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.
Katz, Alan; Martens, Patricia; Chateau, Dan; Bogdanovic, Bodgan; Koseva, Ina
Adults with chronic disease are the most frequent users of the primary healthcare system. In Manitoba, patients are allowed to seek ambulatory (outpatient) care from the provider of their choosing (primary care physician or specialist), with referrals to specialists preferred but not always required. Some patients receive their routine care from specialists. We conducted this study to determine the patterns by which adults with chronic disease access ambulatory care as a prelude to exploring the impact these patterns may have on the quality of care received. Physician claims for all visits between 2007/8-2009/10 were extracted from the Data Repository at the Manitoba Centre for Health Policy. Patients included in the analysis made at least four ambulatory visits to a primary care physician or specialist within the study period, and met the definition criteria for at least one of six chronic diseases: diabetes mellitus; congestive heart failure; mood disorders; ischemic heart disease; total respiratory morbidity; and/or hypertension. Patients were "assigned" to the physician they visited most regularly. Physician visit patterns were assessed by dividing visits into nine visit types based on the type of physician patients visited (assigned primary care physician, other primary care physician, or specialist) and whether or not they received a referral. 347,606 patients with 7,662,411 physician visits were included in the analysis. Most visits were to the patients' assigned primary care physician. About 50% of the visits to specialists were by referral from the assigned primary care physician. However, 26-29% of all visits to a primary care physician were not to the assigned primary care physician, and non-assigned physicians were more likely to refer patients to specialists than assigned primary care physicians. The findings suggest that the current primary care system in Manitoba may not adequately support coordination of ambulatory care. Ambulatory visits to a
Lugo-Palacios, DG; Cairns, J
Ambulatory care sensitive hospitalisations (ACSH) have been widely used to study the quality and effectiveness of primary care. Using data from 248 general hospitals in Mexico during 2001-2011 we identify 926,769 ACSHs in 188 health jurisdictions before and during the health insurance expansion that took place in this period, and estimate a fixed effects model to explain the association of the jurisdiction ACSH rate with patient and community factors. National ACSH rate increased by 50%, but ...
Lugo-Palacios, David G; Cairns, John
Ambulatory care sensitive hospitalisations (ACSH) have been widely used to study the quality and effectiveness of primary care. Using data from 248 general hospitals in Mexico during 2001-2011 we identify 926,769 ACSHs in 188 health jurisdictions before and during the health insurance expansion that took place in this period, and estimate a fixed effects model to explain the association of the jurisdiction ACSH rate with patient and community factors. National ACSH rate increased by 50%, but trends and magnitude varied at the jurisdiction and state level. We find strong associations of the ACSH rate with socioeconomic conditions, health care supply and health insurance coverage even after controlling for potential endogeneity in the rolling out of the insurance programme. We argue that the traditional focus on the increase/decrease of the ACSH rate might not be a valid indicator to assess the effectiveness of primary care in a health insurance expansion setting, but that the ACSH rate is useful when compared between and within states once the variation in insurance coverage is taken into account as it allows the identification of differences in the provision of primary care. The high heterogeneity found in the ACSH rates suggests important state and jurisdiction differences in the quality and effectiveness of primary care in Mexico. Copyright © 2015 Elsevier Ltd. All rights reserved.
Dos Santos de Sá, Francisco; Di Lorenzo Oliveira, Cláudia; de Moura Fernandino, Débora; Menezes de Pádua, Cristiane A; Cardoso, Clareci Silva
The hospitalization for ambulatory care sensitive conditions (ACSC) has been used to assess the effectiveness of primary health care (PHC). Due to the existence of different models of organization of PHC in Brazil, it is important to develop indicators and tools for their assessment. Assessment PHC from the perspective of patients hospitalized for ACSC. A cross-sectional study was carried out. The patients were interviewed for assessment of PHC quality using the primary care assessment tool and a questionnaire. Descriptive analyses were performed and the Primary Health Care Index (PHCI) was calculated according to the health service modality, either the traditional primary health care (TPHC) or the Family Health Program (FHP). The PHCI of the two health care models were compared. A total of 314 ACSC patients were interviewed 26.4% from the FHP and 73.6% from the TPHC. In general, the PHCI dimension with the lowest score was health service access. There was no significant difference in the general PHCI for the two modalities of services (P = 0.16); however, comprehensiveness was better assessed in the TPHC, while longitudinality, family focus and community orientation were better evaluated by FHP users (P ≤ 0.05). The FHP was found to be better qualified to establish longitudinality in the community, an important dimension for continued care. However, promoting access to and consolidating a proactive care model focussed on family shows to be a great challenge for the implementation of a quality and resolutive PHC in large urban centres. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
Gonçalves, Marcelo Rodrigues; Hauser, Lisiane; Prestes, Isaías Valente; Schmidt, Maria Inês; Duncan, Bruce Bartholow; Harzheim, Erno
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: email@example.com.
Reyes-Gilabert, E; Luque-Romero, L-G; Bejarano-Avila, G; Garcia-Palma, A; Rollon-Mayordomo, A; Infante-Cossio, P
To analyze the pre- and postoperative anxiety level in patients undergoing ambulatory oral surgery (AOS) in a primary healthcare center (PHC). Prospective and descriptive clinical study on 45 patients who underwent AOS procedures in the dental clinic of a public PHC of Spain between April and September 2015. Anxiety analysis was carried out with pre- and postoperative anxiety-state (STAI-S), anxiety-trait (STAI-T) and dental anxiety (MDAS) questionnaires. A descriptive, inferential and binary logistic regression analysis were performed for the variables age, sex, educational level, previous experience of oral treatment, type of oral surgery, degree of third molar impaction, surgical time, intraoperative complications, postoperative complications, and pain score with a visual analogue scale (VAS). The majority were female (57.8%) with a mean age of 33.5±9.6 years. The most frequent procedure was the lower third molar removal (82.2%). The mean pain score on the VAS was 1.6±1.8. The incidence of complications was low (7.8%). There was a statistically significant association between post- and preoperative anxiety (r=0.56, p<0.001) and a correlation between pain score and postoperative anxiety (Rho= -0.35, p=0.02). The likelihood of postoperative anxiety was related to preoperative anxiety (OR=1.3, p=0.03). AOS in a PHC is safe and should be more encouraged in the public primary care. The emotional impact on users was relatively low, highlighting that the preoperative anxiety levels were higher than the postoperative ones. Psychological factors related to pre- and postoperative anxiety should be considered in the AOS carried out in PC.
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
Hospitalizations for ambulatory care-sensitive conditions (ACSCs) represent an indirect measure of access and quality of community care. The purpose of this study was to examine the association between one ACSC, uncomplicated hypertension, and previous primary care physician (PCP) utilization. A cohort of patients with hypertension was identified using administrative databases in Alberta between fiscal years 1994 and 2008. We applied the Canadian Institute for Health Information's case definition to detect patients with uncomplicated hypertension as the most responsible reason for hospitalization and/or Emergency Department (ED) visit. We assessed hypertension-related and all-cause PCP visits. The overall adjusted rate of ACSC hospitalizations and ED visits for uncomplicated hypertension was 7.1 and 13.9 per 10,000 hypertensive patients, respectively. The likelihood of ACSC hospitalization for uncomplicated hypertension was associated with age, household income quintile, region of residence, and Charlson comorbidity status (all P hypertension increased from 4.8 per 10,000 hypertensive patients for those without hypertension-related PCP visits before diagnosis to 10.5 per 10,000 hypertensive patients for those with 5 or more hypertension-related PCP visits. The rate of ACSC hospitalizations and/or ED visits for uncomplicated hypertension increased as the number of hypertension-related PCP visits increased even after stratifying according to demographic and clinical characteristics. As the frequency of hypertension-related PCP visits increased, the rate of ACSC hospitalizations and/or ED visits for uncomplicated hypertension increased. This suggests that ACSC hospitalization for uncomplicated hypertension might not be a particularly good indicator for access to primary care. Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
Pessanha, Paulo; Viana, Manuel; Ferreira, Paula; Bertoquini, Susana; Pol?nia, Jorge
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...
Magán, Purificación; Alberquilla, Angel; Otero, Angel; Ribera, José Manuel
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.
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
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.
Carter, Brittany U; Kaylor, Mary Beth
Hypertension is the most commonly diagnosed medical condition in the USA. Unfortunately, patients are misdiagnosed in primary care because of inaccurate office-based blood pressure measurements. Several US healthcare organizations currently recommend confirming an office-based hypertension diagnosis with ambulatory blood pressure monitoring to avoid overtreatment; however, its use for the purpose of confirming an office-based hypertension diagnosis is relatively unknown. This descriptive study surveyed 143 primary-care physicians in Oregon with regard to their current use of ambulatory blood pressure monitoring. Nineteen percent of the physicians reported that they would use ambulatory blood pressure monitoring to confirm an office-based hypertension diagnosis, although over half had never ordered it. The most frequent indication for ordering ambulatory blood pressure monitoring was to investigate suspected white-coat hypertension (37.3%). In addition, many of the practices did not own an ambulatory blood pressure monitoring device (79.7%) and, therefore, had to refer patients to other clinics or departments for testing. Many primary-care physicians will need to change their current clinical practice to align with the shift toward a confirmation process for office-based hypertension diagnoses to improve population health.
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
Mansfield Richard J
Full Text Available Abstract Background Although shoulder pain is a commonly encountered problem in primary care, there are few studies examining its presenting characteristics and clinical management in this setting. Methods We performed secondary data analysis of 692 office visits for shoulder pain collected through the National Ambulatory Medical Care Survey (Survey years 1993–2000. Information on demographic characteristics, history and place of injury, and clinical management (physician order of imaging, physiotherapy, and steroid intraarticular injection were examined. Results Shoulder pain was associated with an injury in one third (33.2% (230/692 of office visits in this population of US primary care physicians. Males, and younger adults (age ≤ 52 more often associated their shoulder pain with previous injury, but there were no racial differences in injury status. Injury-related shoulder pain was related to work in over one-fifth (21.3% (43/202 of visits. An x-ray was performed in 29.0% (164/566 of office visits, a finding that did not differ by gender, race, or by age status. Other imaging (CT scan, MRI, or ultrasound was infrequently performed (6.5%, 37/566. Physiotherapy was ordered in 23.9% (135/566 of visits for shoulder pain. Younger adults and patients with a history of injury more often had physiotherapy ordered, but there was no significant difference in the ordering of physiotherapy by gender or race. Examination of the use of intraarticular injection was not possible with this data set. Conclusion These data from the largest sample of patients with shoulder pain presenting to primary care settings offer insights into the presenting characteristics and clinical management of shoulder pain at the primary care level. The National Ambulatory Medical Care Survey is a useful resource for examining the clinical management of specific symptoms in U.S. primary care offices.
Mann, F.A.; Stewart, N.R.; Terrell, C.B.
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
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...
Rybolt, Ann H.; Staton, Lisa J.; Panda, Mukta; Jones, Roger C.
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
Palaniappan, Latha P; Wong, Eric C; Shin, Jessica J; Moreno, Maria R; Otero-Sabogal, Regina
Objective To collect patient race/ethnicity and language (r/e/l) in an ambulatory care setting. Data Sources/Study Setting The Palo Alto Medical Foundation (PAMF), December 2006–May 2008. Study Design Three pilot studies: (1) Comparing mail versus telephone versus clinic visit questionnaire distribution; (2) comparing the front desk method (FDM) versus exam room method (ERM) in the clinic visit; and (3) determining resource allocation necessary for data entry. Data Collection/Extraction Methods Studies were planned and executed by PAMF's Quality and Planning division. Principal Findings Collecting r/e/l data during clinic visits elicited the highest response rate. The FDM yielded higher response rate than the ERM. One full-time equivalent is initially necessary for data entry. Conclusions Conducting sequential studies can help guide r/e/l collection in a short time frame. PMID:19555396
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...
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.
Swan, Beth Ann; Haas, Sheila A; Chow, Marilyn
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.
Villeneuve, Julie; Genest, Jacques; Blais, Lucie; Vanier, Marie-Claude; Lamarre, Diane; Fredette, Marc; Lussier, Marie-Thérèse; Perreault, Sylvie; Hudon, Eveline; Berbiche, Djamal; Lalonde, Lyne
Background Few studies have reported the efficacy of collaborative care involving family physicians and community pharmacists for patients with dyslipidemia. Methods We randomly assigned clusters consisting of at least two physicians and at least four pharmacists to provide collaborative care or usual care. Under the collaborative care model, pharmacists counselled patients about their medications, requested laboratory tests, monitored the effectiveness and safety of medications and patients’ adherence to therapy, and adjusted medication dosages. After 12 months of follow-up, we assessed changes in low-density lipoprotein (LDL) cholesterol (the primary outcome), the proportion of patients reaching their target lipid levels and changes in other risk factors. Results Fifteen clusters representing a total of 77 physicians and 108 pharmacists were initially recruited, and a total of 51 physicians and 49 pharmacists were included in the final analyses. The collaborative care teams followed a total of 108 patients, and the usual care teams followed a total of 117 patients. At baseline, mean LDL cholesterol level was higher in the collaborative care group (3.5 v. 3.2 mmol/L, p = 0.05). During the study, patients in the collaborative care group were less likely to receive high-potency statins (11% v. 40%), had more visits with health care professionals and more laboratory tests, were more likely to have their lipid-lowering treatment changed and were more likely to report lifestyle changes. At 12 months, the crude incremental mean reduction in LDL cholesterol in the collaborative care group was −0.2 mmol/L (95% confidence interval [CI] −0.3 to −0.1), and the adjusted reduction was −0.05 (95% CI −0.3 to 0.2). The crude relative risk of achieving lipid targets for patients in the collaborative care group was 1.10 (95% CI 0.95 to 1.26), and the adjusted relative risk was 1.16 (95% CI 1.01 to 1.34). Interpretation Collaborative care involving physicians and
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.
The Evidence-base for Using Ontologies and Semantic Integration Methodologies to Support Integrated Chronic Disease Management in Primary and Ambulatory Care: Realist Review. Contribution of the IMIA Primary Health Care Informatics WG.
Liyanage, H; Liaw, S-T; Kuziemsky, C; Terry, A L; Jones, S; Soler, J K; de Lusignan, S
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.
Harpster, L M
This article discusses ambulatory care joint ventures by hospitals and selected members of their medical staffs and emphasizes the resolution of problems in the early planning stages. Failure to follow an orderly and thoughtful planning process not only risks valuable resources of the venture partners, but also jeopardizes the working relationship between the hospital and its medical staff.
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.
Success in the provision of ambulatory personal health services, i.e. providing individuals with treatment for acute illness and preventive health care on an ambulatory basis, is the most significant contributor to the health care system's performance in most developing countries. Ambulatory personal health care has the potential to contribute the largest immediate gains in health status in populations, especially for the poor. At present, such health care accounts for the largest share of the total health expenditure in most lower income countries. It frequently comprises the largest share of the financial burden on households associated with health care consumption, which is typically regressively distributed. The "organization" of ambulatory personal health services is a critical determinant of the health system's performance which, at present, is poorly understood and insufficiently considered in policies and programmes for reforming health care systems. This article begins with a brief analysis of the importance of ambulatory care in the overall health system performance and this is followed by a summary of the inadequate global data on ambulatory care organization. It then defines the concept of "macro organization of health care" at a system level. Outlined also is a framework for analysing the organization of health care services and the major pathways through which the organization of ambulatory personal health care services can affect system performance. Examples of recent policy interventions to influence primary care organization--both government and nongovernmental providers and market structure--are reviewed. It is argued that the characteristics of health care markets in developing countries and of most primary care goods result in relatively diverse and competitive environments for ambulatory care services, compared with other types of health care. Therefore, governments will be required to use a variety of approaches beyond direct public provision
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
Choi, Nam Kyong; Kim, Yooni; Lee, Seung Mi; Park, Byung Joo
To investigate the utilization patterns of non-steroidal anti-inflammatory drugs (NSAIDs) among the elderly with osteoarthritis (OA) undergoing primary ambulatory care in Busan metropolitan city, Korea. OA patients, aged 65 years and over, were identified from the Korean National Health Insurance Review Agency drug prescription database. The subjects had at least one episode of claim for OA (ICD-10-CM: M15-M19) between August 1, 2000 and February 28, 2002. Trends in the determinations of NSAIDs utilization were identified using chi-squared tests for trend. There were 47, 711 osteoarthritic patients. The total number of visits by these patients was 177, 443, with a total frequency for NSAID prescriptions of 214, 952. Seventy-nine percent of the OA patients were female. NSAIDs were prescribed on 133, 284 visits (75.1%) and the proportion of prescriptions was significantly increased with age. Only the proportion of visit when NSAIDs were prescribed decreased, from 65.1 to 43.5%, during the study period (p< 0.001). However, the proportion of combined treatments with anti-ulcer drugs was increased. The use of NSAIDs injections was decreased. Of the individual NSAIDs, diclofenac (28.7% of total frequency of NSAID prescriptions), piroxicam (15.0%) and talniflumate (8.7%), were the most frequently prescribed. Among the NSAIDs prescribed OA visits, 45.7% used two or more NSAIDs. The total proportion of NSAIDs prescribed to the osteoarthritic patients was higher than in other studies. The decline in the use of NSAIDs during the study period, and the frequent selection of safer medications, such as combination therapy with anti-ulcer drug, may reflect the risk awareness of the use of NSAIDs.
Patterson, C; Sinkewich, M; Short, J; Callas, E
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.
Rafael Antoniazzi Abaid
Full Text Available Introduction: Ambulatory Care Sensitive Conditions (ACSC are illnesses that could be prevented with adjusted ambulatorial care. ACSC have been used as indicator in effectiveness of the primary healthcare attention, through the evaluation of hospital admissions. However, we do not have studies to certify the reliability of diagnosis of ACSC in our country. Objective: To determine if the classification of ACSC from the main diagnostic field of the authorization of hospital internment (AHI is reliable. Methods: Transversal study carried through February of 2010 to January of 2011, in the city of Santa Cruz of Sul (RS. A random sample of 389 medical records was selected and evaluated by two medical appraisers. The main diagnosis in the AHI was compared with the classification in ACSC or not ACSC given for the appraisers after the study of each medical record. Kappa ratio agreement was used to calculate the reliability of the ACSC diagnostic. Results: The ratio of agreement between diagnosis from the AIH and CSAP assessment contained in the records was 92%, with a kappa coefficient of 0,784. Conclusions: The diagnostic of ACSC found in main diagnostic field of AHI showed agreement ratios over expected by chance, with kappa value equal to 0.784 and the correlation rated between substantial and almost perfect.
Vincent, Ashley H; Weber, Zachary A
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.
Grezzana, Guilherme B; Stein, Airton T; Pellanda, Lucia C
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
... 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 ...
Allen, Juliet Walshe
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.
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.
David G Lugo-Palacios; John Cairns
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 associ...
Rosemann, Thomas; Marty, Franz; Bhend, Heinz; Wagner, Judith; Brunner, Lorenzo; Zoller, Marco
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.
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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Full Text Available Frederic Kontny1, Terje Risanger2, Arne Bye3, Øyvind Arnesen4, Odd Erik Johansen4 for the TELMIMORE Study Investigators51Dept of Cardiology, Volvat Medical Centre, Oslo, Norway; 2Prinsdal Health Centre, Oslo, Norway; 3Frosta Health Centre, Frosta, Norway; 4Medical Department, Boehringer-Ingelheim Norway KS, Asker, Norway; 5The TELMIMORE Study Investigators are listed at the end of the paperPurpose: Although elevated blood pressure (BP predicts future cardiovascular events, recommended BP targets often is not reached in the general community. In a clinical real-life setting we evaluated BP impact and tolerability of the angiotensin-II receptor blocker telmisartan in patients with essential hypertension.Patients and methods: Patients in this observational study not at target BP started or switched to telmisartan monotherapy (40 or 80 mg or a fixed-dose combination of telmisartan and hydrochlorothiazide (HCT 80 mg/12.5 mg. Office and 24-hour ambulatory BP (AMBP were measured before and after 8 weeks of treatment and physicians reported perceived drug efficacy and tolerability as “Very good”, “Good”, “Moderate” or “Bad”.Results: 100 patients (34% female, 60 years, BMI 29.4 kg/m2, mean office BP 159/92 mmHg of whom 38% were treatment naïve and 30%, 17%, 9% and 6% respectively were on 1, 2, 3 or 4 BP-lowering drugs, completed 8 weeks of treatment. The proportion of patients with office BP < 140/90 mmHg increased from 3% to 54% for systolic (P < 0.001, 38% to 75% for diastolic (P < 0.001, and 2% to 45% for systolic and diastolic BP (P < 0.001. A significant effect on BP levels was seen in patients being either treatment naïve or on 1 to 3 BP-lowering drugs at study entry, whereas no BP improvement occurred in those who switched from 4 drugs. Overall, mean 24-hour AMBP was reduced from 141/85 to 131/79 mmHg (P < 0.001. Drug efficacy and tolerability were perceived as “Very good” or “Good” by 44%/34% and 66%/27%, respectively
O'Malley, Ann S; Reschovsky, James D; Saiontz-Martinez, Cynthia
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
Diverticular Disease of Intestine 562 159 558- trritable bowel Syndrome/Intestinal Disorder NEC 564 160 555- Chronic Enteritis, Ulcerative Colitis 556 161...provider identification, physical examinations, procedures performed, eligibility for care, referrals, disposition to include whether the diagnosis ...identification, physical examinations, procedures performed, eligibility for care, referrals, disposition to include whether the diagnosis was job related, and
O'Neill, Sarah; Calderon, Sherry; Casella, Joanne; Wood, Elizabeth; Carvelli-Sheehan, Jayne; Zeidel, Mark L
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.
Pearson, William S; Gift, Thomas L; Leichliter, Jami S; Jenkins, Wiley D
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.
Ji, A. L.; Davis, S. A.; Feldman, S. R.; Fleischer, A. B.; Baze, M. R.; Feldman, S. R.; Feldman, S. R.; Fleischer, A. B.
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
In ambulatory care diagnostic and therapeutic procedures may only be applied if they have a positive recommendation from the Federal Joint Committee. Both physicians and patients are bound by this rule. Limitations of ambulatory care cannot be attributed to the existing rules applicable to the funding for ambulatory care services; they only affect the pecuniary interests of Statutory Health Insurance (SHI) accredited physicians which are beyond the control of the insured. The prescription of medical drugs, supplements and health aids is subject to stronger restrictions, which can pose a dilemma for physicians: on the one hand, they are allowed by law to prescribe even the most costly medical drugs to every insured patient, if required, but on the other hand, they will have to prepare themselves for drug recourse claims. This situation can be relieved by appropriately handling reviews of so-called average prescription limits. Physicians should support the exertion of indirect influence over their prescription behaviour through measures like substitution ("aut idem" principle) and discount contracts and also, they should actively commit themselves to this approach when facing their patients. Otherwise financial viability, especially with respect to the supply with medical drugs, of the statutory health insurance system will be at risk. Copyright (c) 2010. Published by Elsevier GmbH.
Thomsen, Linda Aagaard; Winterstein, Almut G; Søndergaard, Birthe
OBJECTIVE: To estimate the incidence and describe characteristics of preventable adverse drug events (pADEs) in ambulatory care. DATA SOURCES: Studies were searched in PubMed (1966-March 2007), International Pharmaceutical Abstracts (1970-December 2006), the Cochrane database of systematic reviews...... (1993-March 2007), EMBASE (1980-February 2007), and Web of Science (1945-March 2007). Key words included medication error, adverse drug reaction, iatrogenic disease, outpatient, ambulatory care, primary health care, general practice, patient admission, hospitalization, observational study, retrospective....../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...
Muggah, Elizabeth; Graves, Erin; Bennett, Carol; Manuel, Douglas G
Abstract Background The prevalence of multiple chronic diseases is increasing and is a common problem for primary health care providers. This study sought to determine the patient and health system burden of multiple chronic diseases among adults in Ontario, Canada, with a focus on the ambulatory health care system (outpatient primary health care and specialist services). Methods This population-based study used linked health administrative data from Ontario, Canada. Individuals, aged 20 year...
Success in the provision of ambulatory personal health services, i.e. providing individuals with treatment for acute illness and preventive health care on an ambulatory basis, is the most significant contributor to the health care system's performance in most developing countries. Ambulatory personal health care has the potential to contribute the largest immediate gains in health status in populations, especially for the poor. At present, such health care accounts for the largest share of th...
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
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.
evaluates four main areas of depression: dysphoria , well-being, interpersonal difficulties, and somatic complaints (Cronbach’s !=0.85). The cut off...Statistical Considerations: Because gender is a potential effect-modifying factor, the groups will be matched for gender . Analysis of covariance will be...ID Number: _____ Date _____ Group: CB PP Ctr Gender M F Marital status: 1. Married 2. Divorced/Separated 3. Single 4. Widowed
Sawyers, J E
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.
Deimazar, Ghasem; Kahouei, Mehdi; Zamani, Afsane; Ganji, Zahra
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
Thurgate, Claire; Heppell, Sue
Needle phobia is a term used in practice to describe an anticipatory fear of needle insertion. A proportion of children display high levels of fear, pain and behavioural distress when exposed to, or anticipating, needle insertion. A difficult routine venepuncture in our ambulatory care unit led staff to review practice and develop a three-step approach to overcoming 'needle phobia': relaxation, control and graded exposure. These developments have resulted in the unit becoming a local referral centre for children and young people between the ages of 5-19 years with this problem. Time and skill are needed to prevent or overcome this distressing problem which can be caused by health care professionals not listening to children and young people.
Gotlib, Dorothy; Bostwick, Jolene R.; Calip, Seema; Perelstein, Elizabeth; Kurlander, Jacob E.; Fluent, Thomas
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
Mastal, Margaret; Levine, June
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.
Narayan, N; Gulliford, Stephen R
Ambulatory Emergency Care is a key component of the service for many Acute Medical units across the United Kingdom. A well-functioning ambulatory care unit facilitiates early senior review by a consultant and may reduce the need for hospital admission by managing patients along alternative safe clinical pathways. In this article, we present 12 months of data (January 2014-January 2015) from our Ambulatory Unit at Wrightington, Wigan and Leigh NHS Foundation Trust (WWL NHSFT), which demonstrates how many different conditions can be safely managed along ambulatory care pathways and how this can significantly contribute to postive patient satisfaction survey results and meeting the A&E 4 hour target for a medium-sized Acute Trust such as WWL NHSFT. We also emphasise that the key factors of co-location of ambulatory care with the Emergency Department along with dedicated medical and nursing staff are essential to the success of this model of care.
Lugo-Palacios, David G; Cairns, John
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.
David G Lugo-Palacios
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.
Grasland, A; Mortier, E
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.
Aliyu, Zakari Y; Yousif, Sohair B; Plantholt, Kate; Salihu, Hamisu M; Erinle, Ayodele; Plantholt, Steve
Abstract Introduction The NCEP III -ATP guidelines provide clear clinical directives for lipid management especially statins therapy in appropriate patient groups. Compliance of primary care physicians with these guidelines especially in ambulatory care settings has been shown to be poor. The compliance of cardiologist to these guidelines is less documented. Methods A retrospective chart review of 386 patients managed in a large urban cardiology practice was undertaken. Patients with document...
Pazó, Rosalva Grobério; Frauches, Diana de Oliveira; Molina, Maria del Carmen Bisi; Cade, Nágela Valadão
The aim of this study was to investigate the relationship between health services organization and hospitalization rates for ambulatory care sensitive conditions after adjusting for socioeconomic and demographic variables in municipalities (counties) in Espírito Santo State, Brazil. In an ecological study, data were collected from the Brazilian Unified National Health System (SUS) on the following variables: hospitalization for ambulatory care sensitive conditions, city size, demographic and socioeconomic characteristics, and health services organization. Rates were analyzed by Poisson regression with robust variance. Models were adjusted for the total population and age group. The explanatory variables were ordered hierarchically. Hospitalization rates for ambulatory care sensitive conditions were associated with illiteracy rate (RR: 1.08-1.17), proportion of beds in the SUS (RR: 1.09-1.12), urbanization (RR: 1.02-1.03), proportion of blacks (RR: 0.97-0.98), and health insurance coverage (RR: 0.97-0.98). Some determinants of hospitalization for ambulatory care sensitive conditions involve patterns of health services use and lie outside the scope of primary care.
Muggah, Elizabeth; Graves, Erin; Bennett, Carol; Manuel, Douglas G
The prevalence of multiple chronic diseases is increasing and is a common problem for primary health care providers. This study sought to determine the patient and health system burden of multiple chronic diseases among adults in Ontario, Canada, with a focus on the ambulatory health care system (outpatient primary health care and specialist services). This population-based study used linked health administrative data from Ontario, Canada. Individuals, aged 20 years or older, who had a valid health card, were included. Validated case definitions were used to identify persons with at least one of the following nine chronic diseases: diabetes, congestive heart failure, acute myocardial infarction, stroke, hypertension, asthma, chronic obstructive lung disease, peripheral vascular disease and end stage renal failure. Prevalence estimates for chronic diseases were calculated for April 1, 2009. Ambulatory physician billing records for the two-year period, April 1, 2008 to March 31, 2010, were used to identify the number of outpatient ambulatory care visits. In 2009, 26.3% of Ontarians had one chronic disease, 10.3% had two diseases, and 5.6% had three or more diseases. Annual mean primary health care use increased significantly with each additional chronic disease. Overall, there were twice as many patient visits to primary health care providers compared to specialists across all chronic disease counts. Among those with multiple diseases, primary health care visits increased with advancing age, while specialist care dropped off. While persons with three or more diseases accounted for a disproportionate share of primary health care visits, the largest number of visits were made by those with no or one chronic disease. The burden of care for persons with multiple chronic diseases is considerable and falls largely on the primary health care provider. However persons with no or one chronic disease are responsible for the largest number of ambulatory health care visits
Lenders, Carine M; Manders, Aaron J; Perdomo, Joanna E; Ireland, Kathy A; Barlow, Sarah E
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.
... informed member of your health care team. The “Speak Up” program is sponsored by The Joint Commission. ... prevent health care mistakes, patients are urged to “Speak Up.” S peak up if you have questions or ...
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
Baghi, Heibatollah; Panniers, Teresa L; Smolenski, Mary C
Changes within nursing demand that a specialty conduct periodic, appropriate practice analyses to continually validate itself against preset standards. This study explicates practice analysis methods using ambulatory care nursing as an exemplar. Data derived from a focus group technique were used to develop a survey that was completed by 499 ambulatory care nurses. The validity of the instrument was assessed using principal components analysis; reliability was estimated using Cronbach's alpha coefficient. The focus group with ambulatory care experts produced 34 knowledge and activity statements delineating ambulatory care nursing practice. The survey data produced five factors accounting for 71% of variance in the data. The factors were identified as initial patient assessment, professional nursing issues and standards, client care management skills, technical/clinical skills, and system administrative operations. It was concluded that practice analyses delineate a specialty and provide input for certification examinations aimed at measuring excellence in a field of nursing.
Benyamina, A; Reynaud, M
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
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
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.
Fawcett, Kenneth J; Brummel, Stacy; Byrnes, John J
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.
Shepard, Courtney L; Doerge, Ella J; Eickmeyer, Adam B; Kraft, Kate H; Wan, Julian; Stoffel, John T
We examined the ambulatory health care visit use of children with spina bifida, adults who transitioned to adult care and adults who continued to seek care in a pediatric setting. We evaluated use during a 1-year period of patients with spina bifida who visited any outpatient medical clinic within an integrated health care system. Patients were categorized as pediatric (younger than 18 years) or adult (age 18 or older). Adults were divided into those who did not fully transition to adult care and patients who fully transitioned (adult). Frequency and type of health care use were compared. Subanalysis was performed for patients 18 to 25 years old to examine variables associated with successful complete transition to adult care. During 1 year 382 children, 88 patients who did not transition and 293 adult patients with spina bifida had 4,931 clinic visits. Children had greater ambulatory care use (7.25 visits per year) compared to fully transitioned adults (5.33 visits per year, p=0.046). Children more commonly visited surgical clinics (52.3% of visits) and adults more commonly visited medical clinics (48.9%) (p spina bifida used more ambulatory care than adults and were more likely to visit a surgical specialist. Adult patients with spina bifida who successfully transitioned to adult care were more likely to be female, and patients who failed to transition were more likely to receive more inpatient and emergency care. Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
Nedel, Fúlvio Borges
Hospitalizations due to ambulatory care sensitive conditions (ACSC) are an indirect indicator of primary health care. A package in the R program was developed in order to automatize the classification of codes of the International Statistical Classification of Diseases and Related Health Problems - 10th Revision (ICD-10), according to the Brazilian list of ACSC, and provide functionalities for the management of the "reduced files" of the inpatient hospital authorization (AIH). The csapAIH package contains a homonym function, which reads the data according to its nature (file or data frame with AIH structure, or a factor with ICD-10 codes) and returns, according to defined options, a databank or vector containing the classification for the hospitalization. This article presents the package and the function csapAIH, its installation mode and use, and examples of its functionalities, which may add quickness, precision and validity to the research of ACSC in Brazil.
Wilson, Robert S; Capuano, Ana W; James, Bryan D; Amofa, Priscilla; Arvanitakis, Zoe; Shah, Raj; Bennett, David A; Boyle, Patricia A
To test the hypothesis that higher level of purpose in life is associated with lower subsequent odds of hospitalization. Longitudinal cohort study. Participants' residences in the Chicago metropolitan area. A total of 805 older persons who completed uniform annual clinical evaluations. Participants annually completed a standard self-report measure of purpose in life, a component of well-being. Hospitalization data were obtained from Part A Medicare claims records. Based on previous research, ICD-9 codes were used to identify ambulatory care-sensitive conditions (ACSCs) for which hospitalization is potentially preventable. The relation of purpose (baseline and follow-up) to hospitalization was assessed in proportional odds mixed models. During a mean of 4.5 years of observation, there was a total of 2,043 hospitalizations (442 with a primary ACSC diagnosis; 1,322 with a secondary ACSC diagnosis; 279 with no ACSCs). In initial analyses, higher purpose at baseline and follow-up were each associated with lower odds of more hospitalizations involving ACSCs but not hospitalizations for non-ACSCs. Results were comparable when those with low cognitive function at baseline were excluded. Adjustment for chronic medical conditions and socioeconomic status reduced but did not eliminate the association of purpose with hospitalizations involving ACSCs. In old age, higher level of purpose in life is associated with lower odds of subsequent hospitalizations for ambulatory care-sensitive conditions. Copyright © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.
López-Manning, Mauricio; García-Díaz, Rocío
In 2010 Mexican health authorities enacted an antibiotic sale, prescription, and dispensation bill that increased the presence of a new kind of ambulatory care provider, the doctors adjacent to private pharmacies (DAPPs). To analyze how DAPPs' presence in the Mexican ambulatory care market has modified health care seekers' behavior following a two-stage health care provider selection decision process. The first stage focuses on individuals' propensity to captivity to the health care system structure before 2010. The second stage analyzes individuals' medical provider selection in a health system including DAPPs. This two-stage process analysis allowed us not only to show the determinants of each part in the decision process but also to understand the overall picture of DAPPs' impact in both the Mexican health care system and health care seekers, taking into account conditions such as the origins, evolution, and context of this new provider. We used data from individuals (N = 97,549) participating in the Mexican National Survey of Health and Nutrition in 2012. We found that DAPPs have become not only a widely accepted but also a preferred option among the Mexican ambulatory care providers that follow no specific income-level population user group (in spite of its original low-income population target). Our results showed DAPPs as an urban and rapidly expanded phenomenon, presumably keeping the growing pace of new communities and adapting to demographic changes. Individuals opt for DAPPs when they look for health care: in a nearby provider, for either the most recent or common ailments, and in an urban setting; regardless of most socioeconomic background. The relevance of location and accessibility variables in our study provides evidence of the role taken by this provider in the Mexican health care system. Copyright © 2017. Published by Elsevier Inc.
Maria Aparecida Araújo Figueiredo
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.
Weltermann, Birgitta; Kersting, Christine; Viehmann, Anja
To improve hypertension control, this cluster randomized trial evaluated the effectiveness of physician manager education about hypertension management. After randomization at practice level, primary care physicians of the intervention arm, whose practices collaborated with a university department, participated in a three-session education on evidence-based hypertensiology and practice implementation strategies. The primary outcome was blood pressure (BP) control (ambulatory blood pressure [ABP] hypertension management. Following an intention-to-treat approach, data analyses included crude and adjusted generalized mixed models and sensitivity analyses. These took into account sex, age, ≥ hypertension-related disease and resistant hypertension (RH). The analysis included 103 of 169 patients from 22 practices. Overall, BP decrease was -8.2 systolic and -4.1 mmHg diastolic. The intervention had no effect on BP control (odds ratio 0.84 [95% CI 0.29-2.43]) and BP changes (interventional effect: systolic -2.48 mmHg [95% CI -7.24 to 2.29], diastolic -0.25 mmHg [95% CI 3.31 to 2.82]). Sensitivity analysis indicated effect modification in patients with RH. Intervention practices requested educational input on difficult cases, and newly implemented 3 practice strategies (14.5±2.6 versus 11.4±2.2; P=0.005). After the short follow-up of 5 months, the intervention had no impact on BP control but improved the use of practice strategies.
Putnam, Wayne; Nicol, Kelly; Anderson, David; Brownell, Brenda; Chiasson, Meredith; Burge, Frederick I.; Flowerdew, Gordon; Cox, Jafna
OBJECTIVE: Atrial fibrillation (AF) substantially increases risk of stroke. Evidence suggests that anticoagulation to reduce risk is underused (a "care gap"). Our objectives were to clarify measures of this gap in care by including data from family physicians and to determine why eligible patients were not receiving anticoagulation therapy. DESIGN: Telephone survey of family physicians regarding specific patients in their practices. SETTING: Nova Scotia. PARTICIPANTS: Ambulatory AF patients not taking warfarin who had risk factors that made anticoagulation appropriate. MAIN OUTCOME MEASURES: Proportion of patients removed from the care gap; reasons given for not giving the remainder anticoagulants. RESULTS: Half the patients thought to be in the care gap had previously unknown contraindications to anticoagulation, lacked a clear indication for anticoagulation, or were taking warfarin. Patients' refusal and anticipated problems with compliance and monitoring were among the reasons for not giving patients anticoagulants. CONCLUSION: Adding data from primary care physicians significantly narrowed the care gap. Attention should focus on the remaining reasons for not giving eligible patients anticoagulants. PMID:15508374
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.
Martens, F.M.J.; Kuppevelt, H.J.M. van; Beekman, J.A.; Heijnen, I.C.; D'Hauwers, K.W.M.; Heesakkers, J.P.F.A.
AIMS: Adequate urodynamic assessment of bladder behavior is essential in spinal cord injury (SCI) patients. Ambulatory urodynamics are more sensitive to detect detrusor overactivity (DO) than conventional urodynamics. The primary objective of this study was to determine the value of ambulatory
Frisse, Mark E; Holmes, Rodney L
Data and financial models based on an operational health information exchange suggest that health care delivery costs can be reduced by making clinical data available at the time of care in urban emergency departments. Reductions are the result of decreases in laboratory and radiographic tests, fewer admissions for observation, and lower overall emergency department costs. The likelihood of reducing these costs depends on the extent to which clinicians alter their workflow and take into account information available through the exchange from other institutions prior to initiating a treatment plan. Far greater savings can be realized in theory by identifying individuals presenting to emergency departments whose acute and long-term care needs are more suitably addressed at lower costs in ambulatory settings or medical homes. These alternative ambulatory settings can more effectively address the chronic care needs of those who receive most of their care in emergency departments. To support a shift from emergency room care to clinic care, health care information available through the health information exchange must be made available in both emergency department and ambulatory care settings. If practice workflow and patient behavior can be changed, a more effective and efficient care delivery system will be made possible through the secure exchange of clinical information across regional settings. These projections support the case for the financial viability of regional health information exchanges and motivate participation of hospitals and ambulatory care organizations-particularly in urban settings.
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.
Concistrè, A; Grillo, A; La Torre, G; Carretta, R; Fabris, B; Petramala, L; Marinelli, C; Rebellato, A; Fallo, F; Letizia, C
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.
Grossman, Zachi; van Esso, Diego; Del Torso, Stefano; Hadjipanayis, Adamos; Drabik, Anna; Gerber, Andreas; Miron, Dan
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.
Hensel, Jennifer M; Taylor, Valerie H; Fung, Kinwah; Yang, Rebecca; Vigod, Simone N
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.
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.
Barker, Isaac; Steventon, Adam; Deeny, Sarah R
To assess whether continuity of care with a general practitioner is associated with hospital admissions for ambulatory care sensitive conditions for older patients. Cross sectional study. Linked primary and secondary care records from 200 general practices participating in the Clinical Practice Research Datalink in England. 230 472 patients aged between 62 and 82 years and who experienced at least two contacts with a general practitioner between April 2011 and March 2013. Number of hospital admissions for ambulatory care sensitive conditions (those considered manageable in primary care) per patient between April 2011 and March 2013. We assessed continuity of care using the usual provider of care index, which we defined as the proportion of contacts occurring between April 2011 and March 2013 that were with the most frequently seen general practitioner. On average, the usual provider of care index score was 0.61. Continuity of care was lower among practices with more doctors (average score 0.59 in large practices versus 0.70 in small practices). Higher continuity of care was associated with fewer admissions for ambulatory care sensitive conditions. When modelled, controlling for demographic and clinical patient characteristics, an increase in the usual provider of care index of 0.2 for all patients would reduce these admissions by 6.22% (95% confidence interval 4.87% to 7.55%). There was greater evidence for an association among patients who were heavy users of primary care. Heavy users also experienced more admissions for ambulatory care sensitive conditions than other patients (0.36 admissions per patient for those with ≥18 contacts with a general practitioner, compared with 0.04 admissions per patient for those with 2-4 contacts). Strategies that improve the continuity of care in general practice may reduce secondary care costs, particularly for the heaviest users of healthcare. Promoting continuity might also improve the experience of patients
Kingstrom, P O
This paper introduces a cognitive measure of provider loyalty. Correlates of provider loyalty are investigated, and results are presented comparing provider loyalty with traditionally used measures of patient ties for predicting interest in and choice of a new health care provider. Implications for planning and marketing new forms of ambulatory care delivery systems are discussed and directions for future research are suggested.
Himmel, Konrad; Schneider, Udo
The ambulatory physician payment system in the German Social Health Insurance (SHI) offers incentives to reduce practice activity at the end of a billing period. Most services within a period are reimbursed at full cost only up to a certain threshold. Furthermore, capitated payments make follow-up treatments within a billing period less profitable. Using claims data from Germany's largest sickness fund with about nine million members, we find a decrease of all services limited by a threshold ...
Ha Anh Duc
Full Text Available 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
Claire van Deventer
Keywords: child HIV, doctor involvement, primary health care, quality improvement. Introduction. The national guidelines for the management of children on antiretroviral therapy (ART) in South Africa have been revised three times in the last five years.1–3. This indicates a rapid responsiveness to evidence emerging from ...
van Loenen, Tessa; van den Berg, Michael J.; Westert, Gert P.; Faber, Marjan J.
Often used indicators for the quality of primary care are hospital admissions rates for conditions which are potentially avoidable by well-functioning primary care. Such hospitalizations are frequently termed as ambulatory care sensitive conditions (ACSCs). We aim to investigate which
Loenen, T. van; Berg, M.J. van den; Westert, G.P.; Faber, M.J.
BACKGROUND: Often used indicators for the quality of primary care are hospital admissions rates for conditions which are potentially avoidable by well-functioning primary care. Such hospitalizations are frequently termed as ambulatory care sensitive conditions (ACSCs). OBJECTIVE: We aim to
Krist, Alex H; Cifuentes, Maribel; Dodoo, Martey S; Green, Larry A
Significant investments and effort are being devoted to health care reform, yet little is known about the costs of improvements. Practical tools are needed to allow for systematic assessment of practice expenses. We report here a field trial of a standardized expenditure data collection instrument. Combining economic and primary care practice consultation, an expenditure data collection instrument was created. The instrument underwent observed feasibility testing and was fielded by 10 practice-based research networks in 30 practices conducting 10 different health behavior change interventions. Start-up and operating expenses were successfully collected for 87% and 97% of the practices, respectively. Data collection time and effort were considerable but acceptable. Three elements were necessary to collect expenditure data: (1) an intervention-specific data collection instrument, (2) a field guide, and (3) economic oversight and assistance. Fully 90% of networks reported that they planned to collect expenditure data in the future and study participation increased the likelihood of their participation in a future expenditure study. It is feasible to systematically collect intervention-specific expenses in primary care using formal expenditure methods. However, most practices and researchers lack the knowledge, expertise, and resources to collect such data independently. Further assistance and education is necessary to obtain reliable information about the expenses to transform and improve primary care.
Dong, Liming; Fakeye, Oludolapo A; Graham, Garth; Gaskin, Darrell J
Racial and ethnic disparities in cardiovascular disease (CVD) outcomes are widely reported, but research has largely focused on differences in quality of inpatient and urgent care to explain these disparate outcomes. The objective of this review is to synthesize recent evidence on racial and ethnic disparities in management of CVD in the ambulatory setting. Database searches yielded 550 articles of which 25 studies met the inclusion criteria. Reviewed studies were categorized into non-interventional studies examining the association between race and receipt of ambulatory CVD services with observational designs, and interventional studies evaluating specific clinical courses of action intended to ameliorate disparities. Based on the Donabedian framework, this review demonstrates that significant racial/ethnic disparities persist in process and outcome measures of quality of ambulatory CVD care. Multimodal interventions were most effective in reducing disparities in CVD outcomes.
An Assessment of Satisfaction with Ambulatory Child Psychiatry Consultation Services to Primary Care Providers by Parents of Children with Emotional and Behavioral Needs: The Massachusetts Child Psychiatry Access Project University of Massachusetts Parent Satisfaction Study
Dvir, Yael; Wenz-Gross, Melodie; Jeffers-Terry, Mary; Metz, W. Peter
This study evaluated parents’ experience with University of Massachusetts (UMass) Child Psychiatry Access Project (MCPAP), a consultation service to primary care providers (PCP), aimed at improving access to child psychiatry. Parent satisfaction questionnaire was sent to families referred to UMass MCPAP by their PCP, asking about their concerns leading to the referral, the satisfaction from the service provided, adequacy of the follow up plan, and outcome. Seventy-nine percent of parents agreed or strongly agreed that the services provided were offered in a timely manner. Fifty percent agreed or strongly agreed that their child’s situation improved following their contact with the services. Sixty-nine percent agreed or strongly agreed that the service met their family’s need. The results suggest moderate to high parental satisfaction with MCPAP model, but highlight ongoing challenges in making successful referrals for children’s mental health services in the community, following MCPAP recommendations. PMID:22347867
Gabrielian, Sonya; Yuan, Anita H; Andersen, Ronald M; Gelberg, Lillian
Little is known about how permanent supported housing influences ambulatory care received by homeless persons. To fill this gap, we compared diagnoses treated in VA Greater Los Angeles (VAGLA) ambulatory care between Veterans who are formerly homeless-now housed/case managed through VA Supported Housing ("VASH Veterans")-and currently homeless. We performed secondary database analyses of homeless-experienced Veterans (n = 3631) with VAGLA ambulatory care use from October 1, 2010 to September 30, 2011. We compared diagnoses treated-adjusting for demographics and need characteristics in regression analyses-between VASH Veterans (n = 1904) and currently homeless Veterans (n = 1727). On average, considering 26 studied diagnoses, VASH (vs currently homeless) Veterans received care for more (P homeless Veterans to receive treatment for diagnoses across categories: chronic physical illness, acute physical illness, mental illness, and substance use disorders. Specifically, VASH Veterans had 2.5, 1.7, 2.1, and 1.8 times greater odds of receiving treatment for at least 2 condition in these categories, respectively. Among participants treated for chronic illnesses, adjusting for predisposing and need characteristics, VASH (vs currently homeless) Veterans were 9%, 8%, and 11% more likely to have 2 or more visits for chronic physical illnesses, mental illnesses, and substance use disorder, respectively. Among homeless-experienced Veterans, permanent supported housing may reduce disparities in the treatment of diagnoses commonly seen in ambulatory care. © The Author(s) 2016.
Coates, Allan L; Graham, Brian L; McFadden, Robin G; McParland, Colm; Moosa, Dilshad; Provencher, Steeve; Road, Jeremy
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
Bhattacharjee, Sandipan; Goldstone, Lisa; Ip, Queeny; Warholak, Terri
Background. There is little information regarding depression treatment patterns among adults with MS and depression in ambulatory settings at national level in the United States (US). Objectives. The objectives of this study were to identify patterns and predictors of depression treatment in ambulatory settings in US among adults with MS and depression. Methods. A cross-sectional study was conducted by pooling multiple years (2005–2011) of National Ambulatory Medical Care Survey and the outpa...
Robinson, Hal; Engelhardt, Thomas
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.
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.
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
Payne, Thomas J; Chen, Chieh-I; Baker, Christine L; Shah, Sonali N; Pashos, Chris L; Boulanger, Luke
Tobacco use remains the leading cause of preventable death. The outpatient medical clinic represents an important venue for delivering evidence-based interventions to large numbers of tobacco users. Extensive evidence supports the effectiveness of brief interventions. In a retrospective database analysis of 11,827 adult patients captured in the 2005 National Ambulatory Medical Care Survey (of which 2,420 were tobacco users), we examined the degree to which a variety of patient demographic, clinical and physician-related variables predict the delivery of tobacco counseling during a routine outpatient visit in primary care settings. In 2005, 21.7% of identified tobacco users received a tobacco intervention during their visit. The probability of receiving an intervention differed by gender, geographic region and source of payment. Individuals presenting with tobacco-related health conditions were more likely to receive an intervention. Most physicians classified as specialists were less likely to intervene. The provision of tobacco intervention services appears to be increasing at a modest rate, but remains well below desirable levels. It is a priority that brief interventions be routinely implemented to reduce the societal burden of tobacco use. PsycINFO Database Record (c) 2012 APA, all rights reserved.
Yang, Ling-Yu; Lynn, An-Min; Chen, Tzeng-Ji
Pediatricians play a key role in the healthy development of children. Nevertheless, the practice patterns of pediatricians have seldom been investigated. The current study analyzed the nationwide profiles of ambulatory visits to pediatricians in Taiwan, using the National Health Insurance Research Database. From a dataset that was randomly sampled one out of every 500 records among a total of 309,880,000 visits in 2012 in the country, 9.8% (n = 60,717) of the visits were found paid to pediatricians. Children and adolescents accounted for only 69.3% of the visits to pediatricians. Male pediatricians provided 80.5% of the services and the main workforces were those aged 40-49 years. The most frequent diagnoses were respiratory tract diseases (64.7%) and anti-histamine agents were prescribed in 48.8% of the visits to pediatricians. Our detailed results could contribute to evidence-based discussions on health policymaking.
Full Text Available Pediatricians play a key role in the healthy development of children. Nevertheless, the practice patterns of pediatricians have seldom been investigated. The current study analyzed the nationwide profiles of ambulatory visits to pediatricians in Taiwan, using the National Health Insurance Research Database. From a dataset that was randomly sampled one out of every 500 records among a total of 309,880,000 visits in 2012 in the country, 9.8% (n = 60,717 of the visits were found paid to pediatricians. Children and adolescents accounted for only 69.3% of the visits to pediatricians. Male pediatricians provided 80.5% of the services and the main workforces were those aged 40–49 years. The most frequent diagnoses were respiratory tract diseases (64.7% and anti-histamine agents were prescribed in 48.8% of the visits to pediatricians. Our detailed results could contribute to evidence-based discussions on health policymaking.
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.
com. +234 803 5837179. KEYWORDS. Disease surveillance, notification, resident doctors,. Edo State journal of. COMMUNITY HEALTH. & PRIMARY HEALTH CARE. Journal of Community Medicine and Primary Health Care. 26(2) 107-115 ...
Wright, Robert; Saul, Robert A
Epigenetics, the study of functionally relevant chemical modifications to DNA that do not involve a change in the DNA nucleotide sequence, is at the interface between research and clinical medicine. Research on epigenetic marks, which regulate gene expression independently of the underlying genetic code, has dramatically changed our understanding of the interplay between genes and the environment. This interplay alters human biology and developmental trajectories, and can lead to programmed human disease years after the environmental exposure. In addition, epigenetic marks are potentially heritable. In this article, we discuss the underlying concepts of epigenetics and address its current and potential applicability for primary care providers.
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
Nedel,Fúlvio Borges; Facchini,Luiz Augusto; Bastos,João Luiz; Martín-Mateo,Miguel
Hospitalization rates for Ambulatory Care Sensitive Conditions have been used to assess effectiveness of the first level of health care. From a critical analysis of related concepts, we discuss principles for selecting a list of codes and, taking the example of the Brazilian Family Health Program, propose a methodological pathway for identifying variables in order to inform statistical models of analysis. We argue that for the indicator to be comparable between regions, disease codes should b...
Schmidt, Lauren; Klink, Chris; Iglar, Arlene; Sharpe, Neha
The development and implementation of performance metrics for assessing the impact of pharmacists' activities in ambulatory care clinics are described. Ambulatory care clinic pharmacists within an integrated health system were surveyed to ascertain baseline practices for documenting and tracking performance metrics. Through literature review and meetings with various stakeholders, priorities for metric development were identified; measures of care quality, financial impact, and patient experience were developed. To measure the quality of care, pharmacists' interventions at five ambulatory care clinics within the health system were assessed. Correlation of pharmacist interventions with estimated cost avoidance provided a measure of financial impact. Surveys were distributed at the end of clinic visits to measure satisfaction with the patient care experience. An electronic system for metric documentation and automated tabulation of data on quality and financial impact was built. In a 12-week pilot program conducted at three clinic sites, the metrics were used to assess pharmacists' activities. A total of 764 interventions were documented (a mean of 24 accepted recommendations per pharmacist full-time equivalent each week), resulting in estimated cost avoidance of more than $40,000; survey results indicated high patient satisfaction with the services provided by pharmacists. Biweekly report auditing and solicitation of feedback guided metric refinement and further training of pharmacists. Tools and procedures were established for future metric expansion. Development and implementation of performance metrics resulted in successful capture and characterization of pharmacists' activities and their impact on patient care in three ambulatory care clinics. Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
Isman, Robert E.
Primary oral health care, and the scope of services it includes, are defined. The proposed scope of services is a set of basic dental services used by the Indian Health Service. Policy recommendations for improving the integration of primary oral health services with primary health care and delivery are offered. (Author/MSE)
Harrell, G D; Fors, M F
Although significant changes are occurring in health care delivery, in many instances the new offerings are not based on a clear understanding of market segments being served. This exploratory study suggests that important differences may exist among women with regard to health care selection. Five major women's segments are identified for consideration by health care executives in developing marketing strategies. Additional research is suggested to confirm this segmentation hypothesis, validate segmental differences and quantify the findings.
Ijäs, Jarja; Alanen, Seija; Kaila, Minna
OBJECTIVE: To describe the adoption of the national Hypertension Guideline in primary care and to evaluate the consistency of the views of the health centre senior executives on the guideline's impact on clinical practices in the treatment of hypertension in their health centres. DESIGN: A cross......-sectional telephone survey. SETTING: All municipal health centres in Finland. SUBJECTS: Health centres where both the head physician and the senior nursing officer responded. MAIN OUTCOME MEASURES: Agreement in views of the senior executives on the adoption of clinical practices as recommended in the Hypertension...... that no agreements on recording target blood pressure in patient records existed. A similar discrepancy was seen in recording cardiovascular risk (64% vs. 44%, p executives agreed best on the calibration of sphygmomanometers and the provision of weight-control group counselling. CONCLUSIONS...
Eneli, Ihuoma U; Keast, Debra R; Rappley, Marsha D; Camargo, Carlos A
The National Ambulatory Medical Care Surveys (NAMCS) and National Hospital Ambulatory Medical Care Surveys (NHAMCS) are surveillance systems in the USA that track provider practice patterns at ambulatory care visits. This study investigated the adequacy of the NAMCS/NHAMCS for surveillance of childhood obesity practice patterns. The frequency of obesity visits in the 1997-2000 NAMCS/NHAMCS (outpatient component) was compared with obesity prevalence among children who reported a physician visit in the preceding 12 months in the National Health and Nutrition Examination Survey (NHANES) 1999-2000. Obesity was identified using the International Classification of Diseases 9th revision clinical modification code ICD-9-278.0 in the NAMCS/NHAMCS. For the NHANES, age- and gender-specific body mass index >95th percentile was used. Between 1997 and 2000, obesity was identified in 4.1 million (0.8%) of 516 million ambulatory care visits. With an obesity prevalence of 14.2% from the NHANES survey, NAMCS/NHAMCS only identified 5.6% of all children aged 2-17 years >95th percentile. Of those identified, the rate of obesity visits in the NAMCS/NHAMCS was lowest for non-Hispanic Whites (3.9%) compared with non-Hispanic Blacks (6.9%) and Hispanics (10.2%). The very infrequent reporting of obesity in the NAMCS/NHAMCS suggests that these surveillance systems do not reflect how healthcare providers identify and care for overweight children. Collecting weight and height measures would improve their utility in tracking identification and management of overweight children.
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
Busato, André; Matter, Pius; Künzi, Beat; Goodman, David C
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. 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. 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, gynecology, pediatrics and for psychiatrists whereas
Lin, Yi-Hsuan; Tseng, Yen-Han; Chen, Yi-Chun; Lin, Ming-Hwai; Chou, Li-Fang; Chen, Tzeng-Ji; Hwang, Shinn-Jang
The utilization of medical care for gastrointestinal diseases increased over the past decade worldwide. The aim of the study was to investigate the difference between rural and urban patients in seeking medical service for gastrointestinal diseases at ambulatory sector in Taiwan. From the one-million-people cohort datasets of the National Health Insurance Research Database, the utilization of ambulatory visits for gastrointestinal diseases in 2009 was analyzed. Rural patients were compared with urban and suburban patients as to diagnosis, locality of visits and choice of specialists. Among 295,056 patients who had ambulatory visits for gastrointestinal diseases in 2009, rural patients sought medical care for gastrointestinal diseases more frequently than urban and suburban patients (1.60 ± 3.90 vs. 1.17 ± 3.02 and 1.39 ± 3.47). 83.4% of rural patients with gastrointestinal diseases were treated by non-gastroenterologists in rural areas. Rural people had lower accessibility of specialist care, especially for hepatitis, esophageal disorders and gastroduodenal ulcer. The rural-urban disparity of medical care for gastrointestinal diseases in Taiwan highlighted the importance of the well communication between rural physicians and gastroenterologists. Besides the establishment of the referral system, the medical teleconsultation system and the arrangement of specialist outreach clinics in rural areas might be helpful.
Rollow, William; Cucchiara, Peter
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.
Robinson H; Engelhardt T
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...
An Implantable MEMS Drug Delivery Device for Rapid Delivery in Ambulatory Emergency Care Citation N. Elman , H. Ho Duc, and M. Cima, “An implantable...reducing this burden, to Washington Headquarters Services , Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204...N. M. Elman , H. L Ho Duc, M. J. Cima Massachusetts Institute of Technology, Department of Materials Science and Engineering 77 Massachusetts Ave
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
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.
Brown, Judith Belle; French, Reta; McCulloch, Amy; Clendinning, Eric
Abstract Objective To explore the knowledge and perceptions of fourth-year medical students regarding the new models of primary health care (PHC) and to ascertain whether that knowledge influenced their decisions to pursue careers in family medicine. Design Qualitative study using semistructured interviews. Setting The Schulich School of Medicine and Dentistry at The University of Western Ontario in London. Participants Fourth-year medical students graduating in 2009 who indicated family medicine as a possible career choice on their Canadian Residency Matching Service applications. Methods Eleven semistructured interviews were conducted between January and April of 2009. Data were analyzed using an iterative and interpretive approach. The analysis strategy of immersion and crystallization assisted in synthesizing the data to provide a comprehensive view of key themes and overarching concepts. Main findings Four key themes were identified: the level of students’ knowledge regarding PHC models varied; the knowledge was generally obtained from practical experiences rather than classroom learning; students could identify both advantages and disadvantages of working within the new PHC models; and although students regarded the new PHC models positively, these models did not influence their decisions to pursue careers in family medicine. Conclusion Knowledge of the new PHC models varies among fourth-year students, indicating a need for improved education strategies in the years before clinical training. Being able to identify advantages and disadvantages of the PHC models was not enough to influence participants’ choice of specialty. Educators and health care policy makers need to determine the best methods to promote and facilitate knowledge transfer about these PHC models. PMID:22518904
Vedsted, Peter; Kallestrup, Per
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...... 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...... 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...
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...
Villafane, Juan; Edwards, Thomas C; Diab, Karim A; Satou, Gary M; Saarel, Elizabeth; Lai, Wyman W; Serwer, Gerald A; Karpawich, Peter P; Cross, Russell; Schiff, Russell; Chowdhury, Devyani; Hougen, Thomas J
The objective of this study was to develop quality metrics (QMs) relating to the ambulatory care of children after complete repair of tetralogy of Fallot (TOF). A workgroup team (WT) of pediatric cardiologists with expertise in all aspects of ambulatory cardiac management was formed at the request of the American College of Cardiology (ACC) and the Adult Congenital and Pediatric Cardiology Council (ACPC), to review published guidelines and consensus data relating to the ambulatory care of repaired TOF patients under the age of 18 years. A set of quality metrics (QMs) was proposed by the WT. The metrics went through a two-step evaluation process. In the first step, the RAND-UCLA modified Delphi methodology was employed and the metrics were voted on feasibility and validity by an expert panel. In the second step, QMs were put through an "open comments" process where feedback was provided by the ACPC members. The final QMs were approved by the ACPC council. The TOF WT formulated 9 QMs of which only 6 were submitted to the expert panel; 3 QMs passed the modified RAND-UCLA and went through the "open comments" process. Based on the feedback through the open comment process, only 1 metric was finally approved by the ACPC council. The ACPC Council was able to develop QM for ambulatory care of children with repaired TOF. These patients should have documented genetic testing for 22q11.2 deletion. However, lack of evidence in the literature made it a challenge to formulate other evidence-based QMs. © 2017 Wiley Periodicals, Inc.
Care 54500 54505 Biopsy, Testis (Open) 58340 74741 Hysterosalpingogram 58993 89300 Post Coital Test 59001 59000 Amniocentesis, Genetic 59002 59000...Degeneration 3716 37160 Keratoconus 3720 37200 Conjunctivitis, Acute 3721 37210 Conjunctivitis, Chronic 3722 37220 Blepharoconjuctivitis 3724 37240
Walsh, Carolyn O; Milliren, Carly E; Feldman, Henry A; Taveras, Elsie M
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.
Schootman, Mario; Jeffe, Donna B; Lian, Min; Deshpande, Anjali D; Gillanders, William E; Aft, Rebecca; Sumner, Walton
To estimate the frequency of ambulatory care-sensitive hospitalizations (ACSHs) and to compare the risk of ACSH in breast cancer survivors living in high-poverty with that of those in low-poverty areas. Prospective, multilevel study. National, population-based 1991 to 1999 National Cancer Institute Surveillance, Epidemiology, and End Results Program data linked with Medicare claims data throughout the United States. Breast cancer survivors aged 66 and older. ACSH was classified according to diagnosis at hospitalization. The percentage of the population living below the U.S. federal poverty line was calculated at the census-tract level. Potential confounders included demographic characteristics, comorbidity, tumor and treatment factors, and availability of medical care. Of 47,643 women, 13.3% had at least one ACSH. Women who lived in high-poverty census tracts (>or=30% poverty rate) were 1.5 times (95% confidence interval (CI)=1.34-1.72) as likely to have at least one ACSH after diagnosis as women who lived in low-poverty census tracts (poverty rate). After adjusting for most confounders, results remained unchanged. After adjustment for comorbidity, the hazard ratio (HR) was reduced to 1.34 (95% CI=1.18-1.52), but adjusting for all variables did not further reduce the risk of ACSH associated with poverty rate beyond adjustment for comorbidity (HR=1.37, 95% CI=1.19-1.58). Elderly breast cancer survivors who lived in high-poverty census tracts may be at increased risk of reduced posttreatment follow-up care, preventive care, or symptom management as a result of not having adequate, timely, and high-quality ambulatory primary care as suggested by ACSH.
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.
Department of Community Medicine,. Ahmadu Bello University,Zaria. +234 803 705 3845. Email: firstname.lastname@example.org. Department of Community Medicine, Ahmadu Bello University, Zaria journal of. COMMUNITY MEDICINE. & PRIMARY HEALTH CARE. Journal of Community Medicine and Primary Health Care.
Loenen, T. van; Faber, M.J.; Westert, G.P.; Berg, M.J. van den
OBJECTIVE: Diabetes is a so-called ambulatory care sensitive condition. It is assumed that by appropriate and timely primary care, hospital admissions for complications of such conditions can be avoided. This study examines whether differences between countries in diabetes-related hospitalization
van Loenen, Tessa; Faber, Marjan J.; Westert, Gert P.; van den Berg, Michael J.
Diabetes is a so-called ambulatory care sensitive condition. It is assumed that by appropriate and timely primary care, hospital admissions for complications of such conditions can be avoided. This study examines whether differences between countries in diabetes-related hospitalization rates can be
Full Text Available Background: Nutritional status is a final outcome from a balance between food intake and body’s needs of the nutrients. Elderly is people whose age more than 60 years old. In Indonesia, elderly population has increased. Its phenomena is also known as population aging. Population aging is related to malnutrition in elderly. Malnutrition is defined as the insufficient, excessive or imbalanced consumption of nutrients.The objective of this study was to describe the nutritional status among elderly outpatients in geriatrics clinic of Dr. Hasan Sadikin General Hospital Bandung. Methods: This study was a descriptive cross-sectional study that used primary data in geriatrics clinic Dr. Hasan Sadikin General Hospital Bandung from September 2013 to October 2013. The sampling method was convenience sampling. This study was done with 43 elderly ( women, n=27 and men, n=16 outpatients.The nutritional status was classified by the questionnaire of Mini Nutritional Assessment into malnourished, risk of malnutrition and without malnutrition (adequate. After collecting the data, it was analyzed by Microsoft Excel in presenting the proportion of the elderly nutritional status. Results: Among all the respondents, 27 (63% respondents had adequate nutrition and 16 (37% respondents had risk of malnutrition. There was no respondent who had malnutrition (undernutrition. Conclusions: Majority of elderly outpatients in geriatrics clinic Dr. Hasan Sadikin General Hospital had adequate nutrition. DOI: 10.15850/amj.v4n2.1087
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...
Berner, Eta S; Burkhardt, Jeffrey H; Panjamapirom, Anantachai; Ray, Midge N
To compare the costs of human and automated follow-up processes in ambulatory care. Analysis of costs of nurse-initiated and interactive voice response (IVR) system follow-up interventions. Using national cost data and data on follow-up processes and outcomes from a previous study, we examined the costs to the healthcare system and providers of developing a follow-up process using nurse-initiated telephone calls compared with calls made by an IVR. Whether using nurse-initiated telephone calls or IVR calls, costs over the first 2 years of follow-up for a practice assumed to have 4800 acute care patient visits per year are approximately the same. After 2 years, IVR follow-up is approximately $9000 per year less expensive than nurse follow-up. In addition, overall cost savings are greater with IVR. Follow-up of ambulatory care patients is a way to assess risks of future problems and associated costs and to improve quality of care. An automated follow-up process using IVR is more efficient than one based on nurse-initiated follow-up calls.
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
von Plessen, Christian; Aslaksen, Aslak
PROBLEM: Most patients with advanced lung cancer currently receive much of their health care, including chemotherapy, as outpatients. Patients have to deal with the complex and time consuming logistics of ambulatory cancer care. At the same time, members of staff often waste considerable time...... and energy in organisational aspects of care that could be better used in direct interaction with patients. DESIGN: Quality improvement study using direct observation and run and flow charts, and focus group meetings with patients and families regarding perceptions of the clinic and with staff regarding...... satisfaction with working conditions. SETTING: Thoracic oncology outpatient clinic at a Norwegian university hospital where patients receive chemotherapy and complementary palliative care. KEY MEASURES FOR IMPROVEMENT: Waiting time and time wasted during consultations; calmer working situation at the clinic...
Carlos F. Lerner
Full Text Available Background: In resident primary care continuity clinics, at the end of each academic year, continuity of care is disrupted when patients cared for by the graduating class are redistributed to other residents. Yet, despite the recent focus on the transfers of care between resident physicians in inpatient settings, there has been minimal attention given to patient care transfers in academic ambulatory clinics. We sought to elicit the views of pediatric residents regarding year-end patient handoffs in a pediatric resident continuity clinic.Methods: Residents assigned to a continuity clinic of a large pediatric residency program completed a questionnaire regarding year-end transfers of care.Results: Thirty-one questionnaires were completed out of a total 45 eligible residents (69% response. Eighty seven percent of residents strongly or somewhat agreed that it would be useful to receive a written sign-out for patients with complex medical or social issues, but only 35% felt it would be useful for patients with no significant issues. Residents more frequently reported having access to adequate information regarding their new patients’ medical summary (53% and care plan (47% than patients’ functional abilities (30%, social history (17%, or use of community resources (17%. When rating the importance of receiving adequate sign-out in each those domains, residents gave most importance to the medical summary (87% of residents indicating very or somewhat important and plan of care (84%. Residents gave less importance to receiving sign-out regarding their patients’ functional abilities (71% social history (58%, and community resources (58%. Residents indicated that lack of access to adequate patient information resulted in additional work (80%, delays or omissions in needed care (56%, and disruptions in continuity of care (58%.Conclusions: In a single-site study, residents perceive that they lack adequate information during year-end patient transfers
Paul, Maureen E; Dodge, Laura E; Intondi, Evelyn; Ozcelik, Guzey; Plitt, Ken; Hacker, Michele R
Most medical teamwork improvement interventions have occurred in hospitals, and more efforts are needed to integrate them into ambulatory care settings. In 2014, Affiliates Risk Management Services, Inc. (ARMS), the risk management services organization for a large network of reproductive health care organizations in the United States, launched a voluntary 5-year initiative to implement a medical teamwork system in this network using the TeamSTEPPS model. This article describes the ARMS initiative and progress made during the first 2 years, including lessons learned. The ARMS TeamSTEPPS program consists of the following components: preparation of participating organizations, TeamSTEPPS master training, implementation of teamwork improvement programs, and evaluation. We used self-administered questionnaires to assess satisfaction with the ARMS program and with the master training course. In the first 2 years, 20 organizations enrolled. Participants found the preparation phase valuable and were highly satisfied with the master training course. Although most attendees felt that the course imparted the knowledge and tools critical for TeamSTEPPS implementation, they identified time restraints and competing initiatives as potential barriers. The project team has learned valuable lessons about obtaining buy-in, consolidating the change teams, making the curriculum relevant, and evaluation. Ambulatory care settings require innovative approaches to integration of teamwork improvement systems. Evaluating and sharing lessons learned will help to hone best practices as we navigate this new frontier in the field of patient safety. © 2017 American Society for Healthcare Risk Management of the American Hospital Association.
von Plessen, Christian; Aslaksen, Aslak
; satisfaction among patients. STRATEGIES FOR CHANGE: Rescheduled patients' appointments, automated retrieval of blood test results, systematic reporting in patients' files, design of an information leaflet, and refurnishing of the waiting area at the clinic. EFFECTS OF CHANGE: Interventions resulted......PROBLEM: Most patients with advanced lung cancer currently receive much of their health care, including chemotherapy, as outpatients. Patients have to deal with the complex and time consuming logistics of ambulatory cancer care. At the same time, members of staff often waste considerable time...... and energy in organisational aspects of care that could be better used in direct interaction with patients. DESIGN: Quality improvement study using direct observation and run and flow charts, and focus group meetings with patients and families regarding perceptions of the clinic and with staff regarding...
Schäfer, W.L.A.; Boerma, W.G.W.; Schellevis, F.G.; Groenewegen, P.P.
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
May 1, 2012 ... Journal of Community Medicine and Primary Health Care. 27 (1) 27-36. KEYWORDS out-of-pocket payment, user fees, quality, tertiary health services;. Nigeria. .... and research committee of the Delta State .... Methods of funding and perceived satisfaction patient's waiting time, attitude of health care.
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
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.
Richards, A M; Ikram, H; Crozier, I G; Nicholls, M G; Jans, S
The variability of pulmonary arterial pressure, the relation of pulmonary pressure to systemic pressure, pulmonary pressure responses to stimuli (exercise, hypoxia, smoking, free ambulation), and plasma catecholamine responses were assessed in five patients with primary pulmonary hypertension. Ambulatory monitoring techniques provided data for the computerised analysis of continuous, beat-to-beat, direct recordings of both pulmonary and systemic arterial pressures for 8 to 10 hours. The absol...
Bittle, Mark J; LaMarche, Suzanne
Monitoring hand hygiene guideline compliance in an ambulatory environment can be challenging. For example, direct observation by independent observers is impractical because the sink and hand sanitizer dispensers are most often located inside the examination room. At Johns Hopkins Outpatient Center, an ambulatory care facility located on the campus of The Johns Hopkins Hospital in Baltimore, patients were engaged as an observer in monitoring hand hygiene compliance. The Johns Hopkins Hospital's ambulatory quality and patient safety (AQPS) task force, after assessing common methods of monitoring hand hygiene compliance including direct observation, self-reporting, and product usage, evaluated using the patient as an observer. Of 50 patients interviewed, 43 (86%) indicated a willingness to monitor and report providers' compliance with hand hygiene guidelines. In collaboration with providers, a patient-as-observer hand hygiene monitoring process was developed and piloted. Qualitative feedback postimplementation did not indicate that the process would inhibit the patient-provider relationship. The cost of the program to implement and maintain averages $0.17 per patient encounter. The overall patient response rate was 21.6% (range, 12%-77%), based on completed observation cards to total appointments completed. Hand hygiene compliance as measured by the patient-as-observer process averaged 88% (range, 74%-100%). Independent observation revealed 100% concurrence between the patient's recorded observation and the independent observer. Engaging the patient to report on hand hygiene compliance was found to be efficient and acceptable to patients and providers, and the results of the observations were representative of actual provider behavior.
Phillips, J H
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.
Tran, Christopher; Wijeysundera, Harindra C; Qui, Feng; Tu, Jack V; Bhatia, R Sacha
Little is known about variations in the quality of ambulatory care between urban and rural communities for patients with stable ischemic heart disease. The objectives of this study were to understand the effect of rurality on variations of ambulatory processes of care and outcomes for patients with stable ischemic heart disease. A population-based cohort study was conducted, which included all Ontario patients with stable ischemic heart disease confirmed on cardiac catheterization between October 1, 2008, and September 30, 2011. Patients were categorized as rural or urban based on the Rurality Index for Ontario score. Ambulatory processes of care of interest were diagnostic testing, medication usage, and access to general/speciality physicians over a 1-year time-horizon. Primary outcome was 1-year mortality. Secondary outcomes included 1-year myocardial infarction, repeat cardiac/all-cause hospitalization, and emergency department visits. The cohort consisted of 38 804 patients, of whom 34 949 (90%) were urban and 3855 (10%) were rural patients. After risk-adjustment, rural patients had lower rates of cholesterol assessment (odds ratios 0.41; 95% confidence interval [CI], 0.38-0.44; Purban patients. Rural patients had fewer total ambulatory physician visits (rate ratio 0.76; 95% CI, 0.75-0.78; Pcare (0.76; 95% CI, 0.74-0.78; Prural patients (odds ratios 1.82; 95% CI, 1.70-1.96; Pcare between urban and rural patients with stable ischemic heart disease, there were no outcome differences. © 2014 American Heart Association, Inc.
Antonio, Gisele Damian; Tesser, Charles Dalcanale; Moretti-Pires, Rodrigo Otavio
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
Gisele Damian Antonio
Full Text Available 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.
Antonio, Gisele Damian; Tesser, Charles Dalcanele; Moretti-Pires, Rodrigo Otavio
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.
Auras, Silke; Ostermann, Thomas; de Cruppé, Werner; Bitzer, Eva-Maria; Diel, Franziska; Geraedts, Max
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: email@example.com
Full Text Available Abstract Background The Swiss government decided to freeze new accreditations for physicians in private practice in Switzerland based on the assumption that demand-induced health care spending may be cut by limiting care offers. This legislation initiated an ongoing controversial public debate in Switzerland. The aim of this study is therefore the determination of socio-demographic and health system-related factors of per capita consultation rates with primary care physicians in the multicultural population of Switzerland. Methods The data were derived from the complete claims data of Swiss health insurers for 2004 and included 21.4 million consultations provided by 6564 Swiss primary care physicians on a fee-for-service basis. Socio-demographic data were obtained from the Swiss Federal Statistical Office. Utilisation-based health service areas were created and were used as observational units for statistical procedures. Multivariate and hierarchical models were applied to analyze the data. Results Models within the study allowed the definition of 1018 primary care service areas with a median population of 3754 and an average per capita consultation rate of 2.95 per year. Statistical models yielded significant effects for various geographical, socio-demographic and cultural factors. The regional density of physicians in independent practice was also significantly associated with annual consultation rates and indicated an associated increase 0.10 for each additional primary care physician in a population of 10,000 inhabitants. Considerable differences across Swiss language regions were observed with reference to the supply of ambulatory health resources provided either by primary care physicians, specialists, or hospital-based ambulatory care. Conclusion The study documents a large small-area variation in utilisation and provision of health care resources in Switzerland. Effects of physician density appeared to be strongly related to Swiss
Collecting Practice-level Data in a Changing Physician Office-based Ambulatory Care Environment: A Pilot Study Examining the Physician induction interview Component of the National Ambulatory Medical Care Survey.
Halley, Meghan C; Rendle, Katharine A; Gugerty, Brian; Lau, Denys T; Luft, Harold S; Gillespie, Katherine A
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.
Isaac, Kathleen S; Hay, Jennifer L; Lubetkin, Erica I
Addressing cultural competency in health care involves recognizing the diverse characteristics of the patient population and understanding how they impact patient care. Spirituality is an aspect of cultural identity that has become increasingly recognized for its potential to impact health behaviors and healthcare decision-making. We consider the complex relationship between spirituality and health, exploring the role of spirituality in primary care, and consider the inclusion of spirituality in existing models of health promotion. We discuss the feasibility of incorporating spirituality into clinical practice, offering suggestions for physicians.
Prior, Anders; Vestergaard, Mogens; Davydow, Dimitry S
Dette studie undersøger, om personer med stress og kroniske lidelser har flere potentialet forebyggelige hospitalsindlæggelser for udvalgte sygdomme (såkaldte ambulatory-care sensitive conditions). Disse indlæggelser burde kunne undgås, hvis patienten får tilbudt optimal behandling i almen praksis...... % øget risiko for at dø inden for 30 dage efter indlæggelse. Studiet er baseret på en kohorte fra Den Nationale Sundhedsprofil og bygger på data om selvrapporteret stress og livsstilsfaktorer. Undersøgelsens resultater, som tager højde for køn, alder og prædisponerede sygdomme, tyder på, at stress koblet...
Early detection and treatment of these morbidities could prevent deterioration. The aim of the survey was to determine and compare the prevalence of ..... interventions. Increasing the detection rate of mental morbidity in the community is fundamental. The inclusion of mental health care as a component of primary health ...
Objective: The study aimed at involving adolescents in school-based health promotion activities as a strategy to improve ... Adolescents, perception of risk, sexual behaviour, active participation, health promotion. journal of. COMMUNITY MEDICINE. & PRIMARY HEALTH CARE .... behaviour, importance of self esteem and.
sexual intercourse under the influence of alcohol or adolescents and younger adults. psychoactive substances. Respondents were. Risky sexual behaviour among young people has categorized as engaging in risky sexual behaviour if. JOURNAL OF COMMUNITY MEDICINE AND PRIMARY HEALTH CARE VOL. 26, NO 2 ...
attitudes towards Basic Cardiopulmonary Resuscitation (CPR) among Community Nurses in Remo Area of. Ogun State, Nigeria with ... Knowledge of basic CPR amongst nurses at primary health care level is generally poor with the young ones having better performance. ..... Fetuga, B. Okeniyi, A. Neonatal. Knowledge and ...
Velden, L.F.J. van der; Schellevis, F.G.
Introduction: Previous studies predicted an increase in both the incidence and prevalence of cancer in the Netherlands. Other studies showed that cancer patients use primary care more frequently than non-cancer patients. Finally, during the “chronic phase” of the disease, task substitution from
1,2. Organization, the community health worker was health system when the country adopted the PHC introduced into the health system for various strategy to achieve the goal of health for all. 76. JOURNAL OF COMMUNITY MEDICINE AND PRIMARY HEALTH CARE VOL. 25, NO 2, SEPTEMBER 2013. Correspondence to.
determine the awareness, willingness and use of. Voluntary HIV testing and counseling services by. One of the priorities of national HTC students of Niger Delta University. programmes is to ensure that at least 80% of. JOURNAL OF COMMUNITY MEDICINE AND PRIMARY HEALTH CARE VOL. 25, NO 2, SEPTEMBER ...
Jul 31, 2014 ... The Alma Ata declaration on Primary Health Care (PHC) which was made in 1978 is meant to address the main health problems in communities by providing promotive, preventive, curative and rehabilitative services. Nigeria was among the 134 signatories to this invaluable idea. Subsequently, several ...
population of the big cities live urban slums. our environment are diarrhea diseases, pneumonia,. Urban slums pose special health problems due to. JOURNAL OF COMMUNITY MEDICINE AND PRIMARY HEALTH CARE VOL. 26, NO 1, MARCH 2014. 1. 1Department of Paediatrics, University of Nigeria Teaching Hospital, ...
the stigmatization of people living with HIV/AIDS among traders in model markets in Lagos State. Methodology: ... traders, Pre- intervention and post- intervention. JOURNAL OF COMMUNITY MEDICINE AND PRIMARY HEALTH CARE VOL. 24, NO 1&2, MARCH 2013. 34 ..... Oladele J, Adeiga ZA, Ricketts F, Goodluck H.
CHILDREN,. SCHOOL HEALTH. Correspondence to. Dr Kofoworola A Odeyemi. Department of Community Health, University of Lagos . Lagos. Nigeria. Email firstname.lastname@example.org. Journal of Community Medicine and Primary Health Care. 25 (1) 51-57. Background: Visual impairment is usually due to conditions that ...
order words, it refers to any abusive treatment to women, thus violating the law of basic human ... JOURNAL OF COMMUNITY MEDICINE AND PRIMARY HEALTH CARE VOL. 27, NO 2, SEPTEMBER 2015. 20 journal of ... Some women victims, for the fear of repeated attacks by perpetrators, refused to even to report to. 3.
Conrad, Dianne; Hanson, Patricia A; Hasenau, Susan M; Stocker-Schneider, Julia
This study identified the perceived user barriers to documentation of nursing practice utilizing standardized nursing language (SNL) in the electronic health record (EHR) by ambulatory care nurse practitioners (NPs). A researcher-developed survey was sent to a randomized sample of ambulatory care NPs in the United States who belonged to the American Academy of Nurse Practitioners (n= 1997). Surveyed ambulatory care NPs placed a higher value on documenting medical care versus nursing care. Only 17% of respondents currently use SNL and 30% believe that SNL is not important or appropriate to document NP practice. Barriers to using SNL in EHRs included lack of reimbursement for nursing documentation, lack of time to document, and lack of availability of SNL in electronic records. Respondents identified NP practice as a blend of medical as well as nursing care but NPs have not embraced the current SNLs as a vehicle to document the nursing component of their care, particularly in EHRs. Until these barriers are addressed and discreet data in the form of SNL are available and utilized in the EHR, the impact of the NPs care will be unidentifiable for outcomes reporting. ©2012 The Author(s) Journal compilation ©2012 American Academy of Nurse Practitioners.
Groenewegen, P.; Heinemann, S.; Gress, S.; Schäfer, W.
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.
De Regge, Melissa; De Groote, Hélène; Trybou, Jeroen; Gemmel, Paul; Brugada, Pedro
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.
Song, Hummy; Chien, Alyna T; Fisher, Josephine; Martin, Julia; Peters, Antoinette S; Hacker, Karen; Rosenthal, Meredith B; Singer, Sara J
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.
Song, Hummy; Chien, Alyna T; Fisher, Josephine; Martin, Julia; Peters, Antoinette S; Hacker, Karen; Rosenthal, Meredith B; Singer, Sara J
Objective To develop and validate a survey instrument designed to measure team dynamics in primary care. Data Sources/Study Setting 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. Study Design 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. Data Collection We administered the survey between September 2012 and March 2013. Principal Findings 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). Conclusions 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). PMID:25423886
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.
Berendes, Sima; Heywood, Peter; Oliver, Sandy; Garner, Paul
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
Nyweide, David J; Bynum, Julie P W
We determine whether visit patterns indicative of higher continuity are related to a lower risk of presenting at the emergency department (ED) among older adults. This study was a survival analysis between 2011 and 2013 of a 20% random sample of fee-for-service Medicare beneficiaries aged 66 years or older. Ambulatory visit patterns were measured starting in 2011 for up to 24 months using 2 continuity metrics measured on a 0 to 1 scale-Continuity of Care (COC) score and the Usual Provider Continuity (UPC) score. The composite outcome of an ED episode was defined as occurrence of an ED visit with discharge home, an observation stay, or hospital admission. Time-dependent Cox proportional hazards regression models controlled for patient demographic characteristics, comorbidities, previous use, and regional factors, with censoring for death or occurrence of the composite outcome. In a secondary analysis, continuity was measured in the 12 months preceding an ED episode to test whether it was associated with type of ED episode. The relative rate of ED episodes decreased approximately 1% for every 0.1-point increase in the COC score (adjusted hazard ratio 0.99; 95% confidence interval 0.99 to 0.99; Pcontinuity was associated with a 1% lower risk of observation stay but a 3% to 4% higher risk of hospital admission relative to an ED visit with discharge home. Ambulatory visit patterns exhibiting more continuity were associated with a lower rate of ED utilization for older adults with fee-for-service Medicare coverage. The association of higher continuity with lower risk of ED use but differences in outcome when an ED visit does occur may reflect more appropriate referral to the ED when outpatient management is no longer adequate. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
Weingart, Saul N; Cleary, Angela; Stuver, Sherri O; Lynch, Maureen; Brandoff, Douglas; Schaefer, Kristen G; Zhu, Junya; Berry, Donna L; Block, Susan; Weeks, Jane C
Pain is common among patients with advanced cancer despite the dissemination of clinical pain care guidelines. We sought to assess the quality of pain care among patients with advanced disease. We reviewed the records of 85 adult ambulatory patients with advanced breast, lung, and gastrointestinal cancer treated in 2004-2006. Patients' screening pain intensity scores were at least 7 of 10. Nurse reviewers completed medical record reviews of care rendered at the index visit and over the subsequent 30 days based on the 2004 National Comprehensive Cancer Network pain guideline. An expert panel then rated the quality of the evaluation, treatment, and overall pain care. We used a multivariable model to analyze guideline compliance and resolution of severe pain. Among advanced cancer patients with severe pain, clinicians adjusted pain medications only half the time and made few timely referrals for pain-related consultations. By 30 days after the index visit, 34% of patients continued to report severe pain. The expert panel judged the overall quality of pain care as "fair" or "poor" in about two-thirds of cases because more timely and effective intervention could have reduced the severity and duration of pain. Resolution of severe pain was associated with adjustment of pain medications at the index visit (adjusted odds ratio 3.8, 95% CI 1.3-10.6). There is room for improvement in the pain care of patients with advanced cancer. Additional research is needed to understand the reasons for poor performance. Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Francisco Ignacio MORETA-VELAYOS
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.
Gisele Damian Antonio; Charles Dalcanele Tesser; Rodrigo Otavio Moretti-Pires
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 ...
Susana María Castro Pérez
Full Text Available The psychiatric consultation is broadly defined as an educational relationship between a psychiatrist, a general practitioner and other professionals working in the area of Mental Health. Currently it is a fundamental tool to optimize the treatment of psychiatric patients in primary care, given the high prevalence of these conditions and limited access to hours of specialty. Psychiatric Consulting is centrally positioned because patients are generally reluctant to consult with specialists, either because of the stigma associated with psychiatric illness or the cost effectiveness of the specialty. This leads patients to consult in primary care. Therefore we were interested in reviewing the evidence supporting this activity and what are the benefits it delivers. After reviewing the literature we conclude that the Psychiatric Consultation helps to improve the diagnosis, treatment and monitoring of psychiatric disorders in primary care, particularly the management of depressive disorders and somatoform disorders, improving the resolution capabilities of general practitioners, thus lowering the associated healthcare costs of these conditions. There is no evidence to support the health benefits of training general practitioners.
Agabiti, Nera; Pirani, Monica; Schifano, Patrizia; Cesaroni, Giulia; Davoli, Marina; Bisanti, Luigi; Caranci, Nicola; Costa, Giuseppe; Forastiere, Francesco; Marinacci, Chiara; Russo, Antonio; Spadea, Teresa; Perucci, Carlo A
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. 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. 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 olds than in younger people. The socioeconomic
Laberge, Maude; Wodchis, Walter P; Barnsley, Jan; Laporte, Audrey
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
Woolsey, Sarah; Brown, Brittany; Ralls, Brenda; Friedrichs, Michael; Stults, Barry
This descriptive study examines hypertension diagnostic practices in Utah primary care clinics relative to the 2015 US Preventive Services Task Force (USPSTF) recommendations for the accurate diagnosis of hypertension. We assessed clinic procedures in place to facilitate accurate in-office and out-of-office blood pressure (BP) measurement. An online questionnaire was administered to 321 primary care clinics. We compared current clinic BP measurement practices with the USPTF recommendations and assessed the level of adherence to the recommendations by level of clinic integration with a hospital. Of the 321 primary care clinics that received the assessment, 123 (38.3%) completed the questionnaire. Clinics varied significantly in their ability to provide accurate in-office measurement, ranging from 57.5% to 93.5% of clinics complying with USPSTF recommendations. Only 25.2% of clinics reported having access to ambulatory monitoring and 36.6% had instructional materials for accurate home BP monitoring. Clinics integrated with a hospital were more likely to report adherence to recommendations than solo or independent clinics (36.4% vs 10.5%; P primary care clinics are not well prepared to implement the USPSTF guidelines for accurate diagnosis of hypertension. Most office practices will benefit from support to develop their capacities. © Copyright 2017 by the American Board of Family Medicine.
Rauenzahn, Sherri L; Schmidt, Susanne; Aduba, Ifeoma O; Jones, Jessica T; Ali, Nazneen; Tenner, Laura L
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.
Early diagnosis and treatment are important for the prognosis in eating disorders and will also reduce the burden on the patient as well as n his or her family. On the other hand, community studies show that less than half of clinical cases of eating disorders are identified in primary care; hence, better skills among general practitioners in this field are very important. On the basis of the literature and clinical experience, this article discusses various problems related to identifying, evaluating and treating patients with eating disorders in primary care. The most important tool for the general practitioner is an understanding of the nature of the disorder, but tools for identification and treatment are also useful. Attending the patient and collaboration with hospitals and outpatient clinics could be a challenge. There are guidelines for the treatment of eating disorders in specialised health care, including indications for hospitalisation, but no guidelines for referral to outpatient treatment or for the coordination between the general practitioner and specialised units. The proposed British guidelines might serve as a basis for Norwegian guidelines.
Mendoza del Pino, Mario Valentín
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)
Vogt, Verena; Koller, Daniela; Sundmacher, Leonie
Heart failure is one of the most cost-intensive chronic diseases and the most common cause of hospitalization. More than 60% of the treatment costs of heart failure are incurred in the inpatient sector in Germany. However, hospital admissions due to heart failure are considered to be potentially avoidable through effective and continuous ambulatory care. Our aim is to examine whether continuity in ambulatory care is associated with hospitalizations due to heart failure. Using insurance claims data from Germany's biggest statutory health insurance company, we defined three measures of continuity of care: Continuity of Care Index (COCI), Usual Provider Index (UPC) and the Sequential Continuity Index (SECON). We analyzed whether these measures are associated with hospitalization due to heart failure using separate logistic regression models. We controlled for a wide range of covariates such as sex, age and the Charlson comorbidity index. Data of 382 118 heart failure patients were included in the analyses. Index values range from 0.77 to 0.89. Results of logistic regression analyses indicate that the continuity indices COCI, UPC and SECON based on visits to general practitioners (GPs), cardiologists and internists are negatively associated with the probability of hospitalization whereas of the continuity indices based on GP visits only SECON is significantly associated with hospitalization. The results indicate that the overall continuity in the ambulatory sector is high for heart failure patients in Germany. Public policy should, nevertheless, focus on increasing sequential continuity of specialist and generalist ambulatory care as this was found to be significantly associated with a reduced likelihood of hospitalization. © The Author 2016. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
Chan, Raymond J; Marx, Wolfgang; Bradford, Natalie; Gordon, Louisa; Bonner, Ann; Douglas, Clint; Schmalkuche, Diana; Yates, Patsy
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
Torgovicky, Refael; Goldberg, Avishay; Shvarts, Shifra; Bar Dayan, Yosefa; Onn, Erez; Levi, Yehezkel; BarDayan, Yaron
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.
Judith Ortiz PhD
Full Text Available Background: The Accountable Care Organization (ACO is one of the new models of health care delivery in the United States. To date, little is known about the characteristics of health care organizations that have joined ACOs. We report on the findings of a survey of primary care clinics, the objective of which was to investigate the opinions of clinic management about participation in ACOs and the characteristics of clinic organizational structure that may contribute to joining ACOs or be willing to do so. Methods: A 27-item survey questionnaire was developed and distributed by mail in 3 annual waves to all Rural Health Clinics (RHCs in 9 states. Two dependent variables—participation in ACOs and willingness to join ACOs—were created and analyzed using a generalized estimating equation approach. Results: A total of 257 RHCs responded to the survey. A small percentage (5.2% of the respondent clinics reported that they were participating in ACOs. Rural Health Clinics in isolated areas were 78% less likely to be in ACOs (odds ratio = 0.22, P = .059. Nonprofit RHCs indicated a higher willingness to join an ACO than for-profit RHCs (B = 1.271, P = .054. There is a positive relationship between RHC size and willingness to join an ACO (B = 0.402, P = .010. Conclusion: At this early stage of ACO development, many RHC personnel are unfamiliar with the ACO model. Rural providers’ limited technological and human resources, and the lack of ACO development in rural areas, may delay or prevent their participation in ACOs.
Chea, Nora; Perz, Joseph F; Srinivasan, Arjun; Laufer, Alison S; Pollack, Lori A
Public health activities to identify and monitor persons at risk for Ebola virus disease in the United States include directing persons at risk to assessment facilities that are prepared to safely evaluate for Ebola virus disease. Although it is unlikely that a person with Ebola virus disease will unexpectedly present to a nonemergency ambulatory care facility, the Centers for Disease Control and Prevention have provided guidance for this setting that can be summarized as identify, isolate, and inform. Published by Elsevier Inc.
... 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...
Le-Abuyen, Sheila; Ng, Jessica; Kim, Susie; De La Franier, Anne; Khan, Bibi; Mosley, Jane; Gardam, Michael
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.
Peterson, Caitlin G.; Miyashita, Yosuke
Hypertension (HTN) is a significant global health problem, responsible for 7.5 million deaths each year worldwide. The prevalence of HTN is increasing in the pediatric population likely attributed to the increase in childhood obesity. Recent work has also shown that blood pressure (BP) tends to track from childhood to adulthood including BP-related target organ damage. In the last 25–30 years, pediatric use of ambulatory blood pressure monitoring (ABPM) has been expanding mainly in the setting of initial elevated BP measurement evaluation, HTN therapy efficacy follow-up, and renal disease. However, there are many clinical areas where ABPM could potentially be used but is currently underutilized. This review summarizes the current knowledge and the uses of pediatric ABPM and explores clinical areas where it can be very useful both to detect HTN and its longitudinal follow-up. And thus, ABPM could serve as a critical tool to potentially prevent early cardiovascular mortality and morbidity in wide variety of populations. With solid data to support ABPM’s superiority over clinic BP measurements and these clinical areas for its expansion, ABPM should now be part of standard of care in BP evaluation and management in pediatrics. PMID:28713799
McDermott, S; Royer, J; Mann, J R; Armour, B S
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.
Altirriba, J; Aparicio, P
Oral anticoagulant therapy is currently widespread in the population and primary care plays an important role in its control in Spain. Younger populations, such as those in prisons, often require this treatment for reasons other than atrial fibrillation, often in relation to valvular or congenital or acquired hypercoagulability situations. The possibility of obtaining the INR by portable coagulometers has allowed primary care physicians to tackle the indication of this therapy and the control of these patients in coordination with haematology services. The emergence of new therapeutic alternatives (Dabigatran, Rivaroxaban, Apixaban and Edoxaban, the so called "ACOD") has permitted the expansion of options for oral anticoagulation in some cases, since they do not require systematic monitoring of their effect and interact with far fewer drugs than their predecessors, although there are still restrictions by the health authorities on their widespread use. This article reviews the different indications of oral anticoagulant therapy according to the new recommendations as well as the clinical scenarios in which it should be used.
Stein, Michael D; Cioe, Patricia; Friedmann, Peter D
This study assesses the rate and predictors of treatment retention for primary care patients with opioid dependence-prescribed buprenorphine, a long-acting partial opioid agonist. Observational cohort study of patients prescribed buprenorphine/naloxone and followed for 6 months in the period after the adoption of buprenophine/naloxone by a primary care practice in Rhode Island. Practice policy precluded patient discharges due to continuing drug use. Patients (n=41) had a mean duration of opioid use of 15.7 years and most had a history of heroin use (63.4%). Thirty-nine percent of patients transferred from methadone maintenance. At 24 weeks, 59% remained in treatment. Nearly half of dropouts occurred in the first 30 days. Participants with opiate-positive toxicologies at week 1 were more likely to drop out of the program (Pbuprenorphine maintenance practice reflect those reported in clinical trials. Abstinence during the first week of treatment and receipt of counseling were critical to patient retention.
Full Text Available Abstract Background There has been little systematic research about the extent to which German physicians accept or reject the concept and practice of a clinical practice guidelines (CPG and b evidence based medicine (EBM The aim of this study was to investigate German office-based physicians' perspective on CPGs and EBM and their application in medical practice. Methods Structured national telephone survey of ambulatory care physicians, four thematic blocks with 21 questions (5 point Likert scale. 511 office-based general practitioners and specialists. Main outcome measures were the application of Clinical Practice Guidelines in daily practice, preference for sources of guidelines and degree of knowledge and acceptance of EBM. In the data analysis Pearson's correlation coefficient was used for explorative analysis of correlations. The comparison of groups was performed by Student's t-test. Chi2 test was used to investigate distribution of two or more categorical variables. Results Of the total study population 55.3% of physicians reported already using guidelines in the treatment of patients. Physicians in group practices (GrP as well as general practitioners (GP agreed significantly more with the usefulness of guidelines as a basis for patient care than doctors in single practices (SP or specialists (S (Student's t-test mean GP 2.57, S 2.84, p Conclusion Despite a majority of physicians accepting and applying CPGs a large group remains that is critical and opposed to the utilization of CPGs in daily practice and to the concept of EBM in general. Doctors in single practice and specialists appear to be more critical than physicians in group practices and GPs. Future research is needed to evaluate the willingness to acquire necessary knowledge and skills for the promotion and routine application of CPGs.
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
Samuel A. Silver
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
Di Bella, Alexandra; Blake, Claire; Young, Adrienne; Pelecanos, Anita; Brown, Teresa
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
Salihu Hamisu M
Full Text Available Abstract Introduction The NCEP III -ATP guidelines provide clear clinical directives for lipid management especially statins therapy in appropriate patient groups. Compliance of primary care physicians with these guidelines especially in ambulatory care settings has been shown to be poor. The compliance of cardiologist to these guidelines is less documented. Methods A retrospective chart review of 386 patients managed in a large urban cardiology practice was undertaken. Patients with documented contraindications to use of statins were excluded from the study. Only patients with two or more years of follow-up in the practice were included. Demographic variables and medical history including CAD or its equivalent and its major risk factors were identified. The proportion of patients on statins and adequacy of statins therapy were recorded. The lipid profiles of all patients were also analyzed. Results Fifteen patients with documented contraindications to statins therapy including persistent/severe LFT abnormalities, allergies, and gastrointestinal intolerance were excluded. A total of 371 patients were included in the analysis. The mean age for patients in the study was 65 years (range: 42–84. 236 (64% were males while 141 (36% were females. 161 (43% patients were on statins while 210 (57% weren't. 88 (62% of females were on stain compared to 116 (49% of males (p = 0.001. 68% of patients below the age of 50 yrs were not on statins compared with 55% of those greater than 50 yrs (p = 0.01. 38% of patients on statins therapy had sub-optimal lipid profile despite greater than two years of therapy. No statistically significant differences in race and use of satins were noted. Conclusion This study demonstrates a higher than expected prevalence of sub-optimal management of dyslipidemia among patients with established coronary heart disease without contraindications to statins managed by cardiologists. Cardiology and primary care practices require
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...
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...
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...
Brown, Jonathan D.
Systems of care should be defined in a manner that includes primary care. The current definition of systems of care shares several attributes with the definition of primary care: both are defined as community-based services that are accessible, accountable, comprehensive, coordinated, culturally competent, and family focused. However, systems of…
Dijk, C.E. van; Verheij, R.A.; Hansen, J.; Velden, L. van der; Nijpels, G.; Groenewegen, P.P.; Bakker, D.H. de
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
Yang, Yuze; Ward-Charlerie, Stacy; Dhavle, Ajit A; Rupp, Michael T; Green, James
The prescriber's directions to the patient (Sig) are one of the most quality-sensitive components of a prescription order. Owing to their free-text format, the Sig data that are transmitted in electronic prescriptions (e-prescriptions) have the potential to produce interpretation challenges at receiving pharmacies that may threaten patient safety and also negatively affect medication labeling and patient counseling. Ensuring that all data transmitted in the e-prescription are complete and unambiguous is essential for minimizing disruptions in workflow at prescribers' offices and receiving pharmacies and optimizing the safety and effectiveness of patient care. To (a) assess the quality and variability of free-text Sig strings in ambulatory e-prescriptions and (b) propose best-practice recommendations to improve the use of this quality-sensitive field. A retrospective qualitative analysis was performed on a nationally representative sample of 25,000 e-prescriptions issued by 22,152 community-based prescribers across the United States using 501 electronic health records (EHRs) or e-prescribing software applications. The content of Sig text strings in e-prescriptions was classified according to a Sig classification scheme developed with guidance from an expert advisory panel. The Sig text strings were also analyzed for quality-related events (QREs). For purposes of this analysis, QREs were defined as Sig text content that could impair accurate and unambiguous interpretation by staff at receiving pharmacies. A total of 3,797 unique Sig concepts were identified in the 25,000 Sig text strings analyzed; more than 50% of all Sigs could be categorized into 25 unique Sig concepts. Even Sig strings that expressed apparently simple and straightforward concepts displayed substantial variability; for example, the sample contained 832 permutations of words and phrases used to convey the Sig concept of "Take 1 tablet by mouth once daily." Approximately 10% of Sigs contained QREs
M de Wet
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.
Docherty, Toni; Montalto, Michael; Leslie, Joni; King, Katrina; Niblett, Suzanne; Garrett, Tim
The temperature profiles of antibiotic-containing elastomeric infusion devices used by ambulatory care patients under various environmental conditions were evaluated. A prospective, descriptive survey of temperature exposure was conducted in 4 publically funded hospitals. Over a 12-month period, electronic temperature-recording devices were attached to the antibiotic infusion devices (infusers) of prospectively randomized hospital-in-the-home (HITH) participants. Temperatures were recorded immediately after infuser connection and every 5 minutes thereafter for 24 hours. A structured data collection form was used to collect information on basic clinical and demographic characteristics and aspects of daily living (i.e., how and where the infuser was carried during the day, times the participant went to and arose from bed, location of the infuser while sleeping, and dates and times the infuser was connected and disconnected). A total of 115 patients successfully completed the study (17-91 years old, 55% males). A total of 31,298 temperature readings were collected. The storage location of the infuser did not influence daytime readings. However, the overnight storage location did have a significant impact on the temperatures recorded overnight. The mean temperatures of infusers stored on the bed or on the body overnight were significantly higher than those for infusers stored away from the bed. Diurnal and seasonal influences were also detected. Significantly warmer temperatures were recorded in afternoons and evenings and during the summer months. Antibiotics administered to HITH patients via continuous infusion were frequently exposed to temperatures in excess of 25 °C. Specific patient behaviors and seasonal and chronological factors influenced temperatures. The findings challenge the validity of current fixed-temperature models for testing stability, which do not reflect conditions found in clinical practice. Copyright © 2017 by the American Society of Health
Kringos, D.; Boerma, W.; Bourgueil, Y.; Cartier, T.; Dedeu, T.; Hasvold, T.; Hutchinson, A.; Lember, M.; Oleszczyk, M.; Pavlick, D.R.
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.
Djalali, Sima; Meier, Tatjana; Hasler, Susann; Rosemann, Thomas; Tandjung, Ryan
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
Crosby, Sondra S; Norredam, Marie; Paasche-Orlow, Michael K; Piwowarczyk, Linda; Heeren, Tim; Grodin, Michael A
BACKGROUND The prevalence of torture among foreign-born patients presenting to urban medical clinics is not well documented. OBJECTIVE To determine the prevalence of torture among foreign-born patients presenting to an urban primary care practice. DESIGN A survey of foreign-born patients. PATIENTS Foreign-born patients, age ≥18, presenting to the Primary Care Clinic at Boston Medical Center. MEASUREMENTS Self-reported history of torture as defined by the UN, and history of prior disclosure of torture. RESULTS Of the 308 eligible patients, 88 (29%) declined participation, and 78 (25%) were not included owing to lack of a translator. Par ticipants had a mean age of 47 years (range 19 to 76), were mostly female (82/142, 58%), had been in the United States for an average of 14 years (range 1 month to 53 years), and came from 35 countries. Fully, 11% (16/142, 95 percent confidence interval 7% to 18%) of participants reported a history of torture that was consistent with the UN definition of torture. Thirty-nine percent (9/23) of patients reported that their health care provider asked them about torture. While most patients (15/23, 67%) reported discussing their experience of torture with someone in the United States, 8 of 23 (33%) reported that this survey was their first disclosure to anyone in the United States. CONCLUSION Among foreign-born patients presenting to an urban primary care center, approximately 1 in 9 met the definition established by the UN Convention Against Torture. As survivors of torture may have significant psychological and physical sequelae, these data underscore the necessity for primary care physicians to screen for a torture history among foreign-born patients. PMID:16808779
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
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.
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
Iyer, Sharat P; Young, Alexander S
This study sought to determine if primary care visits for people with serious mental illness (SMI) demonstrate different rates of basic physical health services compared to others, and to determine factors associated with differing rates of these measures in people with SMI. The study used 2005-2010 visit-level primary care data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. The provision of health counseling, receipt of any diagnostic or screening test, measurement of blood pressure or weight and evidence of hypertension control were assessed, adjusting for identified patient, provider and visit-level factors. After adjustment for covariates, we found no significant differences between visits for people with SMI and those without for any outcome. Probability of blood pressure measurement and diagnostic or screening testing significantly increased over time. The lack of significant differences found here might be due to adjustment for covariates, a focus only on primary care visits, the use of visit-level data or evolution over time. Mortality differences for people with SMI may be attributable to those not receiving primary care, self-management of disease or subsets of the population requiring targeted interventions. Published by Elsevier Inc.
U.S. Department of Health & Human Services — The Comprehensive Primary Care (CPC) initiative is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen...
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...
Full Text Available Training primary care physicians and general practitioners/family doctors is performed at different departments of Saratov State Medical University: Ambulatory Care, Polyclinic Therapy and Family Medicine. Since the foundation of department of Polyclinic Therapy, traditional training in polyclinic therapy has been carried out in different directions: outpatient therapy for the general practitioners/family doctors, for the 6th-year students of the Therapeutic faculty, for the 4th-year students of the Medico-prophylactic faculty, and for the 4th-year students of faculty of higher nursing professional education. In the recent years, the educational system is being reformed, so it has led to some changes in all fields of education in general. Innovative technologies, such as multimedia lectures, seminars, discussions, round tables, self-study with the use of different information resources, making out presentations of clinical cases, making reports and discussions in groups, carrying out mini-conferences, role model and business games for the primary care physicians, are introduced to the modern educational process. Therefore it is of high priority to use not only traditional education in the training of a general practitioner, but innovative technologies as well, which can guarantee high level of education and professional development
Veerman, D. P.; van Montfrans, G. A.
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
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.
Jessica W. Skelley
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
Damrongmanee, Alisara; Ukarapol, Nuthapong
pediatric ambulatory care setting. It tended to occur in younger children receiving amoxicillin/clavulanate.
Marabotto, Marco; Raspo, Silvio; Gerardo, Bruno; Cena, Paola; Bonetto, Martina; Cappa, Giorgetta
According to literature, challenges associated with caregiving of demented should be taken into great consideration. The aim of the present study was to evaluate the knowledge about dementia and health services dedicated to demented care among the caregivers of the patients attending our Dementia Ambulatory, caregivers' level of autonomy in taking care of the demented patients, their levels of stress and the degree of their satisfaction as the services provided by our Dementia Ambulatory. Our data show how a memory clinic needs to take care of both patients and their caregivers, with particular stress on caregiver specific education and well-being.
systems deteriorated in parallel with the deepening the gross inequalities in health care system, many economic crisis, while the subsequent introduction countries adopted the National Health Insurance of user fees further impeded access to care and. Scheme (NHIS) as a way of health care financing. 1 aggravated inequity ...
Walsh, Carolyn O; Milliren, Carly E; Feldman, Henry A; Taveras, Elsie M
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.
Tapp, Hazel; Phillips, Shay E; Waxman, Dael; Alexander, Matthew; Brown, Rhett; Hall, Mary
Since the care of patients with multiple chronic diseases such as diabetes and depression accounts for the majority of health care costs, effective team approaches to managing such complex care in primary care are needed, particularly since psychosocial and physical disorders coexist. Uncontrolled diabetes is a leading health risk for morbidity, disability and premature mortality with between 18-31% of patients also having undiagnosed or undertreated depression. Here we describe a team driven approach that initially focused on patients with poorly controlled diabetes (A1c > 9) that took place at a family medicare office. The team included: resident and faculty physicians, a pharmacist, social worker, nurses, behavioral medicine interns, office scheduler, and an information technologist. The team developed immediate integrative care for diabetic patients during routine office visits.
Verbakel, N.J.; van Melle, M.; Langelaan, M.; Verheij, T.J.; Wagner, C.; Zwart, D.L.
Objective. To explore perceptions of safety culture in nine different types of primary care professions and to study possible differences. Design. Cross-sectional survey. Setting. Three hundred and thirteen practices from nine types of primary care profession groups in the Netherlands. Participants.
Wiborg, J.F.; Gieseler, D.; Lowe, B.
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
McGrath, P J; Feldman, W; Rosser, W
The authors describe the major learning problems that confront the primary-care physician. They discuss why they believe that the primary-care physician has an important role in case finding, referral, case management, and advocacy for the child with learning problems and his or her family.
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.
Crampton, P; Dowell, A; Woodward, A
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
Gawaine Powell Davies
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.
Murphy, John W
Primary health care has received a lot of attention since the Alma Ata Conference, convened by the World Health Organization in 1978. Key to the strategy to improve health care outlined at the Alma Ata conference is citizen participation in every phase of service delivery. Although the goals of primary health care have not been achieved, the addition of narrative medicine may facilitate these ends. But a new epistemology is necessary, one that is compatible with narrative medicine, so that local knowledge is elevated in importance and incorporated into the planning, implementation, and evaluation of health programs. In this way, relevant, sustainable, and affordable care can be provided. The aim of this article is to discuss how primary health care might be improved through the introduction of narrative medicine into planning primary health care delivery.
Ng, Chung Wai Mark; How, Choon How; Ng, Yin Ping
Major depression is a common condition seen in the primary care setting. This article describes the suicide risk assessment of a depressed patient, including practical aspects of history-taking, consideration of factors in deciding if a patient requires immediate transfer for inpatient care and measures to be taken if the patient is not hospitalised. It follows on our earlier article about the approach to management of depression in primary care. PMID:28210741
Your story about our primary healthcare conference seems to imply that the nursing profession is being left out of the process of developing primary care services in London, 'Nurses side-stepped in capital's primary healthcare plans' (News November 8). Nothing could be further from the truth.
Lévy, Danièle; Pavot, Jeanne; Doan, Bui Dang Ha
The French sector of ambulatory care is characterized by two features: (i) health care providers are mostly independent practitioners paid on a fee-for-service basis; (ii) a large consensus is observed as concerns the shortage of health workers, particularly physicians and nurses. In such a context, if a task delegation programme is envisaged, attention should be paid, not only to the competencies of task receivers, but equally to the reluctance of health workforce. Given the current doctor shortage, it is probable that the reluctance of physicians is not vigorous. But on the side of task receivers (nurses, physiotherapists, other auxiliary workers...) reluctance should be taken into account. Shortage of nurses and physiotherapists (and consequently their growing workload) lowers their acceptance level (i.e., the proportion accepting task delegation) and reduces the time each accepting worker can devote to the activities delegated by physicians. The model shows that, in the current situation, French physicians can only expect a small reduction of their workload i they undertake to transfer to nurses some parts of their activities. When physician working time is not excessively lengthy, the overall reduction would be between 0.7% and 3.1%. When doctors have to work harder (when their shortage is acute), paradoxically, the reduction is lower, between 0.5% and 2.3%. The fact is easily understood as the stock of task receivers (the nurses) remains unchanged, but the volume of worked hours becomes larger. Other things being equal, the model shows that French southern physicians may take more profit from a task delegation programme than their counterparts practising in the northern areas of the country. As in the southern areas, the nurse/physician ratio is higher, the potential task receivers are in higher numbers and the volume of the tasks transferred may be much broader than in the northern areas. The paradox is that the workload of northern physicians is heavier
Magistri, Paolo; Scordamaglia, Maria Rosa; Giulitti, Diego; Papaspyropoulos, Vassilios; Eleuteri, Edoardo; Coppola, Marcello
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.
Chang, Lo-Yi; Lai, Chou-Cheng; Chen, Chun-Jen; Cho, Ching-Yi; Luo, Yu-Cheng; Jeng, Mei-Jy; Wu, Keh-Gong
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.
ABSTRACT. Background: The well-being of women and children is one of the major determinants of the health of any nation and can ... preconception care, the result showed that majority (65.9%, n=247) of the respondents have not sought the care before pregnancy ... women have optimal health in order to give birth to.
Epstein, R M
Optimal communication between primary care physicians and consultants includes transfer of relevant clinical information, including the patient's perspectives and values, and provides a means of collaboration to provide meaningful and health-promoting interventions. Communication difficulties arise because of lack of time, lack of clarity about the reason for referral, patient self-referral, and unclear follow-up plans. Also, primary care physicians and consultants may have different core values and may have little day-to-day contact with each other. Poor communication leads to disruptions in continuity of care, delayed diagnoses, unnecessary testing, and iatrogenic complications. Changes in the health care system offer the opportunity for improved collaboration between physicians by creating smaller administrative units within large health care systems that facilitate contact between primary care physicians and consultants; incorporation of discussions of uncertainty, patient preferences, and values into referral letters; adoption of a friendlier consultant letter format; and the improvement of the transfer of clinical data.
Radha S Vanmali
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
Ann M. Fugit, Pharm.D., BCPS
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.
Regional variations of perceived problems in ambulatory care from the perspective of general practitioners and their patients - an exploratory focus group study in urban and rural regions of northern Germany.
Hansen, H; Pohontsch, N J; Bole, L; Schäfer, I; Scherer, M
Patients from rural and urban regions should have equitable access to health care. In Germany, the physician-patient-ratio and the supply of medical services vary greatly between urban and rural areas. The aim of our study was to explore the regional variations of the perceived health care problems in ambulatory care from the perspective of affected professionals and laypersons i.e. general practitioners and their patients. We conducted 27 focus groups with general practitioners (n = 65) and patients (n = 145) from urban areas, environs and rural areas in northern Germany. Discussions were facilitated by two researchers using a semi-structured guideline. The transcripts were content analyzed using deductive and inductive categories. General practitioners and patients reported problems due to demographic change and patient behaviour, through structural inequalities and the ambulatory reimbursement system as well as with specialist care and inpatient care. A high physician density, associated with high competition between general practitioners, a high fluctuation of patients and a low status of general practitioners were the main problems reported in urban areas. In contrast, participants from rural areas reported an insufficient physician density, a lack of young recruits in primary care and a resulting increased workload as problematic. All regions are concerned with subjectively inadequate general practitioners' budgets, insufficiently compensated consultations and problems in the cooperation with specialists and inpatient care institutions. Most problems were mentioned by GPs and patients alike, but some (e.g. high competition rates in urban regions and problems with inpatient care) were only mentioned by GPs. While many problems arise in urban regions as well as in rural regions, our results support the notion that there is an urgent need for action in rural areas. Possible measures include the support of telemedicine, delegation of medical services and
Mullangi, Samyukta; Saint, Sanjay
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.
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
Heilmann, Rachel M F; Campbell, Stephanie M; Kroner, Beverly A; Proksel, Jenel R; Billups, Sarah J; Witt, Daniel M; Helling, Dennis K
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.
Calderan, Catiane; Universidade Federal de Pelotas; Vestena Zillmer, Juliana Graciela; Universidade Federal de Santa Catarina; Pereira Torres, Ana Amália; Universidade Federal de Pelotas; Schwartz, Eda; Universidade Federal de Pelotas; Guerreiro Vieira da Silva, Denise; Universidade Federal de Santa Catarina
OBJETIVO: Conhecer as práticas de autocuidado utilizadas por pessoas com insuficiência renal crônica submetidos à diálise peritoneal ambulatorial contínua (CAPD). MÉTODOS: Foi utilizada a abordagem qualitativa, sendo a entrevista semi estruturada como técnica de coleta de dados. Estas foram realizadas entre junho e julho de 2010, com 09 pacientes de um Serviço de Nefrologia localizado em um município da região sul do E...
Simon Steven R
Full Text Available Abstract Background Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record. Methods We reviewed electronic medical records from 834 patients receiving care from 167 physicians (117 internists and 50 pediatricians at 14 sites of a multi-specialty medical group in Massachusetts. We abstracted information for five measures of medical record documentation quality: smoking history, medications, drug allergies, compliance with screening guidelines, and immunizations. From other sources we determined physicians' specialty, gender, year of medical school graduation, and self-reported time spent teaching and in patient care. Results Among internists, unadjusted rates of documentation were 96.2% for immunizations, 91.6% for medications, 88% for compliance with screening guidelines, 61.6% for drug allergies, 37.8% for smoking history. Among pediatricians, rates were 100% for immunizations, 84.8% for medications, 90.8% for compliance with screening guidelines, 50.4% for drug allergies, and 20.4% for smoking history. While certain physician and patient characteristics correlated with some measures of documentation quality, documentation varied depending on the measure. For example, female internists were more likely than male internists to document smoking history (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.27 – 2.83 but were less likely to document drug allergies (OR, 0.51; 95% CI, 0.35 – 0.75. Conclusions Medical record documentation varied depending on the measure, with room for improvement in most domains. A variety of
to improving mood and helping to manage stress . physical activity a day at least five times a week . Sedentary lifestyle is associated with obesity, Greater health benefits can be experienced with. KEYWORDS. Practice,. Exercise,. Leisure,. Work- related,. Overweight,. Obesity. Journal of Community Medicine and Primary ...
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replaced in January 2000, with free health service, which involves supplying free drugs from the state medical store to local government areas. This study aimed to ... The drug revolving fund initiative as a strategic opportunity to support local ... Iwajowa Local Government in symbols of quality care to consumers; in Nigeria,.
enrol in an insurance scheme feeling that they need more information on health insurance and the willingness to enrol in a ... health policy makers. Irrespective of the option, the choice of health care financing should mobilize resources for health and provide financial protection. 1 ..... Opportunities for Sub-Saharan African.
Background. The availability of drugs on a continuous basis is paramount to the success of any health care system. The Bamako Initiative (BI) had provision of essential drugs as one of its key thrusts in order to improve the utilization of health facilities. This study compared the perceived availability of essential drugs and ...
Methodology. A cross-sectional survey of patients at the antiretroviral clinic of the Federal Medical Centre,. Makurdi, Nigeria, was conducted between June and August 2008. An adapted version of the RAND. Patient Satisfaction Questionnaire Long Form was used to assess seven dimensions of care: general satisfaction ...
Sep 2, 2013 ... Background. Disease pattern in Nigeria is changing from communicable diseases to non-communicable diseases. However, the approach to patient care has not changed; neither has the expectations of the general public for quick recovery. These have resulted in poorer treatment outcome and patients'.
campaigns; use of cigarette (nicotine). Information was collected on socio- substitutes and alternative approaches like demographic characteristics of respondents, acupuncture, aromatherapy, hypnosis and knowledge and attitude of the health care. 9-12 herbs. Often times, combinations of workers about smoking cessation ...
microeconomic costs data are useful in assessing. 12 for treatment. the ability of individuals and households to afford health care services. Nigeria receives donor support for malaria control. Global Fund is currently its largest funding partner. This study was conducted to assess the direct cost. Through the Global Fund, SFH ...
Nigeria has one of the largest stocks of. In all situations, volunteers add to the quality and human resources for ... profit making enterprise by the partners the health care objectives, including the involved.Rather, it is a health ..... Investing in volunteerism: The impact of service initiatives in selected state agencies. Austin, TX: ...
catastrophic health expenditures (CHE) and risk of being impoverished as a result of cost of care were assessed. Statistical ... Study found a high prevalence of catastrophic health expenditure and near absence of financial risk protection for patients with long term ... services especially for the target group in Nigeria.
on the patients and families for self-care and the leading to more effective counselling and better clinical decision-making responsibilities .... T2DM were females aged 14 and 16 years diagnosis of diabetes. With regard to acute respectively and ... about body image because of their weight. The responsibility of administering ...
Sep 2, 2013 ... Incidence and reasons for Discharge Against Medical Advice in a tertiary health care facility in Port Harcourt, south-south Nigeria. Ordinioha B. Community Medicine Department. University of Port Harcourt Teaching Hospital,Port Harcourt. Email: email@example.com. +2348037075300.
Wensaas, Knut-Arne; Hungin, Amrit Pali
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 ...
Full Text Available This paper considers indications and obstacles for the development of primary mental health care practice in both developed and under-developed countries. Both are considered as this represents the South African reality. While a significant body of literature has documented the need for primary mental health care, the obstacles (especially in terms of the commodification of health to its fruition are seldom addressed.
Hsieh, Ronan Wenhan; Chen, Likwang; Chen, Tsung-Fu; Liang, Jyh-Chong; Lin, Tzu-Bin; Chen, Yen-Yuan; Tsai, Chin-Chung
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.
Samuelson, M.; Tedeschi, P.; Aarendonk, D.; Cuesta, C. de la; Groenewegen, P.
Primary care is the central pillar of health care. The increasingly complex health needs of the population and individual patients in a changing society can only be met by promoting interprofessional collaboration (IpC) within primary care teams. The aim of this Position Paper of the European Forum
Vanderlip, Erik R; Williams, Nancy A; Fiedorowicz, Jess G; Katon, Wayne
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.
Wells, Nancy; McDowell, M Rachel; Hendricks, Patty; Dietrich, Mary S; Murphy, Barbara
Good cancer pain control requires appropriate assessment and treatment. The purpose of this study was to examine the relationships among physician, nurse practitioner, and nurse knowledge, documentation of assessment, treatment, and pain reduction in cancer patients seen in ambulatory settings. The study method included an assessment of pain knowledge of providers (physicians, nurse practitioners, and nurses) who worked in cancer clinics and a retrospective review of patients' records treated for cancer-related pain in their clinics. Fifty-eight providers from eight cancer clinics completed the knowledge questionnaire; 56 patient records were reviewed for assessment, treatment, and outcome data. Pain relief, the outcome, was obtained from documentation at the next clinic visit. Of the 54 patient records that documented pain relief at the next clinic visit, 61.9% reported no relief. Chi square analysis revealed clinics with a higher level of pain knowledge documented a greater number of elements of an ideal pain assessment (p = 0.03) but was unrelated to treatment and pain relief reported. Assessment and treatment were unrelated to reported pain relief at the next clinic visit. These data suggest that providers' pain knowledge is related to pain assessment but not treatment or outcome. In addition, these data showed no relationship between assessment, treatment prescribed, and pain relief in these ambulatory settings.
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.
We do not need a crystal ball to see the future. Our web-based future has already arrived in all other aspects of our lives--even our mobile phones. The tools for progress--Personal Health Records, Social Networks, and Online medical information--are widely available. The demand is at hand--Millennials are flexing consumer muscles as they enter the healthcare market. Real "Health Care Reform" requires fundamental changes in practice--which in turn requires effective use of information technologies and adaption to changing consumer expectations. The VHA and the MHS are uniquely capable of leveraging political, academic and technological forces to help move American health care through this millennial transformation. Federal health systems are positioned to demonstrate the value of innovation as America seeks healthcare reform.
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
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
Mate, Kedar S; Salinas, Gilbert
There is considerable interest in ideas borrowed from education about "flipping the classroom" and how they might be applied to "flipping" aspects of health care to reach the Triple Aim of improved health outcomes, improved experience of care, and reduced costs. There are few real-life case studies of "flipping health care" in practice at the individual patient level. This article describes the experience of one of the authors as he experienced having to "flip" his primary health care. We describe seven inverted practices in his care, report outcomes of this experiment, describe the enabling factors, and derive lessons for patient-centered primary care redesign. Copyright © 2014 Elsevier Inc. All rights reserved.
Shahly, Victoria; Kessler, Ronald C; Duncan, Ian
Despite levels of health spending that are higher per capita and as share of gross domestic product than any country worldwide, the US health care system is fragmented, technology and administration heavy, and primary care deficient. Studies of regional variations in US health care show similar "disconnects" between higher spending and better health outcomes. Faced with rising health benefit costs and suboptimal workforce health amid economic downturn, concerned US employers have implemented innovative payment and health care delivery strategies such as consumer-driven health plans and targeted prevention programs. The former may impose undue cost shifting, prohibitive out-of-pocket expenses, and health literacy challenges, while the latter have shown inconsistent near-term economic returns and long-term clinical efficacy. Employers have begun exploring more comprehensive health delivery platforms such as integrated worksite primary care clinics that have potential to cost-effectively address several pressing problems with current US health care: the growing primary care physician shortage, poor access to routine care, lack of coordinated and patient-centered treatment models, low rates of childhood immunizations, and "quality-blind" fee-for-service payment mechanisms. Such on-site medical clinics exploit one of the rare comparative strengths of the US health care system-its plentiful supply of highly skilled registered nurses-to offer workers and their dependents convenient, high-quality, affordable care. A relatively recent health care paradigm, worksite clinics must yet develop consistent reporting strategies and credible demonstration of outcomes. This review explores available evidence regarding worksite primary care clinics, including current rationale, historical trends, prevalence and projected growth, expected health and financial benefits, challenges, and future research directions.
Eating disorders are a complex set of illnesses most commonly affecting white adolescent girls and young women. The most common eating disorders seen in the primary care setting are anorexia nervosa, bulimia nervosa, and binge eating disorder. Treatment in the primary care environment ideally involves a physician, therapist, and nutritionist, although complex cases may require psychiatric and other specialist care. Early diagnosis and treatment are associated with improved outcomes, whereas the consequences of untreated eating disorders, particularly anorexia nervosa, can be devastating, including death. Copyright © 2016 Elsevier Inc. All rights reserved.
Sive, Jonathan; Ardeshna, Kirit M; Cheesman, Simon; le Grange, Franel; Morris, Stephen; Nicholas, Claire; Peggs, Karl; Statham, Paula; Goldstone, Anthony H
Since 2005, University College London Hospital (UCLH) has operated a hotel-based Ambulatory Care Unit (ACU) for hematology and oncology patients requiring intensive chemotherapy regimens and hematopoietic stem cell transplants. Between January 2005 and 2011 there were 1443 patient episodes, totaling 9126 patient days, with increasing use over the 6-year period. These were predominantly for hematological malignancy (82%) and sarcoma (17%). Median length of stay was 5 days (range 1-42), varying according to treatment. Clinical review and treatment was provided in the ACU, with patients staying in a local hotel at the hospital's expense. Admission to the inpatient ward was arranged as required, and there was close liaison with the inpatient team to preempt emergency admissions. Of the 523 unscheduled admissions, 87% occurred during working hours. An ACU/hotel-based treatment model can be safely used for a wide variety of cancers and treatments, expanding hospital treatment capacity, and freeing up inpatient beds for those patients requiring them.
Borgès Da Silva, Roxane; Brault, Isabelle; Pineault, Raynald; Chouinard, Maud-Christine; Prud'homme, Alexandre; D'Amour, Danielle
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.
Basu, Sanjay; Phillips, Russell S; Bitton, Asaf; Song, Zirui; Landon, Bruce E
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.
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
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.
Reece, Kelley M; Lozano, Miguel A; Roux, Ryan; Spivey, Susan M
The implementation and evaluation of a gravimetric i.v. workflow software system in an oncology ambulatory care pharmacy are described. To estimate the risk involved in the sterile i.v. compounding process, a failure modes and effects analysis (FMEA) in the oncology ambulatory care pharmacy was performed. When a volumetric-based process was used to reconstitute vials, the actual concentration was unknown since an assumption must be made that the exact volume of diluent was used when reconstituting the drug. This gap in our process was discovered during the FMEA and was resolved with the implementation of an i.v. workflow software solution. The i.v. software system standardized preparation steps and documented each process step, enabling a systematic review of the metrics for safety, productivity, and drug waste. Over the study period, 15,843 doses were prepared utilizing the new technology, with a total of 1,126 errors (7%) detected by the workflow software during dose preparation. Barcode scanning detected 292 (26%) of the total errors, the gravimetric weighing step detected 797 (71%) deviation errors, and 37 (3%) errors were detected at the vial reconstitution step. All errors were detected during compounding, eliminating the need to correct errors after production. Technician production time decreased by 34%, and pharmacist checking time decreased by 37%. Implementation of a gravimetric-based software system that used barcode verification and real-time alerts improved the detection of errors in the chemotherapy preparation process when compared with self-reporting. Standardized workflow processes and the elimination of time-consuming manual steps increased productivity while vial management decreased costs. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
Kim, Gahyun; Kim, Myung Hee; Lee, Sangmin M; Choi, Soo Joo; Shin, Young Hee; Jeong, Hee Joon
The aim of this study was to evaluate the effects of pre-warmed (approximately 41 °C) intravenous fluids (IV) on perioperative hypothermia and postoperative shivering in female patients undergoing short, ambulatory urological surgery under monitored anesthesia care (MAC). Patients between the ages of 35 and 80 years were randomly assigned to either the pre-warmed (n = 27) or the room temperature (n = 26) group. According to group allocation, either pre-warmed IV fluids that had been stored in a warming cabinet for at least 8 h or room temperature IV fluids were administered intraoperatively up to approximately 600-700 ml, including a bolus infusion of 10 ml/kg within 20 min. Perioperative core temperatures at the tympanic membrane, postoperative shivering, subjective thermal comfort, and the use of forced-air warming interventions in the post-anesthesia care unit (PACU) were recorded. Mean core temperatures were significantly higher in the pre-warmed group than they were in the room temperature group after 10 ml/kg preload fluid was administered, at the end of the operation, and on admission to the PACU (p = 0.004, p = 0.02, and p = 0.008, respectively). The incidence of hypothermia (shivering incidence was also significantly lower in the pre-warmed group (n = 2) than in the room temperature group (n = 8, p = 0.039). Infusion of pre-warmed IV fluid improved the postoperative recovery profile by decreasing hypothermia and shivering in female patients undergoing short, ambulatory urological surgery under MAC.
... 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...
Munns, Ailsa; Forde, Karen A; Krouzecky, Miriam; Shields, Linda
Within the current Australian health system is the understanding of a need to change from the predominate biomedical model to incorporate a comprehensive primary health care centred approach, embracing the social contexts of health and wellbeing. Recent research investigated the benefits of the primary health care philosophy and strategies in relation to the Rainbows programme which addresses grief and loss in primary school aged students in Western Australia. A multidisciplinary collaboration between the Western Australian Departments of Health and Education enabled community school health nurse coordinators to train teacher facilitators in the implementation of Rainbows, enabling support for students and their parents. The results of this qualitative study indicate that all participants regard Rainbows as effective, with many perceived benefits to students and their families.
Poirot, I; Laudy, V; Rabilloud, M; Roche, S; Ginhoux, T; Joubrel, I; Porsmoguer, E; Grimont, E; Vuillerot, C; Kassaï, B
To describe the rehabilitation of non-ambulatory children with cerebral palsy and to explore adjustability on their individual needs. Data described are extracted from an on-going national cohort study, following during 10years 385 children with cerebral palsy, aged from 4 to 10, Gross Motor Function Classification System IV and V. We analysed data from the first 190 patients (mean age 6years 10months (SD 2.0), 111 boys), focusing on physiotherapy, ergotherapy, psychomotility and speech therapy in medico-social and liberal sectors. In medico-social sector, duration of paramedical care is significantly more important than in liberal sector (structure of care: median=4.25h/week, liberal sector: median=2.00h/week) (Pliberal sector children benefit from only 2 different types of care a week. In investigators opinion, rehabilitation in structures of care is 71.65% adapted as opposed to 18.75% in the liberal sector (P<0.001). Children level V have less time of rehabilitation than the others (P=0.0424). Rehabilitation of children with cerebral palsy who are not able to walk, with an objective to improve quality of life, is truly multidisciplinary and suitable in medico-social sector. Copyright © 2013 Elsevier Masson SAS. All rights reserved.
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.
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.
Butler, Danielle C; Thurecht, Linc; Brown, Laurie; Konings, Paul
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.
Hyvonen, S; Nikkonen, M
The purpose of this study was to describe and analyse the content of mental health care from the practitioner's point of view. The specific aim of this paper was to outline the types of mental health care tools and the ways in which they are used by primary health care practitioners. The data were derived from interviews with doctors and nurses (n = 29) working in primary health care in six different health care centres of the Pirkanmaa region in Finland. The data were analysed by using qualitative content analysis. The tools of mental health care used in primary health care were categorized as communicative, ideological, technical and collaborative tools. The interactive tools are either informative, supportive or contextual. The ideological tools consist of patient initiative, acceptance and permissiveness, honesty and genuineness, sense of security and client orientation. The technical tools are actions related to the monitoring of the patient's physical health and medical treatment. The collaborative tools are consultation and family orientation. The primary health care practitioner him/herself is an important tool in mental health care. On the one hand, the practitioner can be categorized as a meta-tool who has control over the other tools. On the other hand, the practitioner him/herself is a tool in the sense that s/he uses his/her personality in the professional context. The professional skills and attitudes of the practitioner have a significant influence on the type of caring the client receives. Compared with previous studies, the present informants from primary health care seemed to use notably versatile tools in mental health work. This observation is important for the implementation and development of mental health practices and education.
Wensaas, Knut-Arne; Hungin, Amrit Pali
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.
To identify what can be done to promote research and development (R+D) in primary care. To find the main lines of primary care R+D in the Community of Valencia, Spain. Qualitative research based on consensus group. Concretely, the Phillips technique, modified for the number attending, was employed. Primary care. Twenty-four primary care professionals in the Community of Valencia (75% of 32 invited): physicians, pharmacists, teaching or research unit professionals, medical managers, and researcher-doctors leading primary care R+D projects. Four questions were asked: concerning barriers to research, how to make it easier to take part in competitive R+D contests, how to disseminate results and what topics are of most interest today. Problems identified were: lack of time, need for technical support, and need for day-schools and prizes to promote investigation. It was suggested that research should be given value in job contests, it should be made a requirement to finish training (MIR), funds for projects in health areas should be created and finance for emerging groups should be provided. In summary, it was proposed to create research units in every department/area with professionals given time off to lead projects and with administrative support to gain resources. Doctors should be encouraged to take part by the recognition of research for job contests, in their professional careers and in productivity indicators.
Fortinsky, Richard H.; Zlateva, Ianita; Delaney, Colleen; Kleppinger, Alison
Purpose: This article explores primary care physicians' (PCPs) self-reported approaches and barriers to management of patients with dementia, with a focus on comparisons in dementia care practices between PCPs in 2 states. Design and Methods: In this cross-sectional study, questionnaires were mailed to 600 randomly selected licensed PCPs in…
Arnold, L M; Gebke, K B; Choy, E H S
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.
Riley, Anthony J; Harding, Geoffrey; Underwood, Martin R; Carter, Yvonne H
Homelessness is a social problem that affects all facets of contemporary society. This paper discusses the concept of homelessness in terms of its historical context and the dominance of the pervasive 'victim blaming' ideologies, which, together with the worldwide economic changes that have contributed to a fiscal crisis of the state, and the resultant policies and circumstances, have led to an increase in the number of 'new homeless' people. This paper attempts to challenge the dominant political discourse on homelessness. The widespread healthcare problems and heterogeneity of homeless people have a particular impact on health services, with many homeless people inappropriately accessing local accident and emergency (A&E) departments because of barriers inhibiting adequate access to primary care. A number of primary care schemes have been successfully implemented to enable the homeless to have better access to appropriate care. However, there is no consistency in the level of services around the United Kingdom (UK), and innovations in service are not widespread and by their nature they are ad hoc. Despite the successes of such schemes, many homeless people still access health care inappropriately. Until homeless people are fully integrated into primary care the situation will not change. The question remains, how can appropriate access be established? A start can be made by building on some of the positive work that is already being done in primary care, but in reality general practitioners (GPs) will be 'swimming against the tide' unless a more integrated policy approach is adopted to tackle homelessness.
Full Text Available Abstract Background When patients are asked what they find most anxiety provoking about having surgery, the top concerns almost always include postoperative nausea and vomiting (PONV. Only until recently have there been any published recommendations, mostly derived from expert opinion, as to which regimens to use once a patient develops PONV. The goal of this study was to assess the responses to a written survey to address the following questions: 1 If no prophylaxis is administered to an ambulatory patient, what agent do anesthesiologists use for treatment of PONV in the ambulatory Post-Anesthesia Care Unit (PACU?; 2 Do anesthesiologists use non-pharmacologic interventions for PONV treatment?; and 3 If a PONV prophylaxis agent is administered during the anesthetic, do anesthesiologists choose an antiemetic in a different class for treatment? Methods A questionnaire with five short hypothetical clinical vignettes was mailed to 300 randomly selected USA anesthesiologists. The types of pharmacological and nonpharmacological interventions for PONV treatment were analyzed. Results The questionnaire was completed by 106 anesthesiologists (38% response rate, who reported that on average 52% of their practice was ambulatory. If a patient develops PONV and received no prophylaxis, 67% (95% CI, 62% – 79% of anesthesiologists reported they would administer a 5-HT3-antagonist as first choice for treatment, with metoclopramide and dexamethasone being the next two most common choices. 65% (95% CI, 55% – 74% of anesthesiologists reported they would also use non-pharmacologic interventions to treat PONV in the PACU, with an IV fluid bolus or nasal cannula oxygen being the most common. When PONV prophylaxis was given during the anesthetic, the preferred PONV treatment choice changed. Whereas 3%–7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% (95% confidence intervals, 18% – 36% of practitioners would re
Nora, Carlise Rigon Dalla; Zoboli, Elma Lourdes Campos Pavone; Vieira, Margarida M
to characterize the profile and describe the moral sensitivity of primary health care nurses. this is a quantitative, transversal, exploratory, descriptive study. The data were collected through the Moral Sensitivity Questionnaire translated and adapted to Brazil. 100 primary health care nurses participated, from Rio Grande do Sul, Brazil. The data collection took place during the months of March and July 2016, in an online form. The analysis of the data occurred through descriptive statistical analysis. the nurses had an average moral sensitivity of 4.5 (out of 7). The dimensions with the greatest moral sensitivity were: interpersonal orientation, professional knowledge, moral conflict and moral meaning. the nurses of Rio Grande do Sul have a moderate moral sensitivity, which may contribute to a lower quality in Primary Health Care.
Maria Cristina Barbaro
Full Text Available OBJECTIVE: evaluate prenatal care for adolescents in health units, in accordance with the attributes of Primary Health Care (PHC guidelines. METHOD: quantitative study conducted with health professionals, using the Primary Care Assessment Tool-Brazil to assess the presence and extent of PHC attributes. RESULTS: for all the participating units, the attribute Access scored =6.6; the attributes Longitudinality, Coordination (integration of care, Coordination (information systems and Integrality scored =6.6, and the Essential Score =6.6. Comparing basic units with family health units, the attribute scores were equally distributed; Accessibility scored =6.6, the others attributes scored =6.6; however, in the basic units, the Essential Score was =6.6 and, in the family health units, =6.6. CONCLUSION: expanding the coverage of family health units and the training of professionals can be considered strategies to qualify health care.
Full Text Available OBJETIVO: Conhecer as práticas de autocuidado utilizadas por pessoas com insuficiência renal crônica submetidos à diálise peritoneal ambulatorial contínua (CAPD. MÉTODOS: Foi utilizada a abordagem qualitativa, sendo a entrevista semi estruturada como técnica de coleta de dados. Estas foram realizadas entre junho e julho de 2010, com 09 pacientes de um Serviço de Nefrologia localizado em um município da região sul do Estado do Rio Grande do Sul. Foi utilizada a análise temática evidenciando dois núcleos temáticos. RESULTADOS: O primeiro, práticas de autocuidado relacionado à doença. Nesta temática apresentam-se práticas relacionadas à alimentação, ingesta hídrica, sono, repouso, lazer, e auto-estima. O segundo núcleo, práticas de autocuidado relacionadas à CAPD em que se descrevem as práticas relacionadas ao cateter e procedimento. CONCLUSÃO: Os participantes do estudo utilizam práticas de cuidado semelhantes, o que indica que recebem orientações e são estimulados a cada consulta de enfermagem.
Rizer, Milisa K; Sieck, Cynthia; Lehman, Jennifer S; Hefner, Jennifer L; Huerta, Timothy R; McAlearney, Ann Scheck
To assess patient perceptions of electronic medical record (EMR) intrusiveness during ambulatory visits to clinics associated with a large academic medical center. We conducted a survey of patients seen at any of 98 academic medical center clinics. The survey assessed demographics, visit satisfaction, computer use, and perceived intrusiveness of the computer. Of 7,058 patients, slightly more than 80 percent reported that the physician had used the computer while in the room, but only 24 percent were shown results in the EMR. Most patients were very satisfied or satisfied with their visit and did not find the computer intrusive (83 percent). Younger respondents, those shown results, and those who reported that the physician used the computer were more likely to perceive the computer as intrusive. Qualitative comments suggest different perceptions related to computer intrusiveness than to EMR use more generally. Patients were generally accepting of EMRs and therefore use of computers in the exam room. However, subgroups of patients may require greater study to better understand patient perceptions related to EMR use and intrusiveness. Results suggest the need for greater focus on how physicians use computers in the exam room in a manner that facilitates maintaining good rapport with patients.
Shi, Leiyu; Hung, Li-Mei; Song, Kuimeng; Rane, Sarika; Tsai, Jenna; Sun, Xiaojie; Li, Hui; Meng, Qingyue
China passed a landmark health care reform in 2009, aimed at improving health care for all citizens by strengthening the primary care system, largely through improvements to infrastructure. However, research has shown that the work attitudes of primary care physicians (PCPs) can greatly affect the stability of the overall workforce and the quality and delivery of health care. The purpose of this study is to investigate the relationship between reported work attitudes of PCPs and their personal, work, and educational characteristics. A multi-stage, complex sampling design was employed to select a sample of 434 PCPs practicing in urban and rural primary care settings, and a survey questionnaire was administered by researchers with sponsorship from the Ministry of Health. Four outcome measures describing work attitudes were used, as well as a number of personal-, work-, and practice-related factors. Findings showed that although most PCPs considered their work as important, a substantial number also reported large workloads, job pressure, and turnover intentions. Findings suggest that policymakers should focus on training and educational opportunities for PCPs and consider ways to ease workload pressures and improve salaries. These policy improvements must accompany reform efforts that are already underway before positive changes in reduced disparities and improved health outcomes can be realized in China.
Jan L. Losby
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.
Djalali, Sima; Ursprung, Nadine; Rosemann, Thomas; Senn, Oliver; Tandjung, Ryan
The adoption and use of health information technology (IT) continues to grow around the globe. In Switzerland, the government nor professional associations have to this day provided incentives for health IT adoption. We aim to assess the proportion of physicians who are routinely working with electronic health data and describe to what extent physicians exchange electronic health data with peers and other health care providers. Additionally, we aim to estimate the effect of physicians' attitude towards health IT on the adoption of electronic workflows. Between May and July 2013, we conducted a cross-sectional survey of 1200 practice based physicians in Switzerland. Respondents were asked to report on their technical means and where applicable their paper-based workarounds to process laboratory data, examination results, referral letters and physician's letters. Physicians' view of barriers and facilitators towards health IT use was determined by a composite score. A response rate of 57.1% (n=685) was reached. The sample was considered to be representative for physicians in Swiss ambulatory care. 35.2% of the respondents documented patients' health status with the help of a longitudinal semi-structured electronic text record generated by one or more encounters in the practice. Depending on the task within a workflow, around 11-46% of the respondents stated to rely on electronic workflow practices to process laboratory and examination data and dispatch referral notes and physician's letters. The permanent use of electronic workflow processes was infrequent. Instead, respondents reported paper-based workarounds affecting specific tasks within a workflow. Physicians' attitude towards health IT was significantly associated with the adoption of electronic workflows (OR 1.04-1.31, p<0.05), but the effect sizes of factors related to the working environment (e.g., regional factors, medical specialty, type of practice) were larger. At present, only a few physicians in Swiss
Haggerty, Robert J; Green, Morris
Academic general pediatrics and ambulatory care are closely linked to the development of the Ambulatory Pediatric Association, an organization with nearly 2000 members active in teaching, patient care, and research. Primary care, behavioral-developmental pediatrics, prevention, health promotion, community pediatrics, socioeconomic issues, cultural and ethnic diversity, advocacy, research in education, social issues, and environmental health lie within the purview of general pediatrics. In part, because of their teaching and patient care obligations, but also due to a lack of fellowship research training, many general pediatrics faculty have had difficulty in accomplishing significant research. By supporting fellowship training in general pediatrics, The Robert Wood Johnson Foundation General Pediatrics Academic Development Program and the current fellowship program supported by the Bureau of Health Manpower are important efforts to remedy this deficiency. The sciences basic to general pediatrics research include epidemiology, biostatistics, and the behavioral sciences. In addition, general pediatrics research often borrows from other sciences and collaborates with investigators in other disciplines. Partnerships between general pediatrics divisions and practicing pediatricians for teaching and research, e.g. the Community Education in Community Settings program, provides a realistic educational program for future pediatricians. The Pediatric Research in Office Setting network is another important vehicle for translation of research into the practice of general pediatrics. The steady growth of the Ambulatory Pediatric Association over the past four decades is testimony to the creativity, adaptability, and verve that has characterized the discipline of general pediatrics.
Veenstra, Petra; Kollen, Boudewijn J.; de Jong, Gosse; Baarveld, Frans; van den Berg, J. S. Peter
Introduction Migraine is a common disorder with a high burden. Adequate treatment results in improvement of quality of life. Migraine patients are mainly treated by general practitioners (GPs), but there is still room for improvement. This study investigated whether primary care nurses could improve
Although meniscal tears are a very common phenomenon uncertainty exists about the diagnosis and treatment of meniscal tears in primary care. This thesis aims to provide evidence for general practitioners and physical therapists regarding the diagnosis and management of patients with a suspected
Honkoop, Pieter Jacob
Asthma is a common non-communicable respiratory disease. In this thesis we analysed three different management strategies for adult patients with asthma in primary care. In the first, we targeted the currently recommended aim of ‘Controlled asthma’, which means patients experience hardly any
Bregnhøj, Lisbeth; Thirstrup, Steffen; Kristensen, Mogens Brandt
OBJECTIVE: To describe the prevalence of inappropriate prescribing in primary care in Copenhagen County, according to the Medication Appropriateness Index (MAI) and to identify the therapeutic areas most commonly involved. SETTING: A cross-sectional study was conducted among 212 elderly ( >65 years...
mood and anxiety disorders. He is mar- ried with two sons. Psychiatric emergencies, a primary care perspective. Psychiatric emergencies can be stressful and ... In teenagers the trigger is often relationships or the lack thereof, problems at school or parental expectat i o n s. In middle- age the concerns are divorce and.
Rogers, Andrew T; Semenov, Yevgeniy R; Kwatra, Shawn G; Okoye, Ginette A
Racial health disparities are widespread in the United States, but little is known about racial disparities in the management of dermatological conditions. Nationally representative data on the management of acne vulgaris were gathered from the National Ambulatory Medical Care Survey (NAMCS) for the years 2005-2014. Visits to any specialist were included. Rao-Scott chi-square tests and multivariate adjusted logistic regressions were used to identify differences in patient demographics, visit characteristics and acne medications across races. Black patients are less likely than white patients to visit a dermatologist (adjusted odds ratio (aOR) 0.48, p = 0.001), receive any acne medication (aOR 0.64, p = 0.01), receive a combination acne medication (aOR 0.52, p = 0.007) or receive isotretinoin (aOR 0.46, p = 0.03). Adjusting for management by a dermatologist eliminated the association between race and the prescription of any acne medication as well as between race and the prescription of isotretinoin. Among outpatient visits for acne in the United States, racial disparities exist in the likelihood of seeing a dermatologist and receiving treatment. Treatment disparities are less common when care is provided by a dermatologist. More research is needed to better understand the causes of disparities in acne management and other dermatological conditions.
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
Kolozsvári, László Róbert; Rurik, Imre
The Hungarian primary care quality indicator system has been introduced in 2009, and has been continuously developed since then. The system offers extra financing for family physicians who are achieving the expected levels of indicators. There are currently 16 indicators for adult and mixed practices and 8 indicators are used in paediatric care. Authors analysed the influencing factors of the indicators other than those related to the performance of family physicians. Expectations and compliance of patients, quality of outpatient (ambulatory) care services, insufficient flow of information, inadequate primary care softwares which need to be updated could be considered as the most important factors. The level of financial motivations should also be significantly increased besides changes in the reporting system. It is recommended, that decision makers in health policy and financing have to declare clearly their expectations, and professional bodies should find the proper solution. These indicators could contribute properly to the improvement of the quality of primary care services in Hungary.
Neergaard, Mette Asbjørn; Jensen, AB; Olesen, Frede
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...... sectors.METHOD. A number of focus group interviews were conducted with three types of subgroups: 1) Bereaved relatives, 2) GPs and 3) Various health-care-professionals, namely community nurses, hospital physicians and GPs. The interviews were transcribed and analysed according to a phenomenological......) The primary sector needs easy access to specialist advise, supervision and empowerment. 4) Better and easier communication pathways are important, both within the primary sector and across the sectors to improve accessibility.CONCLUSION. Our study shows a need for improvements in palliative home care...
del Saz Moreno, Vicente; Alberquilla Menéndez-Asenjo, Ángel; Camacho Hernández, Ana M; Lora Pablos, David; Enríquez de Salamanca Lorente, Rafael; Magán Tapia, Purificación
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.
Thrun, Mark W
Expansions in health care coverage, a comprehensive framework for HIV prevention and care, electronic medical records, and novel HIV prevention modalities create a current opportunity to change the trajectory of the HIV epidemic in the United States. HIV is increasingly disproportionately found in populations historically at higher risk, including gay men and other men who have sex with men, transgender women, injection drug users, and persons of color. This underscores the need for providers to identify persons at higher risk for HIV and assure the provision of screening and prevention services. In turn, universal screening for HIV-testing every adolescent and adult at least once in their lifetime-will increasingly be necessary to find the infrequent cases of HIV in lower risk populations. In both these domains, primary care providers will play a unique role in complementing traditional providers of HIV prevention and care services by increasing the proportion of their patients who have been screened for HIV, opening dialogues around sexual health, including asking about sexual orientation and gender identity, and prescribing antivirals as pre- and postexposure prophylaxis for their non-HIV-infected patients. Primary care providers must understand and embrace their importance along the HIV prevention and care continuum.
Blankenstein, T; Lytton, S D; Leidl, B; Atweh, E; Friese, K; Mylonas, I
A new CE-marked portable desktop ion mobility spectrometer (VGTest) was used for detection of malodorous biogenic amines indicative of bacterial vaginosis (BV). This study aimed to assess the performance of this testing method for the first time in a routine ambulatory care clinic and to determine the relative levels of biogenic amines in vaginal fluid of BV. Vaginal and cervical swabs (n = 57) were surveyed for infections. Cases of BV (n = 18) confirmed positive according to "Amsel" criteria and normal controls (n = 39) showing no infection under clinical examination and testing negative in wet mount microscopy were included in the IMS analysis. The trimethylamine (TMA) content in vaginal fluid of the BV-positive cases, AUCTMA/AUCTotal [mean 0.215 (range 0.15-0.35)] was significantly higher than normal controls [mean 0.06 (range 0.048-0.07)] p < 0.0001. The putrescine (1,4-diaminobutane, PUT) and cadaverine (1,5-diaminopentane, CAD) of BV-positive cases were above controls at borderline significance. The AUCTMA/AUCTotal ratios correlated neither with AUCPUT/AUCTotal nor AUCCAD/AUCTotal among BV-positive patients. In contrast, among normal controls all the biogenic amines were at a low level and the linear regression analysis revealed striking positive correlations of AUCTMA/AUCTotal with AUCPUT/AUCTotal (p < 0.05) and AUCCAD/AUCTotal (p < 0.001). The test shows 83 % sensitivity and 92 % specificity at a cut-off of AUCTMA/AUCTotal = 0.112 and AUC of receiver operator characteristic = 0.915 (0.81-0.97, 95 % CI). VGTest-IMS is accurate and feasible for point-of-care testing of BV in the ambulatory care setting. Further evaluations are in progress to assess the utility of VGTest-IMS for differential diagnosis of candidosis, non-BV infection and common inflammatory conditions.
Sibbald, Bonnie; Laurant, Miranda G; Reeves, David
Nurses increasingly work as substitutes for, or to complement, general practitioners in the care of minor illness and the management of chronic diseases. Available research suggests that nurses can provide as high quality care as GPs in the provision of first contact and ongoing care for unselected patients. Reductions in cost are context dependent and rarely achieved. This is because savings on nurses' salaries are often offset by their lower productivity (due to longer consultations, higher patient recall rates, and increased use of tests and investigations). Gains in efficiency are not achieved when GPs continue to provide the services that have been delegated to nurses, instead of focusing on the services that only doctors can provide. Unintended consequences of extending nursing roles include loss of personal continuity of care for patients and increased difficulties with coordination of care as the multidisciplinary team size increases. Rapid access to care is, however, improved. There is a high capital cost involved in moving to multidisciplinary teams because of the need to train staff in new ways of working; revise legislation governing scope of practice; address concerns about legal liability; and manage professional resistance to change. Despite the unintended consequences and the high costs, extending nursing roles in primary care is a plausible strategy for improving service capacity without compromising quality of care or health outcomes for patients.
Dharmarajan, T S; Avula, Sai; Norkus, Edward P
The objective of this study was to determine if a relationship exists between the presence of anemia and the occurrence of falls during hospitalization in ambulatory older adults from long-term care and community settings. All individuals were hospitalized for acute conditions not related to a fall. Three hundred sixty-two hospitalized, ambulatory older (59-104 years) adults. Laboratory values (hemoglobin [Hb], hematocrit [Hct]), routine laboratory tests, pertinent medical history, and demographics. Ambulatory hospitalized patients who fell were compared to controls (no falls during hospitalization) of similar age (P = .283) and gender distribution (P = .554). Patients who fell had significantly lower Hb (P falls and included the covariates of age, gender, place of residence, and race. The model described a 22% decreased risk of falls for every 1.0 g/dL increase in Hb (P falls in anemic patients (P falls during hospitalization. These findings suggest a potentially important link between anemia and the risk of falls during hospitalization in ambulatory older patients. Further studies are needed to determine if the risk of falls can be modified by correction of anemia and to determine the applicability of these findings to older adults in different settings.
Wasson, J H; Jette, A M; Johnson, D J; Mohr, J J; Nelson, E C
Health care is a service industry. A fundamental attribute of many successful service industries is the "small replicable unit (SRU)." There are three essential elements of an SRU: (1) the smallest core unit of activity, (2) micromeasures designed to help manage the core activities, and (3) combinations of the activities and measures to match local customer needs. In this article, we describe a model for geriatric care based on "SRU thinking." We demonstrate how this approach places measurement of patient values, clinical improvement strategies, and research objectives into day-to-day health care delivery.
Rogan, Lisa; Boaden, Ruth
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.
Millman, Andrea; And Others
Presents a model of outpatient interdisciplinary geriatric care provided at a veteran's hospital. Compares characteristics of patients served in this program with those in community-based geriatrics outpatient clinics described in the literature. (Author/ABB)
This is an empirical study of 7 communities among the O-kun Yoruba of Ijumu, Kogi State, Nigeria. The general objective of the study was to investigate the prioritizing pattern of the various Primary Health Care services (PHC) in the study area. Data for the study were generated mainly through multi-stage sampling ...
Ngunyulu, R N; Peu, M D; Mulaudzi, F M; Mataboge, M L S; Phiri, S S
Collaborative HIV care between the nurses and traditional health practitioners is an important strategy to improve health care of people living with HIV. To explore and describe the views of nurses regarding collaborative HIV care in primary healthcare services in the City of Tshwane, South Africa. A qualitative, descriptive design was used to explore and describe the views of nurses who met the study's inclusion criteria. In-depth individual interviews were conducted to collect data from purposively selected nurses. Content analysis was used to analyse data. Two main categories were developed during the data analysis stage. The views of nurses and health system challenges regarding collaborative HIV care. The study findings revealed that there was inadequate collaborative HIV care between the nurses and the traditional health practitioners. It is evident that there is inadequate policy implementation, monitoring and evaluation regarding collaboration in HIV care. The study findings might influence policymakers to consider the importance of collaborative HIV care, and improve the quality of care by strengthening the referral system and follow-up of people living with HIV and AIDS, as a result the health outcomes as implied in the Sustainable Development Goals 2030 might be improved. Training and involvement of traditional health practitioners in the nursing and health policy should be considered to enhance and build a trustworthy working relationship between the nurses and the traditional health practitioners in HIV care. © 2017 International Council of Nurses.
Nunan, David; Thompson, Matthew; Heneghan, Carl J; Perera, Rafael; McManus, Richard J; Ward, Alison
To assess the diagnostic accuracy of recommendations for self-monitoring blood pressure (BP) for diagnosing hypertension in primary care. Two hundred and forty-seven consecutive participants with raised (≥130 mmHg systolic) BP measured by their general practitioner from four primary care practices in the United Kingdom underwent 28 days of self-monitoring followed by 24-h ambulatory BP monitoring (ABPM). Diagnostic accuracy of the first 7 days of self-monitored BP (minimum 4 days, discarding readings on day 1) in detecting hypertension with ambulatory blood pressure was taken as reference. Two hundred and three participants were included, 109 (53.7%) of whom were diagnosed with hypertension using daytime ambulatory BP. The average of days 2-7 self-monitored BP correctly classified 150 of 203 participants [sensitivity 93.6%, 95% confidence interval (CI) 87.2-97.4%; specificity 51.1%, 95% CI 40.5-61.5%). However, the average of days 2-5 self-monitoring correctly classified 152 of 203 participants due to better specificity (53.2%, 95% CI 42.6-63.6%). In sensitivity analysis, diagnostic accuracy was not improved by inclusion of readings beyond day 5, and inclusion of readings taken on day 1 had no impact on diagnostic accuracy. Self-monitoring in the clinic was more accurate than readings taken by the general practitioner, but not self-monitoring outside of the clinic. Hypertension can be ruled out in the majority of patients with elevated clinic BP using the average of the first 5 consecutive days of self-monitored BP, supporting lower limits for self-monitoring readings in current guidelines. Performing readings beyond day 5 and including readings taken on the first day had no clinical impact on diagnostic accuracy.
Borg, Michael A
European countries exhibit significant geographical differences in antibiotic consumption per capita within ambulatory care, especially inappropriate use for colds/flu/sore throat (CFSt). One potential explanation could be national cultural differences resulting in varying perceptions and, therefore, influences. Publicly available data on the proportions of respondents in the 2009 Eurobarometer survey who had taken antibiotics for CFSt were tested for association against country scores derived from the Hofstede cultural dimension model. They were also correlated with knowledge of respondents about various key antibiotic facts. The Eurobarometer dataset incorporated 26,259 responses from all European Union (EU) countries except Cyprus. Using multiple regression, uncertainty avoidance and masculinity were identified as the two national cultural dimensions significantly associated with the use of antibiotics for CFSt (R-adjusted = 0.45; PCFSt was found to be inversely correlated with respondents' knowledge that antibiotics are ineffective against viruses (r=-0.724; P<0.001) and that misuse will render them ineffective in the longer term (r=-0.775; P<0.001). National cultural dimensions, especially uncertainty avoidance and masculinity, appear to have a very significant impact on inappropriate antibiotic use within European countries. Nevertheless, their influence can be reduced by making EU citizens more knowledgeable about antibiotics through appropriate messages and targeted campaigns.
Ortega-Calvo, Manuel; Santos, José Manuel; Lapetra, José
The scientific method is capable of being applied in primary care. In this article we defend the role of the "scientific entertainer "as strategic and necessary in achieving this goal. The task has to include playful and light-hearted content. We explore some words in English that may help us to understand the concept of "scientific entertainer" from a semantic point of view (showman, master of ceremonies, entrepreneur, go-between) also in Spanish language (counsellor, mediator, methodologist) and finally in Latin and Greek (tripalium, negotium, chronos, kairos). We define the clinical, manager or research health-worker who is skilled in primary care as a "primarylogist". Copyright © 2011 Elsevier España, S.L. All rights reserved.
Hestbæk, Lise; Munck, Anders; Hartvigsen, Lisbeth
Study Design. Baseline description of a multicenter cohort study. Objective. To describe patients with low back pain (LBP) in both chiropractic and general practice in Denmark. Background. To optimize standards of care in the primary healthcare sector, detailed knowledge of the patient populations...... in different settings is needed. In Denmark, most LBP-patients access primary healthcare through chiropractic or general practice. Methods. Chiropractors and general practitioners recruited adult patients seeking care for LBP. Extensive baseline questionnaires were obtained and descriptive analyses presented...... separately for general and chiropractic practice patients, Mann-Whitney rank sum test and Pearson's chi-square test, were used to test for differences between the two populations. Results. Questionnaires were returned from 934 patients in chiropractic practice and 319 patients from general practice. Four out...
Bowie, Paul; Jeffcott, Shelly
In the second paper of this series, we provide a brief overview of the scientific discipline of human factors and ergonomics (HFE). Traditionally the HFE focus in healthcare has been in acute hospital settings which are perceived to exhibit characteristics more similar to other high-risk industries already applying related principles and methods. This paper argues that primary care is an area which could benefit extensively from an HFE approach, specifically in improving the performance and well-being of people and organisations. To this end, we define the purpose of HFE, outline its three specialist sub-domains (physical, cognitive and organisational HFE) and provide examples of guiding HFE principles and practices. Additionally, we describe HFE issues of significance to primary care education, improvement and research and outline early plans for building capacity and capability in this setting.
Tsai, Adam G; Remmert, Jocelyn E; Butryn, Meghan L; Wadden, Thomas A
This article outlines some of the behavioral, pharmacologic, and surgical interventions available to primary care physicians (PCPs) to help their patients with weight management. Studies on lifestyle modification, commercial weight loss programs, and medical and surgical options are reviewed. Several clinical suggestions on obesity management that PCPs can take back and use immediately in office practice are offered. Copyright © 2017 Elsevier Inc. All rights reserved.
Smith, Emily; Narang, Puneet; Enja, Manasa; Lippmann, Steven
Pharmacotherapy for insomnia in primary care settings can be challenging. Frequently, there are multiple coexisting medical and psychiatric conditions, drug interactions, concern regarding use of habit-forming sleep aids, and paucity of time in office visits to discuss management of sleep difficulties. This article reports the results of a literature search related to pharmacotherapy for insomnia and presents 4 clinical vignettes with corresponding treatment options.
Bitar, George W; Springer, Paul; Gee, Robert; Graff, Chad; Schydlower, Manuel
Several major policy reports describe the central role of primary care in improving the delivery of behavioral health care services to children and adolescents. Although primary care providers are uniquely positioned to provide these services, numerous obstacles hinder the integration of these services, including time, clinic management and organization issues, training, and resources. Although many of these obstacles have been described in the literature, few studies have investigated these issues from the first-person perspective of front-line providers. The purpose of this study, therefore, is to provide an in-depth description of primary care providers' attitudes and perceptions of adolescent behavioral health care across a diversity of primary care settings (i.e., Federally Qualified Health Center [FQHC], FQHC-Look Alike, school-based, military). Sixteen focus groups were conducted at 5 primary care clinics. Thematic analysis was used to analyze the focus group data. Obstacles to integration are presented as well as strategies to overcome these challenges, using training and education, working groups, and community collaboratives.
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
Lee, Ming-Luen; Cho, Ching-Yi; Hsu, Chien-Lun; Chen, Chun-Jen; Chang, Lo-Yi; Lee, Yu-Sheng; Soong, Wen-Jue; Jeng, Mei-Jy; Wu, Keh-Gong
Antibiotic resistance is a global problem, and the inappropriate overuse of antibiotics is the major cause. Among children seeking medical help, acute respiratory tract infections (ARTIs) are the most common tentative diagnosis made by physicians and the leading condition for which antibiotics are prescribed. This study aimed to examine the trends of prescribing antibiotics in pediatric ambulatory care in Taiwan over a 10-year period. Children younger than 18 years old and being diagnosed as having ARTIs [International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 460, 465, and 466] during ambulatory visits from 2000 to 2009 were retrieved from the systematic random sampling datasets of the National Health Insurance Research Database (NHIRD) in Taiwan. The annual and monthly case numbers were recorded and the children's demographic characteristics, including sex, age, seasonality, location, level of medical institution, physician specialty, and their ambulatory prescriptions of antibiotics were collected and analyzed. Among 565,065 enrolled ambulatory children, 39,324 were prescribed antibiotics. The average antibiotics prescription rate was 7.0% during the 10-year period. There were marked descending trends in case numbers and antibiotic dispensing rates from 2000 to 2009. Female patients, elder ages (≥6 years old), summer and autumn, middle and southern areas of Taiwan, medical centers and regional hospitals, and physicians of pediatric specialty were associated with significantly lower antibiotic dispensing rates than other conditions (p antibiotics prescription rate in ambulatory children with ARTIs was 7.0% and it decreased gradually from 2000 to 2009 in Taiwan. Through understanding the annual trends in antibiotic prescriptions, it may be possible to design interventions to improve the judicious use of antibiotics in children. Copyright © 2014. Published by Elsevier B.V.
Full Text Available Paolo Mannelli,1 Li-Tzy Wu1–41Department of Psychiatry and Behavioral Sciences, 2Department of Medicine, 3Duke Clinical Research Institute, Duke University Medical Center, 4Center for Child and Family Policy, Sanford School of Public Policy, Duke University, Durham, NC, USARecent reports on prescription opioid misuse and abuse have described unprecedented peaks of a national crisis and the only answer is to expand prevention and treatment, including different levels of care.1 Nonetheless, concerns remain about the ability of busy primary care settings to manage problem opioid users along with other patients. In particular, proposed extensions of buprenorphine treatment, a critically effective intervention for opioid use disorder (OUD, are cautiously considered due to the potential risk of misuse or abuse.2 General practitioners are already facing this burden daily in the treatment of chronic pain, and expert supervision and treatment model adjustment are needed to help improve outcomes. Approximately 20% of patients in primary care have noncancer pain symptoms, with most of them receiving opioid prescriptions by their physicians, and their number is increasing.3 Pain diagnoses are comparable in severity to those of tertiary centers and are complicated by significant psychiatric comorbidity, with a measurable lifetime risk of developing OUD.4,5 Some primary care physicians report frustration about opioid abuse and diversion by their patients; support from pain specialists would improve their competence, the quality f their performance, and the ability to identify patients at risk of opioid misuse.6 Thus, buprenorphine treatment should not be adding to a complex clinical scenario. To this end, the promising models of care emphasize the integration of medical with psychological and pharmacological expertise for the management of OUD.
Cadogan, Angela; Mohammed, Khalid D
BACKGROUND AND CONTEXT Frozen shoulder is a painful condition that follows a protracted clinical course. We aim to review the management of patients with a diagnosis of frozen shoulder who are referred for specialist orthopaedic evaluation against existing guidelines in primary care. ASSESSMENT OF PROBLEM Referrals and clinical records were reviewed for all patients referred for orthopaedic specialist assessment who received a specialist diagnosis of frozen shoulder. Diagnostic, investigation and management practices from a regional primary health care setting in New Zealand were compared with guideline-recommended management. RESULTS Eighty patients with frozen shoulder were referred for orthopaedic evaluation in the 13 month study period, mostly from general practice. Fifteen patients (19%) were identified as having a frozen shoulder in their medical referral. Most (99%) had received previous imaging. Seven patients (12%) had received guideline recommended treatment. STRATEGIES FOR IMPROVEMENT Education of all clinicians involved in patient management is important to ensure an understanding of the long natural history of frozen shoulder and provide reassurance that outcomes are generally excellent. HealthPathways now include more information regarding diagnosis, imaging and evidence-based management for frozen shoulder. LESSONS Frozen shoulder may be under-diagnosed among patients referred for orthopaedic review. Ultrasound imaging is commonly used and may identify occult and unrelated pathology in this age-group. When managed according to clinical guidelines, patients report significant clinical and functional improvement with most reporting 80% function compared with normal after 1 year. KEYWORDS Adhesive capsulitis; bursitis; injections; practice guideline; primary health care; ultrasound.
Faber, Marjan J; Burgers, Jako S; Westert, Gert P
The Dutch primary care system has drawn international attention, because of its high performance at low cost. Primary care practices are easily accessible during office hours and collaborate in a unique out-of-hours system. After the reforms in 2006, there are no copayments for patients receiving care in the primary care practice in which they are registered. Financial incentives support the transfer of care from hospital specialists to primary care physicians, and task delegation from primary care physicians to practice nurses. Regional collaborative care groups of primary care practices offer disease management programs. The quality assessment system and the electronic medical record system are predominantly driven by health care professionals. Bottom-up and top-down activities contributed to a successful Dutch primary care system.
impossible. Once again, Reason creates a phrase that eloquently expresses both the dilemma and the challenge of safety and human error: 9...the state of safety is ideal. There must be explicit provision for whistleblowers . All parties have caring trust in each other . . .. all will help
Dini, Frank Lloyd; Simioniuc, Anca; Carluccio, Erberto; Ghio, Stefano; Rossi, Andrea; Biagioli, Paolo; Reboldi, Gianpaolo; Galeotti, Gian Giacomo; Lu, Fei; Zara, Cornelia; Whalley, Gillian; Temporelli, Pier Luigi
We compared the follow-up data on loop diuretic use and renal function, as assessed by serum creatinine levels, and the estimated glomerular filtration rate (eGFR), of two groups of consecutive ambulatory HF patients: 1) the clinically-guided group, in which management was clinically driven based on the institutional protocol of the HF Unit of the Cardiovascular and Thoracic Department of Pisa (standard of care) and 2) the echo and B-type natriuretic peptide (BNP) guided group (patients conforming to the protocol of the Network Labs Ultrasound (NEBULA) in HF Study Group: Pisa, Perugia, Pavia; Verona, Auckland, and Veruno), in which therapy was delivered according to the serial assessment of BNP and echocardiography. Patients whose follow-up was based on standard of care had a significant higher prevalence of worsening renal function, that was likely related to higher diuretic dosages, whilst, a better management of renal function was observed in the echo-BNP-guided group. The data is related to "Echo and natriuretic peptide guided therapy improves outcome and reduces worsening renal function in systolic heart failure: An observational study of 1137 outpatients" (A. Simioniuc, E. Carluccio, S. Ghio, A. Rossi, P. Biagioli, G. Reboldi, G.G. Galeotti, F. Lu, C. Zara, G. Whalley, P.G. Temporelli, F.L. Dini, 2016; K.J. Harjai, H.K. Dinshaw, E. Nunez, M. Shah, H. Thompson, T. Turgut, H.O. Ventura, 1999; A. Ahmed, A. Husain, T.E. Love, G. Gambassi, L.J. Dell׳Italia, G.S. Francis, M. Gheorghiade, R.M. Allman, S. Meleth, R.C. Bourge, 2006) , , .
Frank Lloyd Dini
Full Text Available We compared the follow-up data on loop diuretic use and renal function, as assessed by serum creatinine levels, and the estimated glomerular filtration rate (eGFR, of two groups of consecutive ambulatory HF patients: 1 the clinically-guided group, in which management was clinically driven based on the institutional protocol of the HF Unit of the Cardiovascular and Thoracic Department of Pisa (standard of care and 2 the echo and B-type natriuretic peptide (BNP guided group (patients conforming to the protocol of the Network Labs Ultrasound (NEBULA in HF Study Group: Pisa, Perugia, Pavia; Verona, Auckland, and Veruno, in which therapy was delivered according to the serial assessment of BNP and echocardiography. Patients whose follow-up was based on standard of care had a significant higher prevalence of worsening renal function, that was likely related to higher diuretic dosages, whilst, a better management of renal function was observed in the echo-BNP-guided group. The data is related to “Echo and natriuretic peptide guided therapy improves outcome and reduces worsening renal function in systolic heart failure: An observational study of 1137 outpatients” (A. Simioniuc, E. Carluccio, S. Ghio, A. Rossi, P. Biagioli, G. Reboldi, G.G. Galeotti, F. Lu, C. Zara, G. Whalley, P.G. Temporelli, F.L. Dini, 2016; K.J. Harjai, H.K. Dinshaw, E. Nunez, M. Shah, H. Thompson, T. Turgut, H.O. Ventura, 1999; A. Ahmed, A. Husain, T.E. Love, G. Gambassi, L.J. Dell׳Italia, G.S. Francis, M. Gheorghiade, R.M. Allman, S. Meleth, R.C. Bourge, 2006 [1–3].
Álvarez-Cordovés, M M; Mirpuri-Mirpuri, P G; Gonzalez-Losada, J; Chávez-Díaz, B
We present a case of a patient diagnosed with glioblastoma multiforme refractory to treatment. Glioblastoma multiforme is the most common primary brain tumour and unfortunately the most aggressive, with an estimated mortality of about 90% in the first year after diagnosis. In our case the patient had reached a stage of life where quality of life was importsnt, with palliative care being the only recourse. The family is the mainstay in the provision of care of terminally ill patients, and without their active participation it would be difficult to achieve the objectives in patient care. We must also consider the family of the terminally ill in our care aim, as its members will experience a series of changes that will affect multiple areas where we should take action. Copyright © 2012 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España. All rights reserved.
Sloane, P D; Dallara, J; Roach, C; Bailey, K E; Mitchell, M; McNutt, R
We sought to determine the types of dizziness problems that are commonly seen in primary care practices, and to bring to light clinical and demographic factors that predict management decisions. We undertook a prospective cohort study with a 6-month follow-up using data gathered in nine primary care practices in two North Carolina counties. Subjects were 144 dizziness patients examined by primary care physicians. Data collected included demographic characteristics, a standardized dizziness history, physician estimation of symptom severity and diagnostic certainty, and physician "worry" about arrhythmia, transient ischemic attack, and brain tumor. Physicians reported their management decisions and diagnosis (or differential diagnosis) by responding to a questionnaire after completing the patient encounter. A 6-month follow-up chart review and physician interview were completed on 140 patients (97.2 percent); information obtained included changes in diagnosis and patient mortality. The most common diagnoses were labyrinthitis, otitis media, benign positional vertigo, unspecified presyncope, sinusitis, and transient ischemic attack. The initial diagnosis changed during the 6-month follow-up period in 34 (24.3 percent) of patients. The overall course of these patients was benign, however, with only one death occurring during the 6-month follow-up period. Patients' dizziness tended to be managed using a combination of strategies, including office laboratory testing (33.6 percent), advanced testing (11.4 percent), referral to a specialist (9.3 percent), medication (61.3 percent), observation (71.8 percent), reassurance (41.6 percent), and behavioral recommendations (15.0 percent). Office laboratory testing was associated with younger patient age, a suspected metabolic or endocrine disorder, and physician worry about a cardiac arrhythmia; advanced laboratory testing was associated with suspected cardiovascular or neurologic disorders. Medication tended to be prescribed
Pipas, Catherine F; Peltier, Deborah A; Fall, Leslie H; Olson, Ardis L; Mahoney, John F; Skochelak, Susan E; Gjerde, Craig L
Traditional medical school department-based clerkship structures can lead to redundancy and/or gaps in curriculum, inefficient administrative systems, and academic isolation for clerkship directors. This paper describes the approaches, successes, and challenges three institutions experienced when implementing an interdepartmental collaboration to create an integrated primary care clerkship experience. Each school combined family medicine, ambulatory pediatrics, and ambulatory medicine into contiguous clerkship blocks. In all institutions, each clerkship maintained certain distinct features while the integrated aspects contained longitudinal curriculum of certain primary care topics. Evaluations by students demonstrated favorable responses to the new content and integrated methods of teaching, as did results of the Association of American Medical Colleges graduation survey. Faculty at each institution reported that their multidisciplinary approach has stimulated important educational collaborations, many of which require an economy of scale not often achievable within a single clerkship. These included innovative evaluation/documentation efforts; centralization of administrative tasks; enhanced recruitment, retention, and development of community-based faculty; an increase in the active core group of local and national primary care leaders; and an increase in scholarly activities. The collaborations have not occurred without challenges, primarily in the need for identifying sustainable resources for these and future collaborative educational endeavors. The benefits involved in developing an integrated primary care experience include expansion of curriculum content and methods, as well as enhancement of collegial support and resources to community-based and academic faculty. These integrations do, however, bring added challenges, time, and costs to traditional independent clerkships.
Desai, Mayur M; Rosenheck, Robert A; Kasprow, Wesley J
This study used the Behavioral Model for Vulnerable Populations to identify determinants of receipt of outpatient medical care within 6 months of initial contact with a national homeless veterans outreach program. Prospective study. Homeless veterans contacted through the program in 1999 (n = 26,926). Data from structured interviews conducted at the time of program intake were merged with Veterans Affairs administrative data to determine subsequent medical service use. Logistic regression modeling was used to identify predisposing, enabling, and need factors from traditional and vulnerable domains predictive of receiving medical care. Overall, 41.8% of subjects received at least one medical visit in the 6 months after program intake; of these, 48.7% had three or more visits. In multivariate analyses, the likelihood of receiving medical care was, among other things, positively associated with age, female gender, and placement in residential treatment and negatively associated with duration of homelessness and being contacted through outreach versus referred or self-referred into the homeless program. Mental illness did not appear to be an additional barrier to initiating medical care; however, a diagnosis of substance abuse or schizophrenia was associated with a decreased likelihood of receiving three or more visits. A majority of homeless veterans contacted through a national outreach program failed to receive medical services within 6 months of program entry. Vulnerable-domain factors were important supplements to traditional variables in predicting use of medical services in the homeless population. Greater efforts are needed to ensure that mentally ill homeless persons are successfully linked with and engaged in medical treatment.
Fisher, Elisa; Hasselberg, Michael; Conwell, Yeates; Weiss, Linda; Padrón, Norma A; Tiernan, Erin; Karuza, Jurgis; Donath, Jeremy; Pagán, José A
Health care delivery and payment systems are moving rapidly toward value-based care. To be successful in this new environment, providers must consistently deliver high-quality, evidence-based, and coordinated care to patients. This study assesses whether Project ECHO ® (Extension for Community Healthcare Outcomes) GEMH (geriatric mental health)-a remote learning and mentoring program-is an effective strategy to address geriatric mental health challenges in rural and underserved communities. Thirty-three teleECHO clinic sessions connecting a team of specialists to 54 primary care and case management spoke sites (approximately 154 participants) were conducted in 10 New York counties from late 2014 to early 2016. The curriculum consisted of case presentations and didactic lessons on best practices related to geriatric mental health care. Twenty-six interviews with program participants were conducted to explore changes in geriatric mental health care knowledge and treatment practices. Health insurance claims data were analyzed to assess changes in health care utilization and costs before and after program implementation. Findings from interviews suggest that the program led to improvements in clinician geriatric mental health care knowledge and treatment practices. Claims data analysis suggests that emergency room costs decreased for patients with mental health diagnoses. Patients without a mental health diagnosis had more outpatient visits and higher prescription and outpatient costs. Telementoring programs such as Project ECHO GEMH may effectively build the capacity of frontline clinicians to deliver high-quality, evidence-based care to older adults with mental health conditions and may contribute to the transformation of health care delivery systems from volume to value.
Full Text Available BACKGROUND: Current approaches for AD prediction are based on biomarkers, which are however of restricted availability in primary care. AD prediction tools for primary care are therefore needed. We present a prediction score based on information that can be obtained in the primary care setting. METHODOLOGY/PRINCIPAL FINDINGS: We performed a longitudinal cohort study in 3.055 non-demented individuals above 75 years recruited via primary care chart registries (Study on Aging, Cognition and Dementia, AgeCoDe. After the baseline investigation we performed three follow-up investigations at 18 months intervals with incident dementia as the primary outcome. The best set of predictors was extracted from the baseline variables in one randomly selected half of the sample. This set included age, subjective memory impairment, performance on delayed verbal recall and verbal fluency, on the Mini-Mental-State-Examination, and on an instrumental activities of daily living scale. These variables were aggregated to a prediction score, which achieved a prediction accuracy of 0.84 for AD. The score was applied to the second half of the sample (test cohort. Here, the prediction accuracy was 0.79. With a cut-off of at least 80% sensitivity in the first cohort, 79.6% sensitivity, 66.4% specificity, 14.7% positive predictive value (PPV and 97.8% negative predictive value of (NPV for AD were achieved in the test cohort. At a cut-off for a high risk population (5% of individuals with the highest risk score in the first cohort the PPV for AD was 39.1% (52% for any dementia in the test cohort. CONCLUSIONS: The prediction score has useful prediction accuracy. It can define individuals (1 sensitively for low cost-low risk interventions, or (2 more specific and with increased PPV for measures of prevention with greater costs or risks. As it is independent of technical aids, it may be used within large scale prevention programs.
Paula Giovana Furlan
Full Text Available Introduction: The expansion of the working field of occupational therapists in non-hospital environments and asylums in the last few decades, which came along with the territorial health practices in the National Health System, shows the relationship between the possibilities of professional performance and the existing public policies, including management functions and services. Objectives: To characterize the role of occupational therapists in the management of primary health care in the Distrito Federal and the professional knowledge used in this practice. Method: This was a qualitative research with production and analysis of data carried out through ethnography. Data were produced with aid of observations, field diary, semi-structured interviews and literature review. The study subjects were two occupational therapists from the State Secretariat of Health of the Distrito Federal who work in the management of primary health care. Results: The expansion of the concept of health has resulted in the incorporation of different professionals to compose the management of service and programs. The role of occupational therapists depends on their knowledge about management, collective projects and integral health care. Occupational therapists of this study work on central management and welfare programs to specific populations. Conclusion: The research made it possible to analyze the expansion of the working space of occupational therapists, contributing to future discussions on professional training. It was evident that the formation of the professional core provides subsidies for a larger management practice, such as skills for group and team work, and the work with socially excluded people.
Victor O. Kolade
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.
Shah, Shaival S.; Lutfiyya, May Nawal; McCullough, Joel Emery; Henley, Eric; Zeitz, Howard Jerome; Lipsky, Martin S.
Patient education in asthma management is important; however, there is little known about the characteristics of patients receiving asthma education or how often primary care physicians provide it. The objective of the study was to identify the characteristics of patients receiving asthma education. It was a cross-sectional study using 2001…
Renata Laszlo Torres
Full Text Available Objective To describe the profile of Hospitalizations by Amulatory Care Sensitive Conditions (HACSC, in the Municipality of Cotia, from 2008 to 2012. Method ecological, exploratory, longitudinal study with a quantitative approach. Data on HACSC, by age group and sex, were obtained from the Department of the Unified Health System. For data analysis descriptive statistics were used. Results During the period, there were 46,676 admissions, excluding deliveries, 7,753 (16.61% by HACSC. The main causes were cerebrovascular diseases, 16.96%, heart failure, 15.50%, hypertension, 10.80% and infection of the kidney and urinary tract, 10.51%. Regarding gender, HACSC occurred predominantly in males. There was a greater number of HACSC at extreme age ranges, especially in the elderly. Conclusion Chronic diseases predominate among the leading causes of HACSC and there was no significant difference between sex.
García-Molina Sáez, Celia; Urbieta Sanz, Elena; Madrigal de Torres, Manuel; Piñera Salmerón, Pascual; Pérez Cárceles, María D
To quantify and to evaluate the reliability of Primary Care (PC) computerised medication records of as an information source of patient chronic medications, and to identify associated factors with the presence of discrepancies. A descriptive cross-sectional study. General Referral Hospital in Murcia. Patients admitted to the cardiology-chest diseases unit, during the months of February to April 2013, on home treatment, who agreed to participate in the study. Evaluation of the reliability of Primary Care computerised medication records by analysing the concordance, by identifying discrepancies, between the active medication in these records and that recorded in pharmacist interview with the patient/caregiver. Identification of associated factors with the presence of discrepancies was analysed using a multivariate logistic regression. The study included a total of 308 patients with a mean of 70.9 years (13.0 SD). The concordance of active ingredients was 83.7%, and this decreased to 34.7% when taking the dosage into account. Discrepancies were found in 97.1% of patients. The most frequent discrepancy was omission of frequency (35.6%), commission (drug added unjustifiably) (14.6%), and drug omission (12.7%). Age older than 65 years (1.98 [1.08 to 3.64]), multiple chronic diseases (1.89 [1.04 to 3.42]), and have a narcotic or psychotropic drug prescribed (2.22 [1.16 to 4.24]), were the factors associated with the presence of discrepancies. Primary Care computerised medication records, although of undoubted interest, are not be reliable enough to be used as the sole source of information on patient chronic medications when admitted to hospital. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.
Prior, Anders; Vestergaard, Mogens; Davydow, Dimitry S; Larsen, Karen K; Ribe, Anette R; Fenger-Grøn, Morten
Psychiatric disorders are associated with an increased risk for ambulatory care-sensitive condition (ACSC)-related hospitalizations, but it remains unknown whether this holds for individuals with nonsyndromic stress that is more prevalent in the general population. To determine whether perceived stress is associated with ACSC-related hospitalizations and rehospitalizations, and posthospitalization 30-day mortality. Population-based cohort study with 118,410 participants from the Danish National Health Survey 2010, which included data on Cohen's Perceived Stress Scale, followed from 2010 to 2014, combined with individual-level national register data on hospitalizations and mortality. Multimorbidity was assessed using health register information on diagnoses and drug prescriptions within 39 condition categories. Being in the highest perceived stress quintile was associated with a 2.13-times higher ACSC-related hospitalization risk (95% CI, 1.91, 2.38) versus being in the lowest stress quintile after adjusting for age, sex, follow-up time, and predisposing conditions. The associated risk attenuated to 1.48 (95% CI, 1.32, 1.67) after fully adjusting for multimorbidity and socioeconomic factors. Individuals with above reference stress levels experienced 1703 excess ACSC-related hospitalizations (18% of all). A dose-response relationship was observed between perceived stress and the ACSC-related hospitalization rate regardless of multimorbidity status. Being in the highest stress quintile was associated with a 1.26-times insignificantly increased adjusted risk (95% CI, 0.79, 2.00) for ACSC rehospitalizations and a 1.43-times increased adjusted risk (95% CI, 1.13, 1.81) of mortality within 30 days of admission. Elevated perceived stress levels are associated with increased risk for ACSC-related hospitalization and poor short-term prognosis.
Muñoz Silva, Carolina Andrea; Rojas Orellana, Pedro Antonio; Marzuca-Nassr, Gabriel Nasri
The functional assessment of moderately or severely dependent older people encompasses social, psychological and biological aspects that may influence their quality of life and their degree of independence. This paper reviews the global geriatric assessment that should be performed in primary health care (PHC) for moderately or severely dependent older people. Since 2012 in PHC in Chile, the norm establishes that the degree of independence of older people should be assessed using the Barthel scale and caregiver stress should be evaluated using Zarit scale. People with severe disability should receive home care. We recommend to evaluate also cognitive aspects using the Mini-Mental State Examination (MMSE) to Barthel Index or using the Functional Independence Measure (FIM), since they are closely associated with functional capacity.
Landis, B J
Primary care providers are often the source of information regarding health matters including elective cosmetic surgery. Practitioners should know about the more common cosmetic surgical procedures to assist their clients in making informed decisions regarding these operations. This article describes facial cosmetic surgical procedures performed to modify the signs of aging, which includes rhytidectomy ("face lift"), blepharoplasty ("eyelid surgery"), chemical peels, and dermabrasion. Issues discussed include preoperative considerations, expected outcomes, length of recovery period, costs, and complications (hemorrhage, necrosis, nerve injury, psychologic sequelae). Because facial cosmetic surgery usually has a positive impact on one's self-esteem, there has been an overall increase in facial cosmetic procedures during the past decade.
McDaniel, Susan H; Grus, Catherine L; Cubic, Barbara A; Hunter, Christopher L; Kearney, Lisa K; Schuman, Catherine C; Karel, Michele J; Kessler, Rodger S; Larkin, Kevin T; McCutcheon, Stephen; Miller, Benjamin F; Nash, Justin; Qualls, Sara H; Connolly, Kathryn Sanders; Stancin, Terry; Stanton, Annette L; Sturm, Lynne A; Johnson, Suzanne Bennett
This article reports on the outcome of a presidential initiative of 2012 American Psychological Association President Suzanne Bennett Johnson to delineate competencies for primary care (PC) psychology in six broad domains: science, systems, professionalism, relationships, application, and education. Essential knowledge, skills, and attitudes are described for each PC psychology competency. Two behavioral examples are provided to illustrate each competency. Clinical vignettes demonstrate the competencies in action. Delineation of these competencies is intended to inform education, practice, and research in PC psychology and efforts to further develop team-based competencies in PC.
Interprofessional Relations; Primary Health Care/Organization & Administration; Diabetes Mellitus, Type 2/Prevention & Control; Primary Prevention/Methods; Risk Reduction Behavior; Randomized Controlled Trial; Life Style
Hale, Nathan; Probst, Janice; Robertson, Ashley
This study examined the intersection of rurality and community area deprivation using a nine-state sample of inpatient hospitalizations among children (US census regions with substantial rural representation and varying degrees of community vulnerability was selected. An area deprivation index was constructed and used in conjunction with rurality to examine differences in the rate of ACSC hospitalizations among children in the sample states. A mixed model with both fixed and random effects was used to test influence of rurality and area deprivation on the odds of a pediatric hospitalization due to an ACSC within the sample. Of primary interest was the interaction of rurality and area deprivation. The study found rural counties are disproportionality represented among the most deprived. Within the least deprived counties, the likelihood of an ACSC hospitalization was significantly lower in rural than among their urban counterparts. However, this rural advantage declines as the level of deprivation increases, suggesting the effect of rurality becomes more important as social and economic advantage deteriorates. We also found ACSC hospitalization to be much higher among racial/ethnic minority children and those with Medicaid or self-pay as an anticipated source of payment. These findings further contribute to the existing body of evidence documenting racial/ethnic disparities in important health related outcomes.
Rauenzahn, Sherri; Sima, Adam; Cassel, Brian; Noreika, Danielle; Gomez, Teny Henry; Ryan, Lynn; Wolf, Carl E; Legakis, Luke; Del Fabbro, Egidio
Professional organizations provide no guidelines regarding assessment and management of opioid abuse risk in cancer. Universal precautions (UP) developed for non-cancer pain, include assessments for aberrant behavior, screening questionnaires, and urine drug screens (UDS). The role of UDS for identifying opioid abuse risk in cancer is uncertain. Our aim is to characterize inappropriate UDS, and identify a potential role for UDS in therapeutic decision-making. An observational retrospective chart review of 232 consecutive supportive care clinic patients were seen during the study. Twenty-eight of the two hundred thirty-two did not meet inclusion criteria. One hundred fifty of the two hundred four had active cancer, while 54 had no evidence of active disease. Clinicians ordered UDS based on their clinical judgment of patients' substance misuse risk. Edmonton symptom assessment scores, history of substance abuse, alcohol use, tobacco use, aberrant behavior, and morphine equivalent daily dose (MEDD) were obtained. Pain scores and MEDD were higher (p = 0.021; p psychology, psychiatry, or substance abuse specialists. UDS on the 82 oncology patients at high risk for substance misuse were frequently positive (46%) for non-prescribed opioids, benzodiazepines or potent illicit drugs such as heroin or cocaine, and 39% had inappropriately negative UDS, raising concerns for diversion.
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 ...
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
Brenes Bermúdez, F J; Cozar Olmo, J M; Esteban Fuertes, M; Fernández-Pro Ledesma, A; Molero García, J M
Despite the high incidence of urinary incontinence (UI), health professional awareness of this disease is low, which in itself is not serious but significantly limits the lives of the patients. The Primary Care associations, Sociedad Española de Médicos de Atención Primaria [SEMERGEN], Sociedad Española de Médicos Generales y de Familia [SEMG], Sociedad Española de Medicina de Familia y Comunitaria [semFYC]) along with the Asociación Española de Urología (EAU) have developed this consensus with the proposal of making GPs aware, and to help them in the diagnosis, treatment and referral to Urologists. The first goal in primary care must be the detection of UI, thus an opportunistic screening at least once in the lifetime of asymptomatic women > 40 years old and asymptomatic men > 55 years old. The diagnosis, based on medical history and physical examination, must determine the type and severity of the UI in order to refer severe cases to the Urologist. Except for overactive bladder (OAB), non-pharmacological conservative treatment is the first approach to uncomplicated UI in females and males. Antimuscarinics are the only drugs that have demonstrated efficacy and safety in urge urinary incontinence (UUI) and OAB. In men with mixed symptoms, excluding severe obstruction cases, a combination therapy of alpha-blockers and antimuscarinics should be chosen. Copyright © 2013 Elsevier España, S.L. All rights reserved.
Ricketts, T C
Rural primary care programs were established in areas where there was thought to be no competition for patients. However, evidence from site visits and surveys of a national sample of subsidized programs revealed a pattern of competitive responses by the clinics. In this study of 193 rural primary care programs, mail and telephone surveys produced uniform data on the organization, operation, finances, and utilization of a representative sample of clinics. The programs were found to compete in terms of: (1) price, (2) service mix, (3) staff availability, (4) structural accessibility, (5) outreach, and (6) targeting a segment of the market. The competitive strategies employed by the clinics had consequences that affected their productivity and financial stability. The strategies were related to the perceived missions of the programs, and depended heavily upon the degree of isolation of the program and the targeting of the services. The competitive strategy chosen by a particular program could not be predicted based on service area population and apparent competitors in the service area. The goals and objectives of the programs had more to do with their competitive responses than with market characteristics. Moreover, the chosen strategies may not meet the demands of those markets.
Gutiérrez Angulo, María Luisa; Amenabar Azurmendi, Miren Dolores; Cuesta Solé, María Lourdes; Prieto Esteban, Irene; Mancebo Martínez, Sara; Iglesias Alonso, Amparo
To ascertain the prevalence of obesity and overweight recording in primary care (PC) clinical records. A descriptive, cross-sectional study. The study was conducted in three urban, primary care centers in Gipuzkoa. 620 computerized clinical records randomly selected from a population of 63,820. Patient age older than 14 years was the only inclusion criterion. Recording of the clinical episode referring to obesity and/or overweight. Other variables included age, sex, body mass index (BMI), waist circumference, comorbidity (diabetes, hypertension, heart failure, among others), and variability of the record made by healthcre professionals at each center. Statistical analysis included a Chi-square test or a Fisher's test for low frequencies. A value of P<.05 was considered significant. Analysis was performed using SPSS(®) v.21 software. Prevalence of recorded obesity was 6%, and 78.4% of those with recorded obesity were women. Overweight was recorded in 3% of subjects, of which 33.2% were women. BMI was recorded in 170 cases (27%). At least one comorbidity was found in 241 subjects (39%). Association of BMI with presence of comorbidity was statistically significant (P=.0001). Recording of obesity was associated to presence of comorbidity (P =.0002). This study confirmed that prevalence of obesity is underestimated, mainly because it is inadequately recorded in clinical histories; that prevalence increases in the presence of other risk factors; and that there is a significant variability in data collection between healthcare professionals. Copyright © 2013 SEEN. Published by Elsevier Espana. All rights reserved.
García-Pedrajas, F; Monedero, P
of nociceptive stimuli, avoidance of opioid drugs, rapid and pleasant awakening (excellent for postoperative analgesia), and less need for postoperative analgesics. The postoperative complications seen most often are related to respiration or hypertension, making routine postanesthetic pulse oximetry a recommendation. The most frequently used analgesics are paracetamol, magnesium dipyrone, diclofenac, ketorolac, or codeine compounds. Although the incidence of nausea and vomiting is low in children, they are frequently a cause of hospitalization. Inappropriate postoperative care can increase the rate of admissions and medico-legal problems.(ABSTRACT TRUNCATED AT 400 WORDS)
Hart, Huberta E.; Rutten, Guy E H M
In the Netherlands so-called Diabetes Care Groups organize the primary diabetes care centrally with delegation to different health care providers. A training course for general practitioners who would like to become experts in diabetology in the primary care setting meets the need to guide the
Weide, M.G.; Fakiri, F. el; Kulu Glasgow, I.; Grielen, S.J.; Zee, J. van der
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
Full Text Available This is one of the first studies to (1 describe the out-of-hospital burden of influenza-like-illness (ILI and clinically diagnosed flu, also for patients not seeking professional medical care, (2 assess influential background characteristics, and (3 formally compare the burden of ILI in patients with and without a clinical diagnosis of flu. A general population sample with recent ILI experience was recruited during the 2011-2012 influenza season in Belgium. Half of the 2250 respondents sought professional medical care, reported more symptoms (especially more often fever, a longer duration of illness, more use of medication (especially antibiotics and a higher direct medical cost than patients not seeking medical care. The disease and economic burden were similar for ambulatory ILI patients, irrespective of whether they received a clinical diagnosis of flu. On average, they experienced 5-6 symptoms over a 6-day period; required 1.6 physician visits and 86-91% took medication. An average episode amounted to €51-€53 in direct medical costs, 4 days of absence from work or school and the loss of 0.005 quality-adjusted life-years. Underlying illness led to greater costs and lower quality-of-life. The costs of ILI patients with clinically diagnosed flu tended to increase, while those of ILI patients without clinically diagnosed flu tended to decrease with age. Recently vaccinated persons experienced lower costs and a higher quality-of-life, but this was only the case for patients not seeking professional medical care. This information can be used directly to evaluate the implementation of cost-effective prevention and control measures for influenza. In particular to inform the evaluation of more widespread seasonal influenza vaccination, including in children, which is currently considered by many countries.
Bilcke, Joke; Coenen, Samuel; Beutels, Philippe
This is one of the first studies to (1) describe the out-of-hospital burden of influenza-like-illness (ILI) and clinically diagnosed flu, also for patients not seeking professional medical care, (2) assess influential background characteristics, and (3) formally compare the burden of ILI in patients with and without a clinical diagnosis of flu. A general population sample with recent ILI experience was recruited during the 2011-2012 influenza season in Belgium. Half of the 2250 respondents sought professional medical care, reported more symptoms (especially more often fever), a longer duration of illness, more use of medication (especially antibiotics) and a higher direct medical cost than patients not seeking medical care. The disease and economic burden were similar for ambulatory ILI patients, irrespective of whether they received a clinical diagnosis of flu. On average, they experienced 5-6 symptoms over a 6-day period; required 1.6 physician visits and 86-91% took medication. An average episode amounted to €51-€53 in direct medical costs, 4 days of absence from work or school and the loss of 0.005 quality-adjusted life-years. Underlying illness led to greater costs and lower quality-of-life. The costs of ILI patients with clinically diagnosed flu tended to increase, while those of ILI patients without clinically diagnosed flu tended to decrease with age. Recently vaccinated persons experienced lower costs and a higher quality-of-life, but this was only the case for patients not seeking professional medical care. This information can be used directly to evaluate the implementation of cost-effective prevention and control measures for influenza. In particular to inform the evaluation of more widespread seasonal influenza vaccination, including in children, which is currently considered by many countries.
Galpin, Kevin; Jones-Taylor, Cedrella; Anander, Steven; Demosthenes, Charles; Platt, Susan; Ponkshe, Sanjay
Background The time spent and complexity of work done by primary internal medicine physicians between office visits has not been well studied. Objective To measure the time and complexity of this care. Design Cross-sectional study. Setting General internists practicing on primary care teams with electronic medical records at a tertiary Veterans Health Administration Medical Center. Participants Ten physicians. Main Measures The project was designed to measure physician work between office visits. The electronic record was used to record the number and complexity of work events by physicians for 1 month. Complexity of work was measured on five levels ranging from Level I with no change in management, Level II with change in management of one disease, Level III of two diseases, Level IV of three diseases, and Level V of four or more diseases. Time sampling was done over 5 days to determine the time spent by level of complexity. Total time per physician was calculated by multiplying the number of events each physician captured by the average time for that physician for that level of complexity. Key Results Physicians worked a median of 7.9 h per week between office visits. Work was apportioned among Level I (18.3%), Level II (38.3%), Level III (36.5%), Level IV (4.6%), and Level V (2.3%). Limitations Single VA population and self-reported data. Findings may not be generalizable to other practice settings. Conclusion Primary internists spent a median of 7.9 h per week in work between office visits with 82% of the time involved in changes in management. PMID:20700665
Mangelsdorf, K L; Luna, J; Smith, H L
The health problems of Ecuador are similar to those in other developing countries where the standard of living is low, and housing and sanitation are inadequate. Women, children, and those living in rural areas are those most severely affected. National policy has been to attempt to increase access to health care in rural areas through the construction of new facilities and the appointment of highly paid medical staff. However, little attention was paid to sociocultural factors, which caused the peasantry to reject the medical care system, or to problems of internal efficiency which inhibited utilization. Since the 1970s various national and international organizations have attempted to implement primary health care (PHC) through the use of trained community health workers (CHWs). The primary problems faced by the CHWs were shortages of medicines and supplies, an almost total lack of supervision, and lack of transportation available to take staff to isolated villages. The poor supervision is blamed for the 17% drop out rate among CHWs since 1980. Independent PHC programs have also been established in Ecuador by voluntary organizations. These work best when coordinated with governmental programs, in order to allow monitoring and to avoid the duplication of services. Problems with the establishment of PHC programs in Ecuador will continue, as the government has no clear cut policy, and difficulties financing on a broad national scale. Other problems include the absence of effective supervision and logistical support for even small pilot programs, and inconsistencies in the training and role definition for CHWs. These problems need to be met in the implementation of a national PHC policy.
Kerstein, J; Pauly, M V; Hillman, A
OBJECTIVE. We assess whether physician turnover stems from incorrect physician expectations about the practice environment or from actual constraints or rewards in that environment. DATA SOURCES. Our primary data source contains information about individual HMOs' primary care physicians incentive mechanisms and general HMO characteristics. Our secondary data source is the area resource file (ARF), which contains countywide information about the HMOs' market areas, including physician characteristics, population characteristics, and other market characteristics. DATA COLLECTION. Our primary data source is from a nationwide survey of all HMOs in operation in 1987-1988, as reported to Interstudy. PRINCIPAL FINDINGS. We find that turnover is higher on the part of physicians whose HMO enrollment comprises a greater percentage of their total practice. Our results further indicate that physicians whose compensation is dependent on the behavior of a group of other physicians are more likely to leave the plan than those who bear the risk (and control it) more directly. On the other hand, turnover is increased by basing bonuses on individual productivity and by not sharing surpluses among a group. Market characteristics also are significant in explaining physician turnover in HMOs. CONCLUSIONS. It appears that physicians accurately forecast how they will react to individual financial risk, although they dislike restrictions imposed by HMOs. PMID:8163378
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
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
Stevanović, Ranko; Stanić, Arsen; Varga, Sinisa
The Croatian Ministry of Health started a health care system computerization project aimed at strengthening the collaboration among health care institutions, expert groups and individual health care providers. A tender for informatic system for Primary Health Care (PHC) general practice, pediatrics and gynecology, a vital prerequisite for project realization, has now been closed. Some important reasons for undertaking the project include rationalization of drug utilization, savings through a reduced use of specialists, consultants and hospitalization, then achievement of better cooperation, work distribution, result linking, data quality improvement (by standardization), and ensuring proper information-based decision making. Keeping non-standardized and thus difficult to process data takes too much time of the PHC team time. Since, however, a vast amount of data are collected on only a few indicators, some important information may remain uncovered. Although decisions made by health authorities should rely on evidence and processed information, the authorities spend most of the time working with raw data from which their decisions ultimately derive. The Informatic Technology (IT) in PHC is expected to enable a different approach. PHC teams should be relieved from the tedious task of data gathering and the authorities enabled to work with the information rather than data. The Informatics Communication Technology (ICT) system consists of three parts: hardware (5000 personal computers for work over the Internet), operative system with basic software (editor, etc.), and PHC software for PHC teams. At the national level (National Public Health Informatics System), a software platform will be built for data collection, analysis and distribution. This data collection will be based on the International Classification of Primary Care (ICPC-2) standard to ensure the utilization of medical records and quality assessment. The system permits bi-directional data exchange between
Allwright Shane PA
Full Text Available Abstract Background An industrial dispute between prison doctors and the Irish Prison Service (IPS took place in 2004. Part of the resolution of that dispute was that an independent review of prison medical and support services be carried out by a University Department of Primary Care. The review took place in 2008 and we report here on the principal findings of that review. Methods This study utilised a mixed methods approach. An independent expert medical evaluator (one of the authors, DT inspected the medical facilities, equipment and relevant custodial areas in eleven of the fourteen prisons within the IPS. Semistructured interviews took place with personnel who had operational responsibility for delivery of prison medical care. Prison doctors completed a questionnaire to elicit issues such as allocation of clinician's time, nurse and administrative support and resources available. Results There was wide variation in the standard of medical facilities and infrastructure provided across the IPS. The range of medical equipment available was generally below that of the equivalent general practice scheme in the community. There is inequality within the system with regard to the ratio of doctor-contracted time relative to the size of the prison population. There is limited administrative support, with the majority of prisons not having a medical secretary. There are few psychiatric or counselling sessions available. Conclusions People in prison have a wide range of medical care needs and there is evidence to suggest that these needs are being met inconsistently in Irish prisons.
Almeida, Patty Fidelis de; Santos, Adriano Maia Dos
To analyze the breadth of care coordination by Primary Health Care in three health regions. This is a quantitative and qualitative case study. Thirty-one semi-structured interviews with municipal, regional and state managers were carried out, besides a cross-sectional survey with the administration of questionnaires to physicians (74), nurses (127), and a representative sample of users (1,590) of Estratégia Saúde da Família (Family Health Strategy) in three municipal centers of health regions in the state of Bahia. Primary Health Care as first contact of preference faced strong competition from hospital outpatient and emergency services outside the network. Issues related to access to and provision of specialized care were aggravated by dependence on the private sector in the regions, despite progress observed in institutionalizing flows starting out from Primary Health Care. The counter-referral system was deficient and interprofessional communication was scarce, especially concerning services provided by the contracted network. Coordination capacity is affected both by the fragmentation of the regional network and intrinsic problems in Primary Health Care, which poorly supported in its essential attributes. Although the health regions have common problems, Primary Health Care remains a subject confined to municipal boundaries. Analisar o alcance da coordenação do cuidado pela Atenção Primária à Saúde em três regiões de saúde. Trata-se de estudo de caso, com abordagem quantitativa e qualitativa. Foram realizadas 31 entrevistas semiestruturadas com gestores municipais, regionais e estaduais e estudo transversal com aplicação de questionários para médicos (74), enfermeiros (127) e amostra representativa de usuários (1.590) da Estratégia Saúde da Família em três municípios-sede de regiões de saúde do estado da Bahia. A função de porta de entrada preferencial pela Atenção Primária à Saúde deparava-se com forte concorrência de servi
Shearer, David S
The present article discusses the integration of a civilian prescribing psychologist into a primary care clinic at Madigan Army Medical Center. A description of the role of the prescribing psychologist in this setting is provided. The author asserts that integrating prescribing psychology into primary care can improve patient access to skilled behavioral health services including psychotherapeutic and psychopharmacologic treatment. Potential benefits to the primary care providers (PCPs) working in primary care clinics are discussed. The importance of collaboration between the prescribing psychologist and PCP is emphasized. Initial feedback indicates that integration of a prescribing psychologist into primary care has been well received in this setting.
Kriegel, J; Rebhandl, E; Reckwitz, N; Hockl, W
Current and projected general practitioner (GP) and primary care in Austria shows structural and process inadequacies in the quality as well as assurance of healthcare supply. The aim is therefore to develop solution- and patient-oriented measures that take patient-related requirements and medical perspectives into account. Using an effect matrix, subjective expert and user priorities were ascertained, cause and effect relationships were examined, and an expanded circle of success for the optimization of GP and primary care in Upper Austria was developed. Through this, the relevant levers for target-oriented development and optimization of the complex system of GP and primary care in Upper Austria were identified; these are training to become general practitioners, entrepreneurs as well as management and coordination. It is necessary to further adapt the identified levers conceptually and operationally in a targeted approach. This is to be achieved by means of the primary health care (PHC) concept as well as management tools and information and communication technologies (ICT) associated with it. © Georg Thieme Verlag KG Stuttgart · New York.
Stigler, Florian L; Starfield, Barbara; Sprenger, Martin; Salzer, Helmut J F; Campbell, Stephen M
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.
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
Lawrence, Stephen L.; Lindemann, Janet C.; Gottlieb, Mark
Over 18 months, Medical College of Wisconsin students identified what they had learned during their clerkships in each of seven learning settings; the 3,030 outcomes were divided into 48 categories, and the ten most-frequent learning outcomes are reported. No significant differences by time of year or rural vs. urban clerkships were found.…
Grant, C C; Forrest, C B; Starfield, B
(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.
Yoon, Jean; Rose, Danielle E; Canelo, Ismelda; Upadhyay, Anjali S; Schectman, Gordon; Stark, Richard; Rubenstein, Lisa V; Yano, Elizabeth M
As the Veterans Health Administration (VHA) reorganizes providers into the patient-centered medical home, questions remain whether this model of care can demonstrate improved patient outcomes and cost savings. We measured adoption of medical home features by VHA primary care clinics prior to widespread implementation of the patient-centered medical home and examined if they were associated with lower risk and costs of potentially avoidable hospitalizations. Secondary patient data was linked to clinic administrative and survey data. Patient and clinic factors in the baseline year (FY2009) were used to predict patient outcomes in the follow-up year. 2,853,030 patients from 814 VHA primary care clinics Patient outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC) and their costs and identified through diagnosis and procedure codes from inpatient records. Clinic adoption of medical home features was obtained from the American College of Physicians Medical Home Builder®. The overall mean home builder score in the study clinics was 88 (SD = 13) or 69%. In adjusted analyses an increase of 10 points in the medical home adoption score in a clinic decreased the odds of an ACSC hospitalization for patients by 3% (P = 0.032). By component, higher access and scheduling (P = 0.004) and care coordination and transitions (P = 0.020) component scores were related to lower risk of an ACSC hospitalization, and higher population management was related to higher risk (P = 0.023). Total medical home features was not related to ACSC hospitalization costs among patients with at least one (P = 0.074). Greater adoption of medical home features by VHA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations with access and scheduling and care coordination/transitions in care as key factors.
Goldberg, D. P.; Reed, G. M.; Robles, R.
) in participating countries, and the relationship of BSS and HA to depressive and anxiety disorders and to disability. Method PCPs referred patients judged to have BSS or HA, who were then interviewed using a standardized psychiatric interview and a standardized measure of disability. Results Of 587 patients......-occurring diagnoses of depression, anxiety, or both. Anxious depression was the most common co-occurring psychological disorder, associated with the greatest disability. Conclusion Study results indicate the importance of assessing for mood and anxiety disorders among patients who present multiple somatic symptoms...... without identifiable physical pathology. Although highly co-occurring with each other and with mood and anxiety disorders, BSS and HA represent distinct constructs that correspond to important presentations in primary care. © 2016 Elsevier Inc....
García-Martínez, F J; Pascual, J C; López-Martín, I; Pereyra-Rodríguez, J J; Martorell Calatayud, A; Salgado-Boquete, L; Labandeira-García, J
Hidradenitis suppurativa is a prevalent disease that is noted for its clinical variability and by its severe impact on quality of life. A meticulous scientific literature review is presented in this article in order to give an update on what is known on this condition. Primary Care physicians obviously play an important role in the early diagnosis and management of hidradenitis suppurativa. This review aims to provide a current and practical overview about this disease in order to optimise the healthcare for these patients by making the best use of available resources. Copyright © 2015 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
Ballvé Moreno, José Luis; Pujol Ribó, Gloria; Romaguera Lliso, Amparo; Bonet Esteve, Anna; Rafecas Ruiz, Montserrat; Zarza Carretero, Elvira
To study internal communication between primary care health professionals Cross-sectional, descriptive. Catalan Health Institute Costa de Ponent Primary Care Area, Spain. All workers in the area (n=3565). Three part questionnaire: a) sociodemographic questions; b) questions scoring from 0 to 10 the current importance and operation of certain aspects; and c) questions on new communication tools. Of those sent a questionnaire, 39% (n=1388) responded, with a mean age of 43.2 years (95% CI, 42.75- 43.65), 28.9% being male. The major differences between importance and current events were said to be "to be informed of projects before they appear in the communication media," "by official routes and not by rumour," and "to be aware of projects of other teams." The least communicated within teams. The doctors considered upward communication to be more important. Doctors are those who appreciate communication within teams better and the professionals of the users services unit (UAU) less so. Doctors are the ones who give more importance to being informed of projects at the time. 55% do not use the intranet, mainly due to lack of time. The second reason is that they find it difficult. Sixty-two per cent read e-mail >2-3 times per week. Eighty-nine per cent want an electronic bulletin. The older workers use new technologies less. Downward, upward, and sideways communication needs to be improved, particularly upwards by doctors, and that of the teams for the UAU professionals. Intranet tools must be provided that make the work easier and training in handling new technologies must be offered.
Vilà Falgueras, Maite; Cruzate Muñoz, Carlota; Orfila Pernas, Francesc; Creixell Sureda, Joan; González López, María Pilar; Davins Miralles, Josep
To estimate the prevalence of burnout and the perception of teamwork in Primary Care teams from Barcelona. Multicenter cross-sectional. Primary Health Care Teams from Barcelona. Institut Català de la Salut. All permanent employees or temporary professionals of all categories from 51 teams (N=2398). A total of 879 responses (36.7%) were obtained. The Maslach Burnout Inventory questionnaire, with 3 dimensions, was sent by emotional exhaustion (AE), depersonalization (DP), and personal accomplishment (RP). Burnout is considered present when two or more dimensions scored high marks. Perception of teamwork and evaluation of leaders was evaluated using an ad hoc questionnaire. The prevalence of burnout was17.2% (two or more dimensions affected), and 46.2% had at least one of the three dimensions with a high level. A high level of AE was found in 38.2%, of DP in 23.8%, and 7.7% had low RP. Almost half (49.2%) believe that teamwork is encouraged in their workplace. Social workers overall, have a higher average of dimensions affected at a high level, followed by administrative personnel, dentists, doctors and nurses (p<0.001). Permanent staff have a greater degree of emotional exhaustion (p<0.002). Those who rated their leaders worst and least rated teamwork had more emotional exhaustion, depersonalization and higher level of burnout in general (p<0.001). The level of burnout among professionals is considerable, with differences existing between occupational categories. Teamwork and appreciating their leaders protect from burnout. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.
Full Text Available Abstract Background Care for people with dementia and their informal caregivers is a challenging aim in healthcare. There is an urgent need for cost-effective support programs that prevent informal caregivers of people with dementia from becoming overburdened, which might result in a delay or decrease of patient institutionalization. For this reason, we have developed the Systematic Care Program for Dementia (SCPD. The SCPD consists of an assessment of caregiver's sense of competence and suggestions on how to deal with competence deficiencies. The efficiency of the SCPD will be evaluated in our study. Methods and design In our ongoing, cluster, randomized, single-blind, controlled trial, the participants in six mental health services in four regions of the Netherlands have been randomized per service. Professionals of the ambulatory mental health services (psychologists and social psychiatric nurses have been randomly allocated to either the intervention group or the control group. The study population consists of community-dwelling people with dementia and their informal caregivers (patient-caregiver dyads coming into the health service. The dyads have been clustered to the professionals. The primary outcome measure is the patient's admission to a nursing home or home for the elderly at 12 months of follow-up. This measure is the most important variable for estimating cost differences between the intervention group and the control group. The secondary outcome measure is the quality of the patient's and caregiver's lives. Discussion A novelty in the SCPD is the pro-active and systematic approach. The focus on the caregiver's sense of competence is relevant to economical healthcare, since this sense of competence is an important determinant of delay of institutionalization of people with dementia. The SCPD might be able to facilitate this with a relatively small cost investment for caregivers' support, which could result in a major decrease in
Differences in the prevalence of hospitalizations and utilization of emergency outpatient services for ambulatory care sensitive conditions between asylum-seeking children and children of the general population: a cross-sectional medical records study (2015
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
Differences in the prevalence of hospitalizations and utilization of emergency outpatient services for ambulatory care sensitive conditions between asylum-seeking children and children of the general population: a cross-sectional medical records study (2015).
Lichtl, Célina; Lutz, Thomas; Szecsenyi, Joachim; Bozorgmehr, Kayvan
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. 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. 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]. Asylum-seeking children had significantly higher odds of ACS hospitalization and of utilization of emergency outpatient
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
E. Galvin (Eilish)
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
Gawron, Andrew J; Feinglass, Joseph; Pandolfino, John E; Tan, Bruce K; Bove, Michiel J; Shintani-Smith, Stephanie
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
Bennett, Alice L; Munkholm, Pia; Andrews, Jane M
Healthcare systems throughout the world continue to face emerging challenges associated with chronic disease management. Due to the likely increase in chronic conditions in the future it is now vital that cooperation and support between specialists, generalists and primary health care physicians...... affected by IBD in their caseload, the proportion of patients with IBD-related healthcare issues cared for in the primary care setting appears to be widespread. Data suggests however, that primary care physician's IBD knowledge and comfort in management is suboptimal. Current treatment guidelines for IBD...... is conducted. Inflammatory bowel disease (IBD) is one such chronic disease. Despite specialist care being essential, much IBD care could and probably should be delivered in primary care with continued collaboration between all stakeholders. Whilst most primary care physicians only have few patients currently...
May 10, 2010 ... Responding GPs felt that there is a need for ophthalmology up-skilling courses and 99.9% of them would attend such courses. Also, 82% of GPs felt that primary care doctors, not optometrists, should deliver primary eye care. Conclusion: GPs appear to lack sufficient knowledge to manage primary health ...
Toward More Equitable Primary Health Care in Argentina and Latin America through Intersectoral Approaches. Improving primary health care for everyone requires an effort that extends beyond the formal health sector. This project will examine the value of intersectoral collaborations at the primary healthcare level to ...
Kringos, D.S.; Boerma, W.G.W.
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
... strengthen free-standing primary care capacity by testing a model of comprehensive, accountable primary care... solicitation is directed to public and private health care payers who will respond individually to the... innovative payment and service delivery models that reduce spending under Medicare, Medicaid or CHIP, while...
Ophthalmic Skills Assessment of Primary Health Care Workers at Primary Health Care Facilities in Rural Communities in Cross River State, Nigeria. ... The workers attributed the high failure rate/low score to lack of follow-up and inadequate duration of training on eye care, which was just for one day. The ophthalmic skills ...
Heather L. Maracle
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
Valentijn, P.P.; Schepman, S.M.; Opheij, W.; Bruijnzeels, M.A.
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
Brand, C A; Amatya, B; Gordon, B; Tosti, T; Gorelik, A
Osteoarthritis of the hip and knee is a highly prevalent chronic condition in Australia that commonly affects older people who have other comorbidities. We report the pilot implementation of a new chronic disease management osteoarthritis service, which was multidisciplinary, evidence-based, supported patient self-management and care coordination. A musculoskeletal coordinator role was pivotal to service redesign and osteoarthritis pathway implementation. Impact evaluation included: service utilization, patient and general practitioner service experience, a 'before and after' audit of clinician adherence to recommendations, and 3- and 6-month patient health outcomes (pain, physical function, patient and physician global health (Visual Analogue Scale), disability (Multi-Attribute Prioritisation Tool), Partners in Health Scale and body mass index). A total of 123 patients, median age of 66 years, were assessed. Documentation of osteoarthritis assessment and management improved for all parameters. At 3 months there were improvements in self-reported pain (P preferences for therapy. The cost implications for implementation were low. The osteoarthritis service model is feasible to implement, is well received by patients and staff, and provides a template for translation into other settings.
Arboleda, Valerie A; Garner, Omai B
In this project, we assessed the breadth, quality, trends, and outcomes of point-of-care (POC) testing and regulatory compliance in 200 University of California, Los Angeles (UCLA) Health system outpatient clinics. We retrospectively extracted clinic POC test orders, results, and e-prescription data from the UCLA electronic health record over a 1-year period. Over 100,000 total tests were performed, encompassing 10 POC tests. Initially, 40% of clinics did not have complete licensure, but after implementation of the POC team, this metric improved to 100% licensure within 6 months. Most clinics used two or fewer POC tests, resulted fewer than 200 tests per year, and performed little to no external quality control measures. Our data analytics approach showed that peak POC testing occurred in January 2015, driven by influenza and urinalysis testing, and that both the testing and resulting clinical decision making do not routinely follow society guidelines. This decentralization of laboratory testing presents challenges to ensuring quality POC testing. Optimization and analysis of informatics data allow for the identification of POC test utilization trends, areas of improvement for clinical workflows, and increased education on national guidelines. © American Society for Clinical Pathology, 2017. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org
Isabel Cristina Ramos Vieira Santos
Full Text Available This study aimed to describe the treatment of patients with wounds in the Primary Health Care. A descriptive research with quantitative approach. Ninety-three Family Health Units of the city of Recife-PE, Brazil, were selected, and 112 nurses were interviewed from July to December 2011. The record book of bandages and procedures and the dressing form were used as an additional source of data. Frequencies, measures of central tendency and dispersion, prevalence and, for continuous variables, the analysis of variance were estimated. The prevalence of patients with wounds was 1.9% of the estimated covered population. Vascular ulcers accounted for 74.1% of the treated wounds. The dressing was predominantly performed by Nursing technicians, and the products available for this procedure did not match the current technological development.
Burtscher, Doris; Van den Bergh, Rafael; Toktosunov, Ulan; Angmo, Nilza; Samieva, Nazgul; Rocillo Arechaga, Eva P
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 be countered by
Burtscher, Doris; Van den Bergh, Rafael; Toktosunov, Ulan; Angmo, Nilza; Samieva, Nazgul; Rocillo Arechaga, Eva P.
Objectives 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. Methods 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. Results 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. Conclusions Health promotion activities should aim at improving knowledge on TB and DR-TB, reducing stigma, and fostering the inclusion of vulnerable populations. Health seeking
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.
Thomas, Paul; Graffy, Jonathan; Wallace, Paul; Kirby, Mike
Theory of effective network operation in primary care is underdeveloped. This study aimed to identify how primary care networks can best integrate academic and service initiatives. We performed a comparative case study of 4 primary care research networks in North London, England, for the years 1998-2002. Indicators were selected to assess changes in (1) research capacity, (2) multidisciplinary collaboration, and (3) research productivity. We compared the profiles of network outcome with descriptions of their contexts and organizational types from a previous evaluation. Together, the networks supported 133 viable projects and 30 others; 399 practitioners, managers, and academics participated in the research teams. How the networks organized themselves was influenced by the circumstances in which they were formed. Different ways of organizing were associated with different outcome profiles. Shared projects and learning spaces helped participants to develop trusted relationships. A top-down, hierarchical approach based on institutional alliances and academic expertise attracted more funding and appeared to be stable. The bottom-up, individualistic network with research practices was good at reflecting on practical primary care concerns. Whole-system methods brought together stakeholder contributions from all parts of the system. Networks can help integrate academic research and service development initiatives by facilitating interorganizational interactions and in shared leadership of projects. Researchers and practitioners stand to gain considerably from an integrated approach in both the short and the long term. Success requires agreement about a set of pathways, learning spaces, and feedback mechanisms to harness the insights and efforts of stakeholders throughout the whole system.
Elzubier, Ahmed G.; Bella, Hassan; Sebai, Zohair A.
The orientation about Primary Health Care among staff working in the PHC centers was assessed. Staff members numbering 909 were studied. The main criteria for judging orientation were a working knowledge of the definition and elements of PHC in addition to knowledge of the meaning of the word Alma Ata. Differences of this knowledge depending on sex, age, spoken language, type of job, postgraduate experience, previous experience in PHC and previous training in PHC were assessed. The main findi...
Lukewich, Julia; Edge, Dana S; VanDenKerkhof, Elizabeth; Tranmer, Joan
As the prevalence of chronic diseases continues to increase, emphasis is being placed on the development of primary care strategies that enhance healthcare delivery. Innovations include interprofessional healthcare teams and chronic disease management strategies. To determine the roles of nurses working in primary care settings in Ontario and the extent to which chronic disease management strategies have been implemented. We conducted a cross-sectional survey of a random sample of primary care nurses, including registered practical nurses, registered nurses, and nurse practitioners, in Ontario between May and July 2011. Nurses in primary care reported engaging in chronic disease management activities but to different extents depending on their regulatory designation (licensure category). Chronic disease management strategy implementation was not uniform across primary care practices where the nurses worked. There is the potential to optimize and standardize the nursing role within primary care and improve the implementation of chronic disease management strategies.
Gaal, S.; Laarhoven, E. van; Wolters, R.J.; Wetzels, R.; Verstappen, W.H.J.M.; Wensing, M.J.P.
RATIONALE, AIMS AND OBJECTIVES: Scientific definitions of patient safety may be difficult to apply in routine health care delivery. It is unknown what primary care workers consider patient safety. This study aimed to clarify the concept of patient safety in primary care. METHODS: We held 29
Abraham, V J; Balraj, Vinohar; Shankar, N; Job, Anand; Joseph, A
The feasibility of training teachers of day care centres for children (balwadi teachers) to recognize and manage common ear problems was studied so that they could provide primary care for ear related morbidity in the community. A training module was designed, piloted on grass root level workers and used to train 19 balwadi teachers. Their knowledge, skills and technique of examination was assessed following training. Pathways for referral were established between the balwadis, secondary and tertiary hospitals. The knowledge score of the balwadi teachers increased from a mean of 28.4% to 86%; they scored an average of 75% in an assessment of their examination technique. Their sensitivity in identifying overall ear related morbidity was 75%, and 96% in identifying children with ear discharge, specifically. Age, education and experience did not affect the outcome of their training. While it may be premature to comment on the impact of the training, periodic supervision, close monitoring and review sessions would sharpen the skills of the balwadi teachers and improve their efficiency.
Sandoval, Brian E; Bell, Jennifer; Khatri, Parinda; Robinson, Patricia J
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.
Mejzner, Natasha; Clark, Christopher E; Smith, Lindsay Fp; Campbell, John L
Previous surveys identified a shift to nurse-led care in hypertension in 2010. In 2011 the National Institute for Health and Care Excellence (NICE) recommended ambulatory (ABPM) or home (HBPM) blood pressure (BP) monitoring for diagnosis of hypertension. To survey the organisation of hypertension care in 2016 to identify changes, and to assess uptake of NICE diagnostic guidelines. Questionnaires were distributed to all 305 general practices in South West England. Responses were compared with previous rounds (2007 and 2010). Data from the 2015 Quality and Outcomes Framework (QOF) were used to compare responders with non-responders, and to explore associations of care organisation with QOF achievement. One-hundred-and-seventeen practices (38%) responded. Responders had larger list sizes and greater achievement of the QOF target BP ≤150/90 mmHg. Healthcare assistants (HCAs) now monitor BP in 70% of practices, compared with 37% in 2010 and 19% in 2007 ( P primary care BP monitoring has devolved from GPs and nurses to HCAs. One in 10 practices are not implementing NICE guidelines on ABPM and HBPM for diagnosis of hypertension. Most practices express confidence interpreting HBPM results but less so with ABPM. The need for education and quality assurance for allied health professionals is highlighted, and for training in ABPM interpretation for GPs. © British Journal of General Practice 2017.
Fougère, Bertrand; Oustric, Stéphane; Delrieu, Julien; Chicoulaa, Bruno; Escourrou, Emile; Rolland, Yves; Nourhashémi, Fati; Vellas, Bruno
Aging can be affected by frailty and chronic diseases causing physical, cognitive, sensory, and functional decline evolving gradually to disability. The assessment of older patients is carried out in some geriatric day hospitals (GDHFs). However, it seems difficult to assess all patients in these GDHFs. In this context, a care model, which uses a specialist nurse trained in primary care and geriatric assessment, has been developed. In this article, we describe the organization, details of the evaluation, and provide the main characteristics of the first 200 patients assessed over a 6-month period. Persons aged 70 years and older were invited to undergo an evaluation at the general practitioner's (GP) office by a nurse if the GP thought that the patient was frail or if the patient had cognitive complaint or for both reasons. A total of 200 patients from 14 GP offices were assessed. Overall, the mean age was 81.3 (±5.92) years. More than one-half were female (66%), and 32% of participants lived alone. The average Mini-Mental State Examination score was 25.2 (±4.23); 16.7% had dementia; 12% of mild cognitive impairment were identified; 78% of patients were followed by their GP; and 2.5% were referred to a GDHF, 12% to specialized memory center, and 7.5% to geriatric consultation. This work foreshadows any other ambulatory options for older persons in his/her living area representing an alternative to the GDHF. It seems to meet the needs for this population and demonstrates the feasibility to implement in primary care a nurse trained to assess older patients in a GP office. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.
Giovanella, Ligia; Almeida, Patty Fidelis de
The article analyzes recent reforms in primary health care in the South American countries, discussing the scope and challenges for establishing comprehensive primary health care in the region's health systems. The data sources were case studies conducted in 12 countries, and the analytical lines were the strategic components in the design and implementation of primary health care: national policy approaches, characteristics of financing, organization and provision, and the workforce in primary health care. The crosscutting analysis from a comparative perspective provides an overview of primary health care in the region's countries and highlights convergences and asymmetries. A common trait is the recovery of the expanded definition of primary health care with family and community components, a territorial base, multidisciplinary team, incorporation of community health workers, and social participation. Implementation revealed heterogeneities in the advances and contradictions in the models. Insufficient supply of physicians, difficulties in provision and physician retention in remote and peripheral areas, as well as in primary health care itself, precarious employment relations, and absence of career plans are common problems, and there have been recent initiatives in government intervention to direct the workforce to the public system. Segmentation of the supply of primary health care converges with the segmentation of social protection in the various countries, through maintenance of social insurance or selective and targeted insurance or coverage by private health insurance, and persistent exclusion of populations from the right to health. The article argues that implementation of comprehensive primary health care is conditioned by the prevailing modalities of social protection in health.
Riet-Paap, J.C. van; Boerma, W.; Kringos, D.S.
Background: Due to ageing a larger proportion of the population suffers from multiple and complex health problems that need treatment from more than one health care provider. Fragmentation of care is a critical development that all health care systems in Europe need to cope with. To improve the responsiveness of patient care there is a need for coherent and well coordinated provision of health care services. Methods: On the basis of a systematic review of the literature on primary care (PC) a...
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.
Okunseri, Christopher; Okunseri, Elaye; Xiang, Qun; Thorpe, Joshua M.; Szabo, Aniko
Objective The aim of this study was to examine trends and associated factors in the prescription of opioid analgesics, non-opioid analgesics, opioid and non-opioid analgesic combinations and no analgesics by emergency physicians for nontraumatic dental condition (NTDC)-related visits. Our secondary aim was to investigate whether race/ethnicity is a possible predictor of receiving a prescription for either type of medication for NTDC visits in emergency departments (EDs) after adjustment for potential covariates. Methods We analyzed data from the National Hospital Ambulatory Medical Care Survey for 1997–2000 and 2003–2007, and used multinomial multivariate logistic regression to estimate the probability of receiving a prescription for opioid analgesics, non-opioid analgesics, or a combination of both compared to receiving no analgesics for NTDC-related visits. Results During 1997–2000 and 2003–2007, prescription of opioid analgesics and combinations of opioid and non-opioid analgesics increased and that of no analgesics decreased over time. The prescription rates for opioid analgesics, non-opioid analgesics, opioid and non-opioid analgesic combinations and no analgesics for NTDC-related visits in EDs were 43%, 20%, 12% and 25% respectively. Majority of patients categorized as having severe pain received prescriptions for opioids for NTDC-related visits in EDs. After adjusting for covariates, patients with self-reported dental reasons for visit and severe pain had a significantly higher probability of receiving prescriptions for opioid analgesics and opioid and non-opioid analgesic combinations. Conclusion Prescription of opioid analgesics increased over time. ED physicians were more likely to prescribe opioid analgesics and opioid and non-opioid analgesic combinations for NTDC-related visits with reported severe pain. PMID:24863407
Okunseri, Christopher; Okunseri, Elaye; Xiang, Qun; Thorpe, Joshua M; Szabo, Aniko
The aim of this study was to examine trends and associated factors in the prescription of opioid analgesics, nonopioid analgesics, opioid and nonopioid analgesic combinations, and no analgesics by emergency physicians for nontraumatic dental condition (NTDC)-related visits. Our secondary aim was to investigate whether race/ethnicity is a possible predictor of receiving a prescription for either type of medication for NTDC visits in emergency departments (EDs) after adjustment for potential covariates. We analyzed data from the National Hospital Ambulatory Medical Care Survey for 1997-2000 and 2003-2007, and used multinomial multivariate logistic regression to estimate the probability of receiving a prescription for opioid analgesics, nonopioid analgesics, or a combination of both, compared with receiving no analgesics for NTDC-related visits. During 1997-2000 and 2003-2007, prescription of opioid analgesics and combinations of opioid and nonopioid analgesics increased, and that of no analgesics decreased over time. The prescription rates for opioid analgesics, nonopioid analgesics, opioid and nonopioid analgesic combinations, and no analgesics for NTDC-related visits in EDs were 43 percent, 20 percent, 12 percent, and 25 percent, respectively. Majority of patients categorized as having severe pain received prescriptions for opioids for NTDC-related visits in EDs. After adjusting for covariates, patients with self-reported dental reasons for visit and severe pain had a significantly higher probability of receiving prescriptions for opioid analgesics and opioid and nonopioid analgesic combinations. Prescription of opioid analgesics increased over time. ED physicians were more likely to prescribe opioid analgesics and opioid and nonopioid analgesic combinations for NTDC-related visits with reported severe pain. © 2014 American Association of Public Health Dentistry.
Sobczyk, Karolina; Woźniak-Holecka, Joanna; Holecki, Tomasz; Szałabska, Dorota
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.
Bundeff, Andrew W; Zaiken, Kathy
Previous studies have demonstrated an association between chronic proton pump inhibitor (PPI) utilization and adverse events such as fractures, infections, hypomagnesemia, and vitamin B12 deficiency. Because patients taking PPIs for an extended period of time are more susceptible to these adverse events, an approach to tapering patients off PPIs is clinically warranted. To evaluate the impact of clinical pharmacists' recommendations to clinicians to decrease PPI use in patients when chronic therapy is not indicated. Clinical pharmacists electronically sent PPI taper recommendations for qualifying patients to primary care providers the day before each patient's appointment. Using insurance claims data, an average pills per month (PPM) count was calculated for the 5-month period prior to initiating the PPI taper as well as for the 5-month period after the date of taper initiation. The PPM count was calculated by dividing the total number of pills a patient received by the total number of days in that period, multiplied by 30. The primary outcome for the study was the change in average PPM count from baseline (pretaper period) to follow-up (posttaper period) and was assessed using a paired t-test. Secondary outcomes included change in total annualized PPI costs to the organization, proportion of patients who began the taper protocol after primary care provider recommendation, and whether baseline characteristics were predictors of successful response. Change in annualized PPI costs to the organization was calculated by multiplying the average unit cost per pill (determined using a weighted average of the average wholesale price of the individual drugs) by the PPM change seen with the primary outcome and by the number of patients included in the study and expressed over the period of a full year. Logistic regression analysis was used to determine whether baseline variables including alcohol and tobacco use, diagnosis related to PPI use, PPI dose, dosing frequency
Full Text Available The National Ambulatory Medical Care Survey collects data on office-based physician care from a nationally representative, multistage sampling scheme where the ultimate unit of analysis is a patient-doctor encounter. Patient race, a commonly analyzed demographic, has been subject to a steadily increasing item nonresponse rate. In 1999, race was missing for 17 percent of cases; by 2008, that figure had risen to 33 percent. Over this entire period, single imputation has been the compensation method employed. Recent research at the National Center for Health Statistics evaluated multiply imputing race to better represent the missing-data uncertainty. Given item nonresponse rates of 30 percent or greater, we were surprised to find many estimates’ ratios of multiple-imputation to single-imputation estimated standard errors close to 1. A likely explanation is that the design effects attributable to the complex sample design largely outweigh any increase in variance attributable to missing-data uncertainty.
Fosnot, Caroline D; Fleisher, Lee A; Keogh, John
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
Andrews, James E; Pearce, Kevin A; Sydney, Carey; Ireson, Carol; Love, Margaret
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.
Pim P. Valentijn
Full Text Available 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 understand the complexity of integrated care.Methods: 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.Results: 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.Discussion: 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.
Valentijn, Pim P; Schepman, Sanneke M; Opheij, Wilfrid; Bruijnzeels, Marc A
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.
Full Text Available Abstract Background To evaluate the sensitivity, specificity and predictive values of spirometry for the diagnosis of chronic obstructive pulmonary disease (COPD and asthma in patients suspected of suffering from an obstructive airway disease (OAD in primary care. Methods Cross sectional diagnostic study of 219 adult patients attending 10 general practices for the first time with complaints suspicious for OAD. All patients underwent spirometry and structured medical histories were documented. All patients received whole-body plethysmography (WBP in a lung function laboratory. The reference standard was the Tiffeneau ratio (FEV1/VC received by the spirometric maneuver during examination with WBP. In the event of inconclusive results, bronchial provocation was performed to determine bronchial hyper-responsiveness (BHR. Asthma was defined as a PC20 fall after inhaling methacholine concentration ≤ 16 mg/ml. Results 90 (41.1% patients suffered from asthma, 50 (22.8% suffered from COPD, 79 (36.1% had no OAD. The sensitivity for diagnosing airway obstruction in COPD was 92% (95%CI 80–97; specificity was 84% (95%CI 77–89. The positive predictive value (PPV was 63% (95%CI 51–73; negative predictive value (NPV was 97% (95%CI 93–99. The sensitivity for diagnosing airway obstruction in asthma was 29% (95%CI 21–39; specificity was 90% (95%CI 81–95. PPV was 77% (95%CI 60–88; NPV was 53% (95%CI 45–61. Conclusion COPD can be estimated with high diagnostic accuracy using spirometry. It is also possible to rule in asthma with spirometry. However, asthma can not be ruled out only using spirometry. This diagnostic uncertainty leads to an overestimation of asthma presence. Patients with inconclusive spirometric results should be referred for nitric oxide (NO – measurement and/or bronchial provocation if possible to guarantee accurate diagnosis.
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
Bashshur, Rashid L; Howell, Joel D; Krupinski, Elizabeth A; Harms, Kathryn M; Bashshur, Noura; Doarn, Charles R
This article presents the scientific evidence for the merits of telemedicine interventions in primary care. Although there is no uniform and consistent definition of primary care, most agree that it occupies a central role in the healthcare system as first contact for patients seeking care, as well as gatekeeper and coordinator of care. It enables and supports patient-centered care, the medical home, managed care, accountable care, and population health. Increasing concerns about sustainability and the anticipated shortages of primary care physicians have sparked interest in exploring the potential of telemedicine in addressing many of the challenges facing primary care in the United States and the world. The findings are based on a systematic review of scientific studies published from 2005 through 2015. The initial search yielded 2,308 articles, with 86 meeting the inclusion criteria. Evidence is organized and evaluated according to feasibility/acceptance, intermediate outcomes, health outcomes, and cost. The majority of studies support the feasibility/acceptance of telemedicine for use in primary care, although it varies significantly by demographic variables, such as gender, age, and socioeconomic status, and telemedicine has often been found more acceptable by patients than healthcare providers. Outcomes data are limited but overall suggest that telemedicine interventions are generally at least as effective as traditional care. Cost analyses vary, but telemedicine in primary care is increasingly demonstrated to be cost-effective. Telemedicine has significant potential to address many of the challenges facing primary care in today's healthcare environment. Challenges still remain in validating its impact on clinical outcomes with scientific rigor, as well as in standardizing methods to assess cost, but patient and provider acceptance is increasingly making telemedicine a viable and integral component of primary care around the world.
Sibbald, B.; Laurant, M.G.H.; Reeves, D.
Nurses increasingly work as substitutes for, or to complement, general practitioners in the care of minor illness and the management of chronic diseases. Available research suggests that nurses can provide as high quality care as GPs in the provision of first contact and ongoing care for unselected
Shrank, William H
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.
Creswell, John W.; Fetters, Michael D.; Ivankova, Nataliya V.
BACKGROUND Mixed methods or multimethod research holds potential for rigorous, methodologically sound investigations in primary care. The objective of this study was to use criteria from the literature to evaluate 5 mixed methods studies in primary care and to advance 3 models useful for designing such investigations.
84. JOURNAL OF COMMUNITY MEDICINE AND PRIMARY HEALTH CARE VOL. 29, NO 2, SEPTEMBER 2017. Patient-Focused Quality Improvement in Primary Health Care: Opportunities with the Patient Evaluation Scale. Ogaji DS. Department of Preventive and Social Medicine, University of Port Harcourt, Port Harcourt.
Kringos, Dionne S.; Boerma, Wienke G. W.; Bourgueil, Yann; Cartier, Thomas; Hasvold, Toralf; Hutchinson, Allen; Lember, Margus; Oleszczyk, Marek; Pavlic, Danica Rotar; Svab, Igor; Tedeschi, Paolo; Wilson, Andrew; Windak, Adam; Dedeu, Toni; Wilm, Stefan
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
Verbakel, N.J.; Melle, M. van; Langelaan, M.; Verheij, T.J.M.; Wagner, C.; Zwart, D.L.M.
Objective: To explore perceptions of safety culture in nine different types of primary care professions and to study possible differences. Design Cross-sectional survey: Setting: Three hundred and thirteen practices from nine types of primary care profession groups in the Netherlands. Participants:
Hall, Mary Barbera
When a unit's staff changed from a team nursing to a primary nursing approach to care, the role of students gaining experience there changed to that of associate nurse, who is accountable for providing continuity of care to the primary nurses' patients. (Editor/TA)
Oort, M. van; Devillé, W.; Bakker, D. de
In 2000 policymakers decided that primary care for asylum seekers should be organized as it is for Dutch residents. Nurses of the Community Health Services organize selection and referral to primary care. General practitioners have practice in the different Centres of Asylum Seekers or in their own
Kringos, D.S.; Boerma, W.G.W.; Zee, J. van der; Groenewegen, P.P.
This article explores various contributing factors to explain differences in the strength of the primary care (PC) structure and services delivery across Europe. Data on the strength of primary care in 31 European countries in 2009/10 were used. The results showed that the national political agenda,
Kringos, D.S.; Boerma, W.G.W.; Zee, J. van der; Groenewegen, P.P.
This article explores various contributing factors to explain differences in the strength of the primary care (PC) structure and services delivery across Europe. Data on the strength of primary care in 31 European countries in 2009/10 were used. The results showed that the national political
Kringos, Dionne S.; Boerma, Wienke G. W.; van der Zee, Jouke; Groenewegen, Peter P.
This article explores various contributing factors to explain differences in the strength of the primary care (PC) structure and services delivery across Europe. Data on the strength of primary care in 31 European countries in 2009/10 were used. The results showed that the national political agenda,
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 ...
Background: Few eligible candidates are referred from primary care for bariatric surgery in spite of improvement in its safety and efficacy. Objective: The aim of this study was to identify factors affecting primary care physicians' (PCPs) referral to bariatric surgery in morbid obesity. Methods: This study is a cross-sectional ...
The Abbreviated Pandemic Influenza Plan Template for Primary Care Provider Offices is intended to assist primary care providers and office managers with preparing their offices for quickly putting a plan in place to handle an increase in patient calls and visits, whether during the 2009-2010 influenza season or future influenza seasons.
Faber, M.J.; Burgers, J.S.; Westert, G.P.
The Dutch primary care system has drawn international attention, because of its high performance at low cost. Primary care practices are easily accessible during office hours and collaborate in a unique out-of-hours system. After the reforms in 2006, there are no copayments for patients receiving
In the main, writing about care seems to contrast the ethics of justice with the ethics of care. Whilst the former deploys objectivity, the latter holds that individuals are connected. Problematically, contemporary primary education seemingly holds a-personal, justice conceptions as its basis and rationale. In turn, primary education, in parts,…
Melville, C. A.; Finlayson, J.; Cooper, S.-A.; Allan, L.; Robinson, N.; Burns, E.; Martin, G.; Morrison, J.
Primary health care teams have an important part to play in addressing the health inequalities and high levels of unmet health needs experienced by people with intellectual disabilities (ID). Practice nurses have an expanding role within primary health care teams. However, no previous studies have measured their attitudes, knowledge, training…
A survey using shareholders' contribution mechanism of primary health care financing was conducted in the Eastern part of Nigeria. The willingness of the shareholders in private and public corporations to offer a part or whole of their annual dividend in financing primary health care programme was assessed. The research ...
Kiely, Deirdre; Schwartz, Shira
Individuals who are given a preventive exam by a primary care provider are more likely to agree to cancer screening. The provider recommendation has been identified as the strongest factor associated with screening utilization. This article provides a framework for breast cancer risk assessment for an advanced practice registered nurse working in primary care practice.
Talmi, Ayelet; Stafford, Brian; Buchholz, Melissa
After birth, newborns and their caregivers are seen routinely and frequently in pediatric primary care settings. The close succession of visits in the first few months of life puts pediatric primary care professionals in a unique position to enhance infant mental health by developing strong relationships with caregivers, supporting babies and…
Meyer, William J.; Morrison, Patrick; Lombardero, Anayansi; Swingle, Kelsey; Campbell, Duncan G.
Unwillingness to share depression experiences with primary care physicians contributes to the undertreatment of depression. This project examined college students' reasons for depression nondisclosure to primary care providers (PCPs). Undergraduate participants read a vignette describing someone with depression and completed measures of disclosure…
Wiborg, J.F.; Gieseler, D.; Fabisch, A.B.; Voigt, K.; Lautenbach, A.; Lowe, B.
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
Methods: This study was carried out in all primary health care centers in Kuwait. All nurses who were currently working in these centers during the ... primary care nurses had poor knowledge regarding DV. Although female nurses are somewhat more knowledgeable about DV, many more educational activities are needed.
In this thesis, the primary aim was to gain insight into management of obstetric emergencies occurring in primary midwifery care in the Netherlands. Secondly, we aimed to develop preventative strategies and tools to optimise care in case of an obstetric emergency. From 2008-2010, a unique dataset of
Dubovsky, Amelia N; Kiefer, Meghan M
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.
Poulsen, Erik; Overgaard, Søren; Vestergaard, Jacob T
BACKGROUND: Hip osteoarthritis (OA) is the most common diagnosis in primary care adult patients presenting with hip pain but pain location and pain distribution in primary care patients with hip OA have been reported inadequately. OBJECTIVE: To describe pain location and pain distribution...... in primary care patients with clinical and radiographic confirmed hip OA. METHODS: Primary care patients with unilateral clinical and radiographic hip OA living on the island of Funen, Denmark were recruited from primary care to participate in a randomized clinical trial. At baseline, patients recorded pain...... intensity using an 11-box numeric rating scale and the distribution of hip pain using a manikin displaying three separate views: front, back and lateral. Pain drawings were analysed using a template to determine the most frequent pain locations and distribution of pain. RESULTS: Pain drawings were completed...
... 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, ...
Kwok, Jonas; Olayiwola, J Nwando; Knox, Margae; Murphy, Elizabeth J; Tuot, Delphine S
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
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
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
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
Ornstein, Steven M; Nemeth, Lynne S; Nietert, Paul J; Jenkins, Ruth G; Wessell, Andrea M; Litvin, Cara B
Submission of clinical quality measures (CQMs) data are 1 of 3 major requirements for providers to receive meaningful use (MU) incentive payments under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act. Some argue that CQMs are the most important component of MU. Developing an evidence base for how practices can successfully use electronic health records (EHRs) to achieve improvement in CQMs is essential and may benefit from the study of exemplars who have successfully implemented EHRs and demonstrated high performance on CQMs. Conducted in PPRNet, a national primary care practice-based research network, this study used a multimethod approach combining an EHR-based CQM performance assessment, a provider survey, and focus groups among high CQM performers. Practices whose providers had attested for stage 1 MU were eligible for the study. Performance on 21 CQMs included in the 2014 MU CQM set and a summary measure was assessed as of October 1, 2013, through an automated data extract and standard analytic procedures. A web-based provider survey, conducted in November to December 2013, assessed provider agreement, staff education, use of EHR reminders, standing orders, and EHR-based patient education related to the 21 CQMs. The survey also had more general questions about the practices' use of EHR functionality and quality improvement (QI) strategies. Statistical analyses using general linear mixed models assessed the associations between responses to the survey and CQM performance, adjusted for several practice covariates. Three focus groups, held in early 2014, provided an opportunity for clinicians to provide their perspectives on the validity of the statistical analyses and to provide context-specific examples from their practice that supported their assessment. Seventy-one practices completed the study, and 319 (92.1%) of their providers completed the survey. There was wide variability in performance on the 21 CQMs among the
Frichtel, Christina M
Bariatric surgery is on the rise as treatment for the increasing number of obese patients in the US population. As this procedure becomes more common, primary care physicians are assuming increased responsibility not only for preoperative selection and education of bariatric surgery candidates but also for their postoperative care and monitoring—two factors necessary for a successful surgical outcome. This article highlights some issues relevant for primary care physicians and reports an illu...
Walley, John; Lawn, Joy E; Tinker, Anne; de Francisco, Andres; Chopra, Mickey; Rudan, Igor; Bhutta, Zulfiqar A; Black, Robert E
The principles agreed at Alma-Ata 30 years ago apply just as much now as they did then. "Health for all" by the year 2000 was not achieved, and the Millennium Development Goals (MDGs) for 2015 will not be met in most low-income countries without substantial acceleration of primary health care. Factors have included insufficient political prioritisation of health, structural adjustment policies, poor governance, population growth, inadequate health systems, and scarce research and assessment on primary health care. We propose the following priorities for revitalising primary health care. Health-service infrastructure, including human resources and essential drugs, needs strengthening, and user fees should be removed for primary health-care services to improve use. A continuum of care for maternal, newborn, and child health services, including family planning, is needed. Evidence-based, integrated packages of community and primary curative and preventive care should be adapted to country contexts, assessed, and scaled up. Community participation and community health workers linked to strengthened primary-care facilities and first-referral services are needed. Furthermore, intersectoral action linking health and development is necessary, including that for better water, sanitation, nutrition, food security, and HIV control. Chronic diseases, mental health, and child development should be addressed. Progress should be measured and accountability assured. We prioritise research questions and suggest actions and measures for stakeholders both locally and globally, which are required to revitalise primary health care.
Patricia Sodré Araújo
Full Text Available ABSTRACT OBJECTIVE To characterize the activities of clinical nature developed by pharmacists in basic health units and their participation in educational activities aiming at health promotion. METHODS This article is part of the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos – Serviços, 2015 (PNAUM – National Survey on Access, Use and Promotion of Rational Use of Medicines – Services, 2015, a cross-sectional and exploratory study, of evaluative nature, consisting of a survey of information in a representative sample of cities, stratified by the Brazilian regions that constitute domains of study, and a subsample of primary health care services. The interviewed pharmacists (n=285 were responsible for the delivery of medicines and were interviewed in person with the use of a script. The characterization of the activities of clinical nature was based on information from pharmacists who declared to perform them, and on participation in educational activities aiming at health promotion, according to information from all pharmacists. The results are presented in frequency and their 95% confidence intervals. RESULTS From the interviewed subjects, 21.3% said they perform activities of clinical nature. Of these, more than 80% considered them very important; the majority does not dispose of specific places to perform them, which hinders privacy and confidentiality in these activities. The main denominations were “pharmaceutical guidance” and “pharmaceutical care.” The registration of activities is mainly made in the users’ medical records, computerized system, and in a specific document filed at the pharmacy, impairing the circulation of information among professionals. Most pharmacists performed these activities mainly along with physicians and nurses; 24.7% rarely participated in meetings with the health team, and 19.7% have never participated. CONCLUSIONS Activities of clinical nature
Liu, Su; Yam, Carrie H K; Huang, Olivia H Y; Griffiths, Sian M
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.
Duran, Bonnie; Malcoe, Lorraine Halinka; Sanders, Margaret; Waitzkin, Howard; Skipper, Betty; Yager, Joel
To examine (1) the prevalence, types, and severity of child abuse and neglect (CAN) and (2) the relationship between CAN and lifetime psychiatric disorders among American Indian women using primary care services. A cross-sectional study was conducted among 234 American Indian women, age 18-45 who presented for outpatient ambulatory services at a community-based Indian Health Service Hospital in Albuquerque, New Mexico. Dependent measures included mood, substance abuse, and anxiety disorders as well as posttraumatic stress disorder (PTSD) as measured by the Composite International Diagnostic Interview. CAN was assessed using the Childhood Trauma Questionnaire. Approximately three-quarters of respondents (76.5%; 95% CI = 70.4, 81.7) reported some type of childhood abuse or neglect; over 40% reported exposure to severe maltreatment. Severity of child maltreatment was associated in a dose response manner with lifetime diagnosis of mental disorders. After adjusting for social and demographic correlates, severe child maltreatment was strongly associated with lifetime PTSD (prevalence ratio [PR] 3.9; 95% CI = 1.9, 8.0); and was moderately associated with lifetime substance use disorders (PR = 2.3; 95% CI = 1.6, 3.3); mood disorders (PR = 2.1; 95% CI 1.4, 3.2); and with two or more disorders (PR = 2.3; 95% CI = 1.6, 3.4). CAN was common in our sample of American Indian women in primary care and was positively associated with lifetime psychiatric disorders outcomes. Screening for CAN and psychiatric disorders would enhance the treatment of patients seeking primary care services. Primary prevention of child maltreatment might reduce the high prevalence of mental disorders among American Indian women.
Mazzaglia, Giampiero; Lapi, Francesco; Silvestri, Caterina; Roti, Lorenzo; Giustini, Saffi Ettore; Buiatti, Eva
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.
Fernald, Douglas H.; Pace, Wilson D.; Harris, Daniel M.; West, David R.; Main, Deborah S.; Westfall, John M.
BACKGROUND We examined reports to a primary care, ambulatory, patient safety reporting system to describe types of errors reported and differences between anonymous and confidential reports. METHODS Applied Strategies for Improving Patient Safety (ASIPS) is a demonstration project designed to collect and analyze medical error reports from clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). A major component of ASIPS is a voluntary patient safety reporting system that accepts reports of errors anonymously or confidentially. Reports are coded using a multiaxial taxonomy. RESULTS Two years into this project, 33 practices with a total of 475 clinicians and staff have participated in ASIPS. Participants submitted 708 reports during this time (66% using the confidential reporting form). We successfully followed up on 84% of the confidential reports of interest within the allotted 10-day time frame. We ended up with 608 relevant, codable reports. Communication problems (70.8%), diagnostic tests (47%), medication problems (35.4%), and both diagnostic tests and medications (13.6%) were the most frequently reported errors. Confidential reports were significantly more likely than anonymous reports to contain codable data. CONCLUSION A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in primary care settings. Information from confidential reports appears to be superior to that from anonymous reports and may be more useful in understanding errors and designing interventions to improve patient safety. PMID:15335131
The author describes the practices of primary caregiving and continuity of care as necessary components of a high quality child care setting. Yet recent evidence suggests that continuity of care is rare for infants and toddlers because young children are often moved from room to room as they grow. The author describes the benefits of primary…
Steiner, Rose M.; Walsworth, David T.
Introduction: Improving Performance in Practice (IPIP) is an initiative convened by the American Board of Medical Specialties. It investigates the efficacy of coaches in helping primary-care practices improve the care of patients with diabetes and asthma. Most IPIP states use coaches who have a health care background, and are trained in quality…
Fiddes, P J; Brooks, P M; Komesaroff, P
The patient's role as the key to medical student education was enunciated by Osler in 1903 and remains central to the broader imperative of interprofessional education. Interprofessional education needs to progress from the patient's passive bedside or office role to assume a more active and primary role by his/her participation as the teacher, immersed in student education. To date, the achievements in interprofessional education have been limited, but ambulatory patient-centred learning opportunities involving direct student to patient dialogues and mixed health professional student engagement with patients as teachers are emerging within various interprofessional student clinic formats. There is good evidence that such approaches lead to actual improvements in patient outcomes. © 2013 The Authors; Internal Medicine Journal © 2013 Royal Australasian College of Physicians.
Leung, Lucinda B; Yoon, Jean; Escarce, José J; Post, Edward P; Wells, Kenneth B; Sugar, Catherine A; Yano, Elizabeth M; Rubenstein, Lisa V
Primary care-mental health integration (PC-MHI) aims to increase access to general mental health specialty (MHS) care for primary care patients thereby decreasing referrals to non-primary care-based MHS services. It remains unclear whether new patterns of usage of MHS services reflect good mental health care. This study examined the relationship between primary care clinic engagement in PC-MHI and use of different MHS services. This was a retrospective longitudinal cohort study of 66,638 primary care patients with mental illnesses in 29 Southern California Veterans Affairs clinics (2008-2013). Regression models used clinic PC-MHI engagement (proportion of all primary care clinic patients who received PC-MHI services) to predict relative rates of general MHS visits and more specialized MHS visits (for example, visits for serious mental illness services), after adjustment for year and clinic fixed effects, other clinic interventions, and patient characteristics. Patients were commonly diagnosed as having depression (35%), anxiety (36%), and posttraumatic stress disorder (22%). For every 1 percentage point increase in a clinic's PC-MHI engagement rate, patients at the clinic had 1.2% fewer general MHS visits per year (pPrimary care clinics with greater engagement in PC-MHI showed reduced general MHS use rates, particularly for patients with depression, without accompanying reductions in use of more specialized MHS services.
appropriate care to be given in PHC facilities without transfer. Currently paediatric surgery ... necessary information. International outreach via telemedicine aids training in ... Telepaediatrics, which has the potential to improve paediatric care if expert knowledge is not locally available, involves transfer of information between ...
Hall, Bonnie J
.... Several factors contributing to this concern are the variability of primary care managers, deficiencies in the continuity of care, the lack of internal policies governing primary care practices...
Kostanjšek, Diana; Benčić, Miro; Keglević, Mladenka Vrcić
Conditions for which a hospital and emergency utilization can be considered avoidable are often referred as ambulatory care sensitive conditions (ACSCs). Until now, there has been no published research related to ACSCs in Croatia. This study was undertaken with the aim of determining the trends relating to ACSCs in out-of-hospital ES from 1995-2012. The study is based on data from the Croatian Health Service Yearbooks. Five chronic and three acute conditions were chosen: diabetes, hypertension, congestive heart failure, angina pectoris, asthma and COPD, bacterial pneumonia, urinary tract infections and skin infections. The results indicate that the ES in Croatia is overused, and consequently ACSCs are over-represented; 23.3% Croatian citizens visited the ES and around 15% of all diagnoses belonged to the ACSCs, with decreased trend. The leading diagnosis is hypertension, followed by asthma and COPD. For a better understanding of the importance of ACSC within the Croatian context, further research is needed.
Sánchez-Henarejos, Ana; Fernández-Alemán, José Luis; Toval, Ambrosio; Hernández-Hernández, Isabel; Sánchez-García, Ana Belén; Carrillo de Gea, Juan Manuel
The appearance of electronic health records has led to the need to strengthen the security of personal health data in order to ensure privacy. Despite the large number of technical security measures and recommendations that exist to protect the security of health data, there is an increase in violations of the privacy of patients' personal data in healthcare organizations, which is in many cases caused by the mistakes or oversights of healthcare professionals. In this paper, we present a guide to good practice for information security in the handling of personal health data by health personnel, drawn from recommendations, regulations and national and international standards. The material presented in this paper can be used in the security audit of health professionals, or as a part of continuing education programs in ambulatory care facilities. Copyright © 2013 Elsevier España, S.L. All rights reserved.
Wound care is expensive and can cause immeasurable stress and inconvenience to patients and their significant others. It is therefore in the best interest of the patient, their significant others and the NHS as a whole that wounds are expertly assessed, managed and healed in the quickest timeframe possible. Nurses play a pivotal role in the process of accurate holistic wound assessment, evaluation and treatment. This article aims to help further develop and enhance both professional and clinical wound care assessment and evaluation skills. Pertinent wound care literature is critically reviewed and the crucial nature and important components of comprehensive wound assessment for facilitating the highest possible quality wound care to patients are presented alongside recommendations regarding how the enhanced knowledge and skills could be applied into everyday wound care practice.
Röttger, Julia; Blümel, Miriam; Engel, Susanne; Grenz-Farenholtz, Brigitte; Fuchs, Sabine; Linder, Roland; Verheyen, Frank; Busse, Reinhard
The responsiveness of a health system is considered to be an intrinsic goal of health systems and an essential aspect in performance assessment. Numerous studies have analysed health system responsiveness and related concepts, especially across different countries and health systems. However, fewer studies have applied the concept for the evaluation of specific healthcare delivery structures and thoroughly analysed its determinants within one country. The aims of this study are to assess the level of perceived health system responsiveness to patients with chronic diseases in ambulatory care in Germany and to analyse the determinants of health system responsiveness as well as its distribution across different population groups. The target population consists of chronically ill people in Germany, with a focus on patients suffering from type 2 diabetes and/or from coronary heart disease (CHD). Data comes from two different sources: (i) cross-sectional survey data from a postal survey and (ii) claims data from a German sickness fund. Data from both sources will be linked at an individual-level. The postal survey has the purpose of measuring perceived health system responsiveness, health related quality of life, experiences with disease management programmes (DMPs) and (subjective) socioeconomic background. The claims data consists of information on (co)morbidities, service utilization, enrolment within a DMP and sociodemographic characteristics, including the type of residential area. RAC is one of the first projects linking survey data on health system responsiveness at individual level with claims data. With this unique database, it will be possible to comprehensively analyse determinants of health system responsiveness and its relation to other aspects of health system performance assessment. The results of the project will allow German health system decision-makers to assess the performance of nonclinical aspects of healthcare delivery and their determinants in two
Paulo, Marília Silva; Loney, Tom; Lapão, Luís Velez
Abu Dhabi is the capital of the United Arab Emirates (UAE) and the largest of the seven emirates in terms of land mass and population. Abu Dhabi emirate has three different geographical regions: the Central Capital District, the Eastern Region, and the Western Region. The health system has been regulated by the Health Authority - Abu Dhabi (HAAD), and has been provided by the Abu Dhabi Health Services Company (SEHA), since 2007. The UAE has a high population-burden of morbidity and mortality related to chronic diseases. This paper aims to characterize the Primary Health Care (PHC) public services in Abu Dhabi using the Chronic Care Model (CCM) as a framework. Officially published data from HAAD, SEHA and the UAE Ministry of Health and Prevention was reviewed and abstracted. The Preferred Reporting Items Systematic Reviews and Meta-Analysis (PRISMA) statement was used as a baseline to review the PHC services through the CCM approach and to identify potential opportunities for improvement. There are 38 SEHA Ambulatory Healthcare Centers (AHS) that provide PHC, from which 20 are located in the Eastern Region and the other 18 in the Central Capital District. The AHS adopted the principles of the patient-centered medical home model, aiming at providing structured, proactive and coordinated care. Implementation of the CCM elements aligns with those standards and is positively associated with the use of interventions targeting high-risk behaviors. The UAE has a strong foundation in place for addressing the growing problem of chronic diseases. The CCM has been shown to have beneficial effects on clinical outcomes reinforcing the PHC procedures and processes of care and should continue to inform systematic efforts to improve the care that lead to better lives for the Abu Dhabi community.
Hung, Dorothy Y; Harrison, Michael I; Truong, Quan; Du, Xue
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
Processo de cuidar do idoso em Diálise Peritoneal Ambulatorial Contínua no domicílio Proceso de cuidar del anciano, que hace Diálisis Peritoneal Ambulatorial Contínua en el domicilio Home care for the elderly undergoing Continuous Ambulatory Peritoneal Dialysis
Daniele Favaro Ribeiro
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.
Edwards, Samuel T; Rubenstein, Lisa V; Meredith, Lisa S; Schmidt Hackbarth, Nicole; Stockdale, Susan E; Cordasco, Kristina M; Lanto, Andrew B; Roos, Philip J; Yano, Elizabeth M
Unclear roles in interdisciplinary primary care teams can impede optimal team-based care. We assessed perceived task allocation among primary care providers (PCPs) and staff during implementation of a new patient-centered care model in Veterans Affairs (VA) primary care practices. We performed a cross-sectional survey of PCPs and primary care staff (registered nurses (RNs), licensed practical/vocational nurses (LPNs), and medical assistants/clerks (MAs)) in 23 primary care practices within one VA region. We asked subjects whether PCPs performed each of 14 common primary care tasks alone, or relied upon staff for help. Tasks included gathering preventive service history, disease screening, evaluating patients and making treatment decisions, intervening on lifestyle factors, educating patients about self-care activities and medications, refilling prescriptions, receiving and resolving patient messages, completing forms, tracking diagnostic data, referral tracking, and arranging home health care. We then performed multivariable regression to determine predictors of perceived PCP reliance on staff for each task. 162 PCPs and 257 staff members responded, a 60% response rate. For 12/14 tasks, fewer than 50% of PCPs reported relying on staff for help. For all 14 tasks, over 85% of RNs reported they were relied upon. For 12/14 tasks, over 50% of LPNs reported they were relied on, while for 5/14 tasks a majority of MAs reported being relied upon. Nurse practitioners and physician assistants (NP/PAs) reported relying on staff less than physicians. Early in the implementation of a team-based primary care model, most PCPs perceived they were solely responsible for most clinical tasks. RNs, and LPNs felt they were relied upon for most of the same tasks, while medical assistants/clerks reported being relied on for fewer tasks. Better understanding of optimal inter-professional team task allocation in primary care is needed. Published by Elsevier Inc.
Nelson, Kevin E; Hersh, Adam L; Nkoy, Flory L; Maselli, Judy H; Srivastava, Raj; Cabana, Michael D
Evidence-based guidelines recommend smoking cessation treatment, including screening and counseling, for all smokers, including those with chronic diseases exacerbated by smoking. Physician treatment improves smoking cessation. Little data describes smoking treatment guideline uptake for patients with chronic cardiopulmonary smoking-sensitive diseases. Describe U.S. primary care physician (PCP) smoking cessation treatment during patient visits for chronic cardiopulmonary smoking-sensitive diseases. The National (Hospital) Ambulatory Medical Care Survey captured PCP visits. We examined smoking screening and counseling time trends for smokers with chronic diseases. Multivariable logistic regression assessed factors associated with smoking counseling for smokers with chronic smoking-sensitive diseases. From 2001-2009 smoking screening and counseling for smokers with chronic smoking-sensitive cardiopulmonary diseases were unchanged. Among smokers with chronic smoking-sensitive diseases, 50%-72% received no counseling. Smokers with chronic obstructive pulmonary disease (COPD) (odds ratio (OR)=6.54, 95% confidence interval (CI) 4.85-8.83) and peripheral vascular disease (OR=4.50, 95% CI 1.72-11.75) were more likely to receive smoking counseling at chronic/preventive care visits, compared with patients without smoking-sensitive diseases. Other factors associated with increased smoking counseling included non-private insurance, preventive and longer visits, and an established PCP. Asthma and cardiovascular disease showed no association with counseling. Smoking cessation counseling remains infrequent for smokers with chronic smoking-sensitive cardiopulmonary diseases. New strategies are needed to encourage smoking cessation counseling. Copyright © 2014 Elsevier Inc. All rights reserved.
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.
Biswas, Rakesh; Joshi, Ankur; Joshi, Rajeev; Kaufman, Terry; Peterson, Chris; Sturmberg, Joachim P; Maitra, Arjun; Martin, Carmel M
India has rudimentary and fragmented primary health care (PHC) and family medicine systems, yet it also has the policy expectation that PHC should meet the needs of extremely large populations with slums and difficult to reach groups, rapid social and epidemiological transition from developing to developed nation profiles. Historically, the system has lacked impetus to achieve PHC. To provide an overview of PHC approaches and the current state of PHC and family medicine in India in order to assess the opportunities for their revitalization. A narrative review of the published and grey literature on PHC, family medicine, Web2.0 and health informatics key papers and policy documents, pertinent to India. A conceptual framework and recommendations for policy makers and practitioner audiences. PHC is constructed through systems of local providers who address individual, family and local community basic health needs with strong community participation. Successful PHC is a pre-eminent strategy for India to address the determinants of health and the almost chaotic of massive social transition in its institutions and health care sector. There is a lack of an articulated comprehensive framework for the publicly stated goals of improving health and implementing PHC. Also, there exists a very limited education and organization of a medical and PHC workforce who are trained and resourced to address individual, family and local community health and who have become increasingly specialized. However, emerging technology, Health2.0 and user generated health care informatics, which are largely conducted through mobile phones, are co-evolving patient-driven health systems, and potentially enhance PHC and family medicine workforce development. In order to improve health outcomes in an equitable manner in India, there is a pressing need for a framework for implementing PHC. The co-emergence of information technologies accessible to the mass population and user-driven health care
Miller, P; Craig, N; Scott, A; Walker, A; Hanlon, P
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
Leach, Brandi; Morgan, Perri; Strand de Oliveira, Justine; Hull, Sharon; Østbye, Truls; Everett, Christine
Current recommendations for strengthening the US healthcare system consider restructuring primary care into multidisciplinary teams as vital to improving quality and efficiency. Yet, approaches to the selection of team designs remain unclear. This project describes current primary care team designs, primary care professionals' perceptions of ideal team designs, and perceived facilitating factors and barriers to implementing ideal team-based care. Qualitative study of 44 health care professionals at 6 primary care practices in North Carolina using focus group discussions and surveys. Data was analyzed using framework content analysis. Practices used a variety of multidisciplinary team designs with the specific design being influenced by the social and policy context in which practices were embedded. Practices overwhelmingly located barriers to adopting ideal multidisciplinary teams as being outside of their individual practices and outside of their control. Participants viewed internal organizational contexts as the major facilitators of multidisciplinary primary care teams. The majority of practices described their ideal team design as including a social worker to meet the needs of socially complex patients. Primary care multidisciplinary team designs vary across practices, shaped in part by contextual factors perceived as barriers outside of the practices' control. Facilitating factors within practices provide a culture of support to team members, but they are insufficient to overcome the perceived barriers. The common desire to add social workers to care teams reflects practices' struggles to meet the complex demands of patients and external agencies. Government or organizational policies should avoid one-size-fits-all approaches to multidisciplinary care teams, and instead allow primary care practices to adapt to their specific contextual circumstances.
Ewald, Dominik A; Huss, Gottfried; Auras, Silke; Caceres, Juan Ruiz-Canela; Hadjipanayis, Adamos; Geraedts, Max
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
Baldor, R A; Brooks, W B; Warfield, M E; O'Shea, K
To assess the interest, perceptions, and needs of primary care physicians with regard to office-based precepting of medical students. Random survey. The New England region of the United States (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut). Family physicians, general internists and paediatricians. These included: (1) practice and preceptor demographics; (2) Likert scale agreement or disagreement with various positive and negative perceptions about precepting students; rating (from unimportant to necessary) of potential benefits from medical schools associated with the support of precepting in the office setting, and (3) comparisons among physician groups to determine differences in perceptions and needs. There is a high level of interest in precepting regardless of primary care specialty, practice structure, payment mechanism, or precepting experience. Negative impacts included decreased productivity and increased length of the day by a median of 60 minutes. Positive impacts included keeping one's own knowledge up-to-date and enhanced enjoyment of practice. Benefits such as academic appointments, continuing medical education credits, faculty development, computer linkages for clinical information and medical library access are rated highly. Monetary payment, whether as a modest honorarium or as compensation for lost time/income, was felt to be important by half of our sample. A significant interest in precepting medical students on a regular basis is expressed by primary care physicians in the ambulatory medicine setting. The results of this survey can be used by medical schools to address negative perceptions and to develop appropriate benefits packages to recruit and retain these primary care preceptors.
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.
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
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
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.
Wong, Christopher J; Pagalilauan, Genevieve
Solid organ transplantation (SOT) is one of the major advances in medicine. Care of the SOT recipient is complex and continued partnership with the transplant specialist is essential to manage and treat complications and maintain health. The increased longevity of SOT recipients will lead to their being an evolving part of primary care practice, with ever more opportunities for care, education, and research of this rewarding patient population. This review discusses the overall primary care management of adult SOT recipients. Copyright © 2015 Elsevier Inc. All rights reserved.
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.
Verstappen, Wim; Gaal, Sander; Bowie, Paul; Parker, Diane; Lainer, Miriam; Valderas, Jose M.; Wensing, Michel; Esmail, Aneez
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
Villaseñor, Sally; Krouse, Helene J
There is a niche for urgent care clinics as an alternate source of health care in the United States. This systematic review examines whether the use of urgent care clinics can improve access to care or if these facilities undermine continuity of primary care. Databases used were Cumulative Index for Nursing and Allied Health (CINAHL) and Medical Literature Analysis and Retrieval System Online (MEDLINE). Articles from 2004 to 2014 were searched using keywords-access, barriers, continuity of care, nurse practitioner (NP), urgent care, retail clinic, emergency, and primary care. Urgent care clinics can improve access to care, but may also negatively impact continuity of care, preventative services, and ongoing management of chronic conditions. Barriers to primary care and benefits of urgent care are inversely related. Insufficient knowledge regarding navigation of the healthcare system, perceived urgency of medical need, and deflection of care contribute to use of urgent care over primary care. NPs are frontline healthcare providers essential to developing and maintaining successful communication and collaboration among providers across healthcare settings. In both primary care and urgent care facilities, NPs can ensure continuity of care, decreased healthcare costs, and optimized health outcomes for patients. ©2015 American Association of Nurse Practitioners.
Yano, Elizabeth M; Soban, Lynn M; Parkerton, Patricia H; Etzioni, David A
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.
Acharya, Bibhav; Tenpa, Jasmine; Thapa, Poshan; Gauchan, Bikash; Citrin, David; Ekstrand, Maria
Globally, access to mental healthcare is often lacking in rural, low-resource settings. Mental healthcare services integration in primary care settings is a key intervention to address this gap. A common strategy includes embedding mental healthcare workers on-site, and receiving consultation from an off-site psychiatrist. Primary care provider perspectives are important for successful program implementation. We conducted three focus groups with all 24 primary care providers at a district-level hospital in rural Nepal. We asked participants about their concerns and recommendations for an integrated mental healthcare delivery program. They were also asked about current practices in seeking referral for patients with mental illness. We collected data using structured notes and analyzed the data by template coding to develop themes around concerns and recommendations for an integrated program. Participants noted that the current referral system included sending patients to the nearest psychiatrist who is 14 h away. Participants did not think this was effective, and stated that integrating mental health into the existing primary care setting would be ideal. Their major concerns about a proposed program included workplace hierarchies between mental healthcare workers and other clinicians, impact of staff turnover on patients, reliability of an off-site consultant psychiatrist, and ability of on-site primary care providers to screen patients and follow recommendations from an off-site psychiatrist. Their suggestions included training a few existing primary care providers as dedicated mental healthcare workers, recruiting both senior and junior mental healthcare workers to ensure retention, recruiting academic psychiatrists for reliability, and training all primary care providers to appropriately screen for mental illness and follow recommendations from the psychiatrist. Primary care providers in rural Nepal reported the failure of the current system of referral, which