and patient services. These costs are usually constructed from historical accounting records. The second approach attempts to cost the joint products separately, based upon estimates of future changes in program costs, if the product in question is added to or removed from the program. The second approach relates to typical decisions facing the managers of medical centers and practices used for teaching purposes. This article reports such a study of costs in a primary-care residency training program in a hospital outpatient setting. The costs of the product, i.e., on-the-job training, are evaluated using a replacement-cost concept under different levels of patient services. The results show that the cost of the product, training, is small at full clinical utilization and is sensitive to changes in the volume of services provided.
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Managing obesity in primary care.
Goldie, Christine; Brown, Jenny
Obesity is a complex problem and often difficult to tackle in primary care. A year-long pilot of a practice nurse-led scheme that used a holistic approach towards self-care in obesity management was set up to reduce the cardiovascular risk of patients who were obese and improve their quality of life. This person-centred approach may offer an important tool in the management of these patients in the GP surgery.
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Environmental Factors Associated with Primary Care Access Among Urban Older Adults
Ryvicker, Miriam; Gallo, William T.; Fahs, Marianne C.
2012-01-01
Disparities in primary care access and quality impede optimal chronic illness prevention and management for older adults. Although research has shown associations between neighborhood attributes and health, little is known about how these factors – in particular, the primary care infrastructure – inform older adults’ primary care use. Using geographic data on primary care physician supply and surveys from 1,260 senior center attendees in New York City, we examined factors that facilitate and ...
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COMMUNITY HEALTH & PRIMARY HEALTH CARE
African Journals Online (AJOL)
adedamla
Quarry industry has become a major means of livelihood in Ebonyi state, but insufficient data exists on their operations ... of Dust Mask among Crushers of Selected Quarry (Crushed ... Journal of Community Medicine and Primary Health Care.
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Outsourcing of Primary Health Cares: Which Activities?
Directory of Open Access Journals (Sweden)
Sayed Mahdi Madani
2016-07-01
Full Text Available the primary health cares are among the individuals’ primary rights and their outsourcing can pave the way to more suitable use of resources for the field inside and outside of the organization and in this way make possible the better cares. The aim of this study was to determine the type of primary health cares that can be outsourced in Iran; this study embarked upon specifying which one, among the primary health cares, has ability of being outsourced by contractors outside the organization. This applied study has been done by a descriptive and cross-sectional method. According to the other studies at first a general framework was founded; hence the main framework with respect to the opinions of 30 experts. Thereafter a questionnaire was compiled for ensuring its correctness and gathering other experts’ opinions. The method of experts’ judgment was used for validity and for its reliability with distribution of 30 copies the method of calculating Cronbach’ salpha, which was 0.925. Then it was distributed among experts and 786 questionnaires were completed and collected; by using the method of factor of factor and confirmatory analysis as well as the descriptive statistics we embarked upon investigating and deducing the results. For statistical investigation the software SPSS21 and AMOS20 were used. In the factor of outsourcing activities one factor only covering 55.25% of variables variance was discovered. The results suggest that the item q10, “possibility of outsourcing the concrete activities”, with factor load of 0.791 and the item q6, "outsourcing and standardization", with factor load of 0.668 have respectively the highest load and the lowest one in the definition of the factor of cares of outsourcing. The more the primary health cares are more concrete, more simple, more standardized and have the further differentiability, their successful outsourcing is highly possible; in addition only those activities are able to be
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Directory of Open Access Journals (Sweden)
Spinhoven Philip
2009-09-01
Full Text Available Abstract Background Panic disorder (PD and generalized anxiety disorder (GAD are two of the most disabling and costly anxiety disorders seen in primary care. However, treatment quality of these disorders in primary care generally falls beneath the standard of international guidelines. Collaborative stepped care is recommended for improving treatment of anxiety disorders, but cost-effectiveness of such an intervention has not yet been assessed in primary care. This article describes the aims and design of a study that is currently underway. The aim of this study is to evaluate effects and costs of a collaborative stepped care approach in the primary care setting for patients with PD and GAD compared with care as usual. Methods/design The study is a two armed, cluster randomized controlled trial. Care managers and their primary care practices will be randomized to deliver either collaborative stepped care (CSC or care as usual (CAU. In the CSC group a general practitioner, care manager and psychiatrist work together in a collaborative care framework. Stepped care is provided in three steps: 1 guided self-help, 2 cognitive behavioral therapy and 3 antidepressant medication. Primary care patients with a DSM-IV diagnosis of PD and/or GAD will be included. 134 completers are needed to attain sufficient power to show a clinically significant effect of 1/2 SD on the primary outcome measure, the Beck Anxiety Inventory (BAI. Data on anxiety symptoms, mental and physical health, quality of life, health resource use and productivity will be collected at baseline and after three, six, nine and twelve months. Discussion It is hypothesized that the collaborative stepped care intervention will be more cost-effective than care as usual. The pragmatic design of this study will enable the researchers to evaluate what is possible in real clinical practice, rather than under ideal circumstances. Many requirements for a high quality trial are being met. Results of
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Community nurses working in piloted primary care teams: Irish Republic.
LENUS (Irish Health Repository)
Burke, Triona
2010-08-01
Primary care health services in the Irish Republic have undergone fundamental transformation with the establishment of multidisciplinary primary care teams nationwide. Primary care teams provide a community-based health service delivered through a range of health professionals in an integrated way. As part of this initiative ten pilot teams were established in 2003. This research was undertaken in order to gain an understanding of nurse\\'s experiences of working in a piloted primary care team. The methodology used was a focus group approach. The findings from this study illustrated how community nurse\\'s roles and responsibilities have expanded within the team. The findings also highlighted the benefits and challenges of working as a team with various other community-based health-care disciplines.
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Oneib, Bouchra; Sabir, Maria; Otheman, Yassine; Abda, Naima; Ouanass, Abderrazzak
2016-01-01
The aim of the study is to estimate the prevalence of suicidal ideation among Moroccan consultants in primary health care system. We conducted a cross sectional survey in three health care centers in two cities of Morocco to estimate the prevalence of suicidal ideation, plan and suicide attempts among 396 consultants in the primary health care system, using the Mini International neuropsychiatric interview. Patients were 18 years and older, without known psychiatric or chronic somatic disease. Statistical analysis was performed by the SPSS 13.0 software. The prevalence of suicidal ideation was 5.3%, and 2.7% of the patients planned their suicide and 1.2% tried to commit suicide. The multivariate analysis did not demonstrate significant association. Suicidal ideation, plan and suicide attempts are prevalent in primary health care patients, but they are still under diagnosed. An adequate training of physicians and the establishment of education programs is essential to reduce the rate of suicide.
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Self-care practice of patients with arterial hypertension in primary health care
Directory of Open Access Journals (Sweden)
Cláudia Rayanna Silva Mendes
2016-02-01
Full Text Available Objective: to evaluate the practice of self-care performed by patients with systemic arterial hypertension in primary health care. Methods: this is a descriptive and cross-sectional study, conducted with 92 individuals with arterial hypertension in a primary care unit. The data collection occurred through script and data analyzed using descriptive statistics (frequency, mean and standard deviation and through the understanding of the adaption between capacity and self-care demand. Results: it was identified as a practice of self-care: adequate water intake, salt intake and restricted coffee, satisfactory sleep period, abstinence from smoking and alcoholism, continuing pharmacological treatment and attending medical appointments. As the demands: inadequate feeding, sedentary lifestyle, had no leisure activities, self-reported stress, and limited knowledge. Conclusion: although patients performed treatment a few years ago, still showed up self-care deficits, highlighting the need for nurses to advise and sensitize about the importance of self-care practice.
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Ambulatory Assessment of Depression in Primary Care
2016-06-29
retrospective reporting of data, by obtaining the self-report closer to the actual event (Hufford, Stone, Shiffman, Schwartz, & Broderick , 2002; Stone, Shiffman...Schwartz, Broderick , & Hufford, 2003). Paper-and-pencil diaries have several advantages but also many disadvantages (Stone, Shiffman, Schwartz... Broderick , & Hufford, 2002). The advantages of paper-and-pencil diaries include: reproduced at relatively little expense, easy to handle by the
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Retail clinics versus traditional primary care: Employee satisfaction guaranteed?
Lelli, Vanessa R; Hickman, Ronald L; Savrin, Carol L; Peterson, Rachel A
2015-09-01
To examine if differences exist in the levels of autonomy and job satisfaction among primary care nurse practitioners (NPs) employed in retail clinics versus traditional primary care settings. Data were collected from 310 primary care NPs who attended the American Association of NP's 28th Annual Conference in June 2013. Participants completed a demographic form, the Misener NP Job Satisfaction Scale, and the Dempster Practice Behavior Scale. Overall, there were no differences in job satisfaction or autonomy among NPs by practice setting. Retail NPs felt less valued and were less satisfied with social interaction, but more satisfied with benefits compared to NPs in traditional settings. NPs working in retail clinics were less likely to have intentions to leave current position compared to NPs in traditional practice settings. The results of this study enhance our current understanding of the linkages between levels of autonomy, job satisfaction, and practice setting among primary care NPs. The findings of this descriptive study offer valuable insights for stakeholders devoted to the development of the primary care workforce and identify modifiable factors that may influence retention and turnover rates among NPs. ©2015 American Association of Nurse Practitioners.
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Grezzana, Guilherme B; Stein, Airton T; Pellanda, Lucia C
2017-04-01
Arterial hypertension is an important risk factor for cardiovascular outcomes. Blood pressure (BP) control levels remain largely out of target among primary healthcare (PHC) patients. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) may contribute toward the identification of cardiovascular risk groups. To assess concordance between conventional office BP measurements and 24-h ABPM of hypertension control in cardiovascular risk groups of PHC hypertensive patients. A cross-sectional study with 569 hypertensive patients was carried out. The evaluation of BP was performed by a PHC doctor, and the 24-h ABPM was performed by a different and blinded provider. The therapeutic targets for BP followed the guidance of The Eighth Joint National Committee, the Brazilian guideline, and the 2013 European Society of Hypertension. Considering the hypertension control therapeutic targets, the guidelines were not similar and were used to evaluate differences in BP value concordances compared with BP standard measurements. After a multivariate logistic regression analysis, a conventional BP was used in comparison with ABPM in different cardiovascular risk groups of hypertensive patients. According to the ABPM by European Society of Hypertension guideline, the subgroup of inactive patients (P=0.006), with altered glycemia (P=0.015) and over 30 mg/dl albuminuria (P=0.001), presented discordance among methods. When a conventional BP measurement in comparison with the ABPM results according to the Brazilian ABPM guideline was used, the discordance occurred significantly in inactive (P=0.001) and microalbuminuria more than 30 mg/dl (P=0.022) subgroups. However, in this comparison, a concordance between high-density lipoprotein more than 60 mg/dl (P=0.015) and obesity (P=0.035) subgroups occurred. Uncontrolled glucose levels, a sedentary lifestyle, and the presence of microalbuminuria correspond to some cardiovascular risk groups that would particularly benefit from 24-h
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Health psychology in primary care: recent research and future directions
Directory of Open Access Journals (Sweden)
Thielke S
2011-06-01
Full Text Available Stephen Thielke1, Alexander Thompson2, Richard Stuart31Psychiatry and Behavioral Sciences, University of Washington, Geriatric Research, Education, and Clinical Center, Puget Sound VA Medical Center, Seattle, WA, USA; 2Group Health Cooperative, Seattle, WA, USA; 3Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USAAbstract: Over the last decade, research about health psychology in primary care has reiterated its contributions to mental and physical health promotion, and its role in addressing gaps in mental health service delivery. Recent meta-analyses have generated mixed results about the effectiveness and cost-effectiveness of health psychology interventions. There have been few studies of health psychology interventions in real-world treatment settings. Several key challenges exist: determining the degree of penetration of health psychology into primary care settings; clarifying the specific roles of health psychologists in integrated care; resolving reimbursement issues; and adapting to the increased prescription of psychotropic medications. Identifying and exploring these issues can help health psychologists and primary care providers to develop the most effective ways of applying psychological principles in primary care settings. In a changing health care landscape, health psychologists must continue to articulate the theories and techniques of health psychology and integrated care, to put their beliefs into practice, and to measure the outcomes of their work.Keywords: health psychology, primary care, integrated care, collaborative care, referral, colocation
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New antithrombotic agents in the ambulatory setting.
Gibbs, Neville M; Weightman, William M; Watts, Stephen A
2014-12-01
Many patients presenting for surgical or other procedures in an ambulatory setting are taking new antiplatelet or anticoagulant agents. This review assesses how the novel features of these new agents affect the management of antithrombotic therapy in the ambulatory setting. There have been very few studies investigating the relative risks of continuing or ceasing new antithrombotic agents. Recent reviews indicate that the new antithrombotic agents offer greater efficacy or ease of administration but are more difficult to monitor or reverse. They emphasize the importance of assessing the bleeding risk of the procedure, the thrombotic risk if the agent is ceased, and patient factors that increase the likelihood of bleeding. The timing of cessation of the agent, if required, depends on its pharmacokinetics and patients' bleeding risks. Patients at high risk of thrombotic complications may require bridging therapy. Once agreed upon, the perioperative plan should be made clear to all involved. As there are few clinical studies to guide management, clinicians must make rational decisions in relation to continuing or ceasing new antithrombotic agents. This requires knowledge of their pharmacokinetics, and a careful multidisciplinary assessment of the relative thrombotic and bleeding risks in individual patients.