Full Text Available ABSTRACT: This study considers both spatial and a-spatial variables in examining accessibility to primary healthcare in the three largest urban areas of Ohio (Cleveland, Columbus, and Cincinnati. Spatial access emphasizes the importance of geographic barriers between individuals and primary care physicians, while a-spatial variables include non-geographic barriers or facilitators such as age, sex, race, income, social class, education, living conditions and language skills. Population and socioeconomic data were obtained from the 2000 Census, and primary care physician data for 2008 was provided by the Ohio Medical Board. We first implemented a two-step method based on a floating catchment area using Geographic Information Systems to measure spatial accessibility in terms of 30-minute travel times. We then used principal component analysis to group various socio-demographic variables into three groups: (1 socioeconomic disadvantages, (2 living conditions, and (3 healthcare needs. Finally, spatial and a-spatial variables were integrated to identify areas with poor access to primary care in Cleveland, Columbus, and Cincinnati. KEYWORDS: Geographic information systems, healthcare access, spatial accessibility, primary care shortage areas
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.
Chiauzzi, Emil; Trudeau, Kimberlee J.; Zacharoff, Kevin; Bond, Kathleen
Introduction: Primary care physicians (PCPs) treat a high proportion of chronic pain patients but often lack training about how to assess and address issues associated with prescribing opioids when they are an appropriate component of therapy. The result may be that they may avoid treating these patients, which can lead to an undertreatment of…
Kuo, Alice A; Ciccarelli, Mary R; Sharma, Niraj; Lotstein, Debra S
The transition from pediatric to adult health care is a vulnerable period for youth with special health care needs. Although successful transitions are recognized as critical for improving adult outcomes and reducing health care utilization and cost, an educational gap in health care transitions for physicians persists. Our aim with this project was to develop a national health care transition residency curriculum for primary care physicians, using an expert-based, consensus-building process. Medical professionals with expertise in health care transition were recruited to participate in a survey to assist in the development of a health care transition curriculum for primary care physicians. By using a modified Delphi process, curricular goals and objectives were drafted, and participants rated the importance of each objective, feasibility of developing activities for objectives, and appropriateness of objectives for specified learners. Mean and SDs for each response and percent rating for the appropriateness of each objective were calculated. Fifty-six of 246 possible respondents participated in round 1 of ratings and 36 (64%) participated in the second round. Five goals with 32 associated objectives were identified. Twenty-five of the 32 objectives (78%) were rated as being appropriate for "proficient" learners, with 7 objectives rated as "expert." Three objectives were added to map onto the Got Transition guidelines. The identified goals and objectives provide the foundation and structure for future curriculum development, facilitating the sharing of curricular activities and evaluation tools across programs by faculty with a range of expertise. Copyright © 2018 by the American Academy of Pediatrics.
Richardson, Jo; Coid, Jeremy; Petruckevitch, Ann; Chung, Wai Shan; Moorey, Stirling; Feder, Gene
Objectives To measure the prevalence of domestic violence among women attending general practice; test the association between experience of domestic violence and demographic factors; evaluate the extent of recording of domestic violence in records held by general practices; and assess acceptability to women of screening for domestic violence by general practitioners or practice nurses. Design Self administered questionnaire survey. Review of medical records. Setting General practices in Hackney, London. Participants 1207 women (>15 years) attending selected practices. Main outcome measures Prevalence of domestic violence against women. Association between demographic factors and domestic violence reported in questionnaire. Comparison of recording of domestic violence in medical records with that reported in questionnaire. Attitudes of women towards being questioned about domestic violence by general practitioners or practice nurses. Results 425/1035 women (41%, 95% confidence interval 38% to 44%) had ever experienced physical violence from a partner or former partner and 160/949 (17%, 14% to 19%) had experienced it within the past year. Pregnancy in the past year was associated with an increased risk of current violence (adjusted odds ratio 2.11, 1.39 to 3.19). Physical violence was recorded in the medical records of 15/90 (17%) women who reported it on the questionnaire. At least 202/1010 (20%) women objected to screening for domestic violence. Conclusions With the high prevalence of domestic violence, health professionals should maintain a high level of awareness of the possibility of domestic violence, especially affecting pregnant women, but the case for screening is not yet convincing. What is already known on this topicDomestic violence is associated with a wide range of health and social problems for women and their childrenWomen experiencing violence are often not identified by health professionals in hospital settingsProfessional organisations and
Hernan, Andrea L; Giles, Sally J; Fuller, Jeffrey; Johnson, Julie K; Walker, Christine; Dunbar, James A
Patients can have an important role in reducing harm in primary-care settings. Learning from patient experience and feedback could improve patient safety. Evidence that captures patients' views of the various contributory factors to creating safe primary care is largely absent. The aim of this study was to address this evidence gap. Four focus groups and eight semistructured interviews were conducted with 34 patients and carers from south-east Australia. Participants were asked to describe their experiences of primary care. Audio recordings were transcribed verbatim and specific factors that contribute to safety incidents were identified in the analysis using the Yorkshire Contributory Factors Framework (YCFF). Other factors emerging from the data were also ascertained and added to the analytical framework. Thirteen factors that contribute to safety incidents in primary care were ascertained. Five unique factors for the primary-care setting were discovered in conjunction with eight factors present in the YCFF from hospital settings. The five unique primary care contributing factors to safety incidents represented a range of levels within the primary-care system from local working conditions to the upstream organisational level and the external policy context. The 13 factors included communication, access, patient factors, external policy context, dignity and respect, primary-secondary interface, continuity of care, task performance, task characteristics, time in the consultation, safety culture, team factors and the physical environment. Patient and carer feedback of this type could help primary-care professionals better understand and identify potential safety concerns and make appropriate service improvements. The comprehensive range of factors identified provides the groundwork for developing tools that systematically capture the multiple contributory factors to patient safety. Published by the BMJ Publishing Group Limited. For permission to use (where not
O'Donnell, Patrick; Tierney, Edel; O'Carroll, Austin; Nurse, Diane; MacFarlane, Anne
The involvement of patients and the public in healthcare has grown significantly in recent decades and is documented in health policy documents internationally. Many benefits of involving these groups in primary care planning have been reported. However, these benefits are rarely felt by those considered marginalised in society and they are often excluded from participating in the process of planning primary care. It has been recommended to employ suitable approaches, such as co-operative and participatory initiatives, to enable marginalised groups to highlight their priorities for care. This Participatory Learning and Action (PLA) research study involved 21 members of various marginalised groups who contributed their views about access to primary care. Using a series of PLA techniques for data generation and co-analysis, we explored barriers and facilitators to primary healthcare access from the perspective of migrants, Irish Travellers, homeless people, drug users, sex workers and people living in deprivation, and identified their priorities for action with regard to primary care provision. Four overarching themes were identified: the home environment, the effects of the 'two-tier' healthcare system on engagement, healthcare encounters, and the complex health needs of many in those groups. The study demonstrates that there are many complicated personal and structural barriers to accessing primary healthcare for marginalised groups. There were shared and differential experiences across the groups. Participants also expressed shared priorities for action in the planning and running of primary care services. Members of marginalised groups have shared priorities for action to improve their access to primary care. If steps are taken to address these, there is scope to impact on more than one marginalised group and to address the existing health inequities.
Haj-Hassan, Tanya Ali; Thompson, Matthew J; Mayon-White, Richard T; Ninis, Nelly; Harnden, Anthony; Smith, Lindsay F P; Perera, Rafael; Mant, David C
Symptoms are part of the initial evaluation of children with acute illness, and are often used to help identify those who may have serious infections. Meningococcal disease is a rapidly progressive infection that needs to be recognised early among children presenting to primary care. To determine the diagnostic value of presenting symptoms in primary care for meningococcal disease. Data on a series of presenting symptoms were collected using a parental symptoms checklist at point of care for children presenting to a GP with acute infection. Symptom frequencies were compared with existing data on the pre-hospital features of 345 children with meningococcal disease. UK primary care. The study recruited a total of 1212 children aged under 16 years presenting to their GP with an acute illness, of whom 924 had an acute self-limiting infection, including 407 who were reported by parents to be febrile. Symptom frequencies were compared with those reported by parents of 345 children with meningococcal disease. Main outcome measures were diagnostic characteristics of individual symptoms for meningococcal disease. Five symptoms have clinically useful positive likelihood ratios (LR+) for meningococcal disease: confusion (LR+ = 24.2, 95% confidence interval [CI] = 11.5 to 51.3), leg pain (LR+ = 7.6, 95% CI = 4.9 to 11.9), photophobia (LR+ = 6.5, 95% CI = 3.8 to 11.0), rash (LR+ = 5.5, 95% CI = 4.3 to 7.1), and neck pain/stiffness (LR+ = 5.3, 95% CI = 3.5 to 8.3). Cold hands and feet had limited diagnostic value (LR+ = 2.3, 95% CI = 1.9 to 3.0), while headache (LR+ = 1.0, 95% CI = 0.8 to 1.3), and pale colour (LR+ = 0.3, 95% CI = 0.2 to 0.5) did not discriminate meningococcal disease in children. This study confirms the diagnostic value of classic 'red flag' symptoms of neck stiffness, rash, and photophobia, but also suggests that the presence of confusion or leg pain in a child with an unexplained acute febrile illness should also usually prompt a face-to-face assessment to
Haj-Hassan, Tanya Ali; Thompson, Matthew J; Mayon-White, Richard T; Ninis, Nelly; Harnden, Anthony; Smith, Lindsay FP; Perera, Rafael; Mant, David C
Background Symptoms are part of the initial evaluation of children with acute illness, and are often used to help identify those who may have serious infections. Meningococcal disease is a rapidly progressive infection that needs to be recognised early among children presenting to primary care. Aim To determine the diagnostic value of presenting symptoms in primary care for meningococcal disease. Design of study Data on a series of presenting symptoms were collected using a parental symptoms checklist at point of care for children presenting to a GP with acute infection. Symptom frequencies were compared with existing data on the pre-hospital features of 345 children with meningococcal disease. Setting UK primary care. Method The study recruited a total of 1212 children aged under 16 years presenting to their GP with an acute illness, of whom 924 had an acute self-limiting infection, including 407 who were reported by parents to be febrile. Symptom frequencies were compared with those reported by parents of 345 children with meningococcal disease. Main outcome measures were diagnostic characteristics of individual symptoms for meningococcal disease. Results Five symptoms have clinically useful positive likelihood ratios (LR+) for meningococcal disease: confusion (LR+ = 24.2, 95% confidence interval [CI] = 11.5 to 51.3), leg pain (LR+ = 7.6, 95% CI = 4.9 to 11.9), photophobia (LR+ = 6.5, 95% CI = 3.8 to 11.0), rash (LR+ = 5.5, 95% CI = 4.3 to 7.1), and neck pain/stiffness (LR+ = 5.3, 95% CI = 3.5 to 8.3). Cold hands and feet had limited diagnostic value (LR+ = 2.3, 95% CI = 1.9 to 3.0), while headache (LR+ = 1.0, 95% CI = 0.8 to 1.3), and pale colour (LR+ = 0.3, 95% CI = 0.2 to 0.5) did not discriminate meningococcal disease in children. Conclusion This study confirms the diagnostic value of classic ‘red flag’ symptoms of neck stiffness, rash, and photophobia, but also suggests that the presence of confusion or leg pain in a child with an unexplained acute
Rakotz, Michael K; Ewigman, Bernard G; Sarav, Menaka; Ross, Ruth E; Robicsek, Ari; Konchak, Chad W; Gavagan, Thomas F; Baker, David W; Hyman, David J; Anderson, Kenneth P; Masi, Christopher M
The goal of this study was to develop a technology-based strategy to identify patients with undiagnosed hypertension in 23 primary care practices and integrate this innovation into a continuous quality improvement initiative in a large, integrated health system. In phase 1, we reviewed electronic health records (EHRs) using algorithms designed to identify patients at risk for undiagnosed hypertension. We then invited each at-risk patient to complete an automated office blood pressure (AOBP) protocol. In phase 2, we instituted a quality improvement process that included regular physician feedback and office-based computer alerts to evaluate at-risk patients not screened in phase 1. Study patients were observed for 24 additional months to determine rates of diagnostic resolution. Of the 1,432 patients targeted for inclusion in the study, 475 completed the AOBP protocol during the 6 months of phase 1. Of the 1,033 at-risk patients who remained active during phase 2, 740 (72%) were classified by the end of the follow-up period: 361 had hypertension diagnosed, 290 had either white-coat hypertension, prehypertension, or elevated blood pressure diagnosed, and 89 had normal blood pressure. By the end of the follow-up period, 293 patients (28%) had not been classified and remained at risk for undiagnosed hypertension. Our technology-based innovation identified a large number of patients at risk for undiagnosed hypertension and successfully classified the majority, including many with hypertension. This innovation has been implemented as an ongoing quality improvement initiative in our medical group and continues to improve the accuracy of diagnosis of hypertension among primary care patients. © 2014 Annals of Family Medicine, Inc.
Morris, Rebecca Lauren; Stocks, Susan Jill; Alam, Rahul; Taylor, Sian; Rolfe, Carly; Glover, Steven William; Whitcombe, Joanne; Campbell, Stephen M
To identify the top 10 unanswered research questions for primary care patient safety research. A modified nominal group technique. UK. Anyone with experience of primary care including: patients, carers and healthcare professionals. 341 patients and 86 healthcare professionals submitted questions. A top 10, and top 30, future research questions for primary care patient safety. 443 research questions were submitted by 341 patients and 86 healthcare professionals, through a national survey. After checking for relevance and rephrasing, a total of 173 questions were collated into themes. The themes were largely focused on communication, team and system working, interfaces across primary and secondary care, medication, self-management support and technology. The questions were then prioritised through a national survey, the top 30 questions were taken forward to the final prioritisation workshop. The top 10 research questions focused on the most vulnerable in society, holistic whole-person care, safer communication and coordination between care providers, work intensity, continuity of care, suicide risk, complex care at home and confidentiality. This study was the first national prioritisation exercise to identify patient and healthcare professional priorities for primary care patient safety research. The research priorities identified a range of important gaps in the existing evidence to inform everyday practice to address primary care patient safety. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Loton, Dan; Lubman, Dan I
For most people, playing video games is a passionate leisure pursuit: a source of relaxation, fun, socialisation and culture. Moderate play has been associated with greater wellbeing and cognitive abilities in some studies. Yet, for a small subgroup, gaming can become excessive and problematic. This article presents an overview of the world of video games and the recently proposed internet gaming disorder (IGD), as well as advice regarding relevant treatment approaches within primary care. Similar to other addictive disorders (including problem gambling), IGD is characterised by excessive use despite negative consequences, with associated difficulties in reducing or stopping. Studies that have examined individuals with IGD have identified multiple harms, including lower psychosocial wellbeing, greater levels of psychopathology and diminished functioning. As yet, few studies have rigorously examined effective treatment options, but adapting psychological interventions used in the treatment of other addictions (eg motivational interviewing and cognitive behavioural therapy) that incorporate harm minimisation approaches, and addressing underlying issues and associated problems, are recommended.
Full Text Available Abstract Background The roles of pharmacists have evolved from product oriented, dispensing of medications to more patient-focused services such as the provision of pharmaceutical care. Such pharmacy service is also becoming more widely practised in Malaysia but is not well documented. Therefore, this study is warranted to fill this information gap by identifying the types of pharmaceutical care issues (PCIs encountered by primary care patients with diabetes mellitus, hypertension or hyperlipidaemia in Malaysia. Methods This study was part of a large controlled trial that evaluated the outcomes of multiprofessional collaboration which involved medical general practitioners, pharmacists, dietitians and nurses in managing diabetes mellitus, hypertension and hyperlipidaemia in primary care settings. A total of 477 patients were recruited by 44 general practitioners in the Klang Valley. These patients were counselled by the various healthcare professionals and followed-up for 6 months. Results Of the 477 participants, 53.7% had at least one PCI, with a total of 706 PCIs. These included drug-use problems (33.3%, insufficient awareness and knowledge about disease condition and medication (20.4%, adverse drug reactions (15.6%, therapeutic failure (13.9%, drug-choice problems (9.5% and dosing problems (3.4%. Non-adherence to medications topped the list of drug-use problems, followed by incorrect administration of medications. More than half of the PCIs (52% were classified as probably clinically insignificant, 38.9% with minimal clinical significance, 8.9% as definitely clinically significant and could cause patient harm while one issue (0.2% was classified as life threatening. The main causes of PCIs were deterioration of disease state which led to failure of therapy, and also presentation of new symptoms or indications. Of the 338 PCIs where changes were recommended by the pharmacist, 87.3% were carried out as recommended. Conclusions This study
Helsper, C.W.|info:eu-repo/dai/nl/338910816; van Essen, G.A.|info:eu-repo/dai/nl/141200065; Frijling, B.D.; de Wit, N.J.|info:eu-repo/dai/nl/100525393
BACKGROUND: Hepatitis C (HCV) and hepatitis B (HBV) virus infection can lead to serious complications if left untreated, but often remain undetected in primary care. Mild alanine aminotransferase (ALT) elevations (30-100 IU/l) are commonly found and could be associated with viral hepatitis;
Bich N Dang
Full Text Available OBJECTIVE: This study seeks to understand the drivers of overall patient satisfaction in a predominantly low-income, ethnic-minority population of HIV primary care patients. The study's primary aims were to determine 1 the component experiences which contribute to patients' evaluations of their overall satisfaction with care received, and 2 the relative contribution of each component experience in explaining patients' evaluation of overall satisfaction. METHODS: We conducted a cross-sectional study of 489 adult patients receiving HIV primary care at two clinics in Houston, Texas, from January 13-April 21, 2011. The participation rate among eligible patients was 94%. The survey included 15 questions about various components of the care experience, 4 questions about the provider experience and 3 questions about overall care. To ensure that the survey was appropriately tailored to our clinic population and the list of component experiences reflected all aspects of the care experience salient to patients, we conducted in-depth interviews with key providers and clinic staff and pre-tested the survey instrument with patients. RESULTS: Patients' evaluation of their provider correlated the strongest with their overall satisfaction (standardized β = 0.445, p<0.001 and accounted for almost half of the explained variance. Access and availability, like clinic hours and ease of calling the clinic, also correlated with overall satisfaction, but less strongly. Wait time and parking, despite receiving low patient ratings, did not correlate with overall satisfaction. CONCLUSIONS: The patient-provider relationship far exceeds other component experiences of care in its association with overall satisfaction. Our study suggests that interventions to improve overall patient satisfaction should focus on improving patients' evaluation of their provider.
Buckley, Brian S
OBJECTIVE: To ascertain the risk of acute myocardial infarction, invasive cardiac procedures, and mortality among patients with newly diagnosed angina over five years. DESIGN: Incident cohort study of patients with primary care data linked to secondary care and mortality data. SETTING: 40 primary care practices in Scotland. PARTICIPANTS: 1785 patients with a diagnosis of angina as their first manifestation of ischaemic heart disease, 1 January 1998 to 31 December 2001. MAIN OUTCOME MEASURES: Adjusted hazard ratios for acute myocardial infarction, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, death from ischaemic heart disease, and all cause mortality, adjusted for demographics, lifestyle risk factors, and comorbidity at cohort entry. RESULTS: Mean age was 62.3 (SD 11.3). Male sex was associated with an increased risk of acute myocardial infarction (hazard ratio 2.01, 95% confidence interval 1.35 to 2.97), death from ischaemic heart disease (2.80, 1.73 to 4.53), and all cause mortality (1.82, 1.33 to 2.49). Increasing age was associated with acute myocardial infarction (1.04, 1.02 to 1.06, per year of age increase), death from ischaemic heart disease (1.09, 1.06 to 1.11, per year of age increase), and all cause mortality (1.09, 1.07 to 1.11, per year of age increase). Smoking was associated with subsequent acute myocardial infarction (1.94, 1.31 to 2.89), death from ischaemic heart disease (2.12, 1.32 to 3.39), and all cause mortality (2.11, 1.52 to 2.95). Obesity was associated with death from ischaemic heart disease (2.01, 1.17 to 3.45) and all cause mortality (2.20, 1.52 to 3.19). Previous stroke was associated with all cause mortality (1.78, 1.13 to 2.80) and chronic kidney disease with death from ischaemic heart disease (5.72, 1.74 to 18.79). Men were more likely than women to have coronary artery bypass grafting or percutaneous transluminal coronary angioplasty after a diagnosis of angina; older people were less likely to
Bottino, Clement J; Rhodes, Erinn T; Kreatsoulas, Catherine; Cox, Joanne E; Fleegler, Eric W
To describe a clinical approach for food insecurity screening incorporating a menu offering food-assistance referrals, and to examine relationships between food insecurity and referral selection. Caregivers of 3- to 10-year-old children presenting for well-child care completed a self-administered questionnaire on a laptop computer. Items included the US Household Food Security Survey Module: 6-Item Short Form (food insecurity screen) and a referral menu offering assistance with: 1) finding a food pantry, 2) getting hot meals, 3) applying for Supplemental Nutrition Assistance Program (SNAP), and 4) applying for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Referrals were offered independent of food insecurity status or eligibility. We examined associations between food insecurity and referral selection using multiple logistic regression while adjusting for covariates. A total of 340 caregivers participated; 106 (31.2%) reported food insecurity, and 107 (31.5%) selected one or more referrals. Forty-nine caregivers (14.4%) reported food insecurity but selected no referrals; 50 caregivers (14.7%) selected one or more referrals but did not report food insecurity; and 57 caregivers (16.8%) both reported food insecurity and selected one or more referrals. After adjustment, caregivers who selected one or more referrals had greater odds of food insecurity compared to caregivers who selected no referrals (adjusted odds ratio 4.0; 95% confidence interval 2.4-7.0). In this sample, there was incomplete overlap between food insecurity and referral selection. Offering referrals may be a helpful adjunct to standard screening for eliciting family preferences and identifying unmet social needs. Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
Petty, T L
Spirometry can predict lung health and monitor disease and response to therapy. This noninvasive test can and should be done regularly by primary care providers. It can identify patients at risk for lung cancer as well as heart attack and stroke. Patients with abnormal spirometric findings can be warned that airflow obstruction has begun, which may provide the motivation to quit smoking. Abnormal spirometry measurements correlate with all-cause mortality. Approaches to early diagnosis of lung cancer continue to expand. For example, use of the new fluorescent bronchoscope can increase diagnostic accuracy in lung cancer by highlighting lesions that are malignant or likely to be malignant. For now, however, identification of airflow obstruction with spirometry and follow-up with sputum cytology provide the widest benefit.
Baarnes, Camilla Boslev; Kjeldgaard, Peter; Nielsen, Mia
The asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) remains poorly characterised. Our aim was to describe an algorithm for identifying possible ACOS in adults with newly diagnosed COPD in primary care. General practitioners (n=241) consecutively recruited subjects ⩾35...... years, with tobacco exposure, at least one respiratory symptom and no previous diagnosis of obstructive lung disease. Possible ACOS was defined as chronic airflow obstruction, i.e., post-bronchodilator (BD) forced expiratory volume 1/forced vital capacity (FEV1/FVC) ratio... of the applied ACOS definition, no significant difference in life-time tobacco exposure was found between ACOS- and COPD-only patients. In subjects with a new diagnosis of COPD, the prevalence of ACOS is high. When screening for COPD in general practice among patients with no previous diagnosis of obstructive...
Full Text Available Mark J Makowsky,1 Andrew J Cave,2 Scot H Simpson1 1Faculty of Pharmacy and Pharmaceutical Sciences, 2Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada Background and objectives: Pharmacists working in primary care clinics are well positioned to help optimize medication management of community-dwelling patients who are at high risk of experiencing medication-related problems. However, it is often difficult to identify these patients. Our objective was to test the feasibility of a self-administered patient survey, to facilitate identification of patients at high risk of medication-related problems in a family medicine clinic. Methods: We conducted a cross-sectional, paper-based survey at the University of Alberta Hospital Family Medicine Clinic in Edmonton, Alberta, which serves approximately 7,000 patients, with 25,000 consultations per year. Adult patients attending the clinic were invited to complete a ten-item questionnaire, adapted from previously validated surveys, while waiting to be seen by the physician. Outcomes of interest included: time to complete the questionnaire, staff feedback regarding impact on workflow, and the proportion of patients who reported three or more risk factors for medication-related problems. Results: The questionnaire took less than 5 minutes to complete, according to the patient's report on the last page of the questionnaire. The median age (and interquartile range of respondents was 57 (45–69 years; 59% were women; 47% reported being in very good or excellent health; 43 respondents of 100 had three or more risk factors, and met the definition for being at high risk of a medication-related problem. Conclusions: Distribution of a self-administered questionnaire did not disrupt patients, or the clinic workflow, and identified an important proportion of patients at high risk of medication-related problems. Keywords: screening tool, pharmacists, primary
Koh, Chee S; Kang, Melissa; Usherwood, Tim
Background Individuals who identify as gay, lesbian, bisexual, transgender or queer (GLBTQ) suffer higher rates of illness and morbidity compared with the general population but may experience significant barriers to accessing primary health care. We used an online questionnaire to explore GLBTQ adults' experiences of accessing primary health care in Australia. We developed the questionnaire in consultation with individuals who belonged to or worked closely with the GLBTQ community. Questions were open-ended and sought information about four topic areas: sexual identity and its meaning, utilisation of primary health care services, disclosure of sexual identity to primary care providers and experiences of accessing primary health care. Data were analysed by coding free-text responses into themes. Ninety-nine valid responses were received. Participants were 18-60+ years old (modal age group: 20-29 years); 70% lived in cities. Of these, 49% identified as gay, 35% as lesbian, 13% as bisexual, 8% as queer and 3% as transgender. Some participants indicated more than one identity. GLBTQ-identifying adults often divided care, seeking different primary care services for different health concerns. Themes in relation to disclosure of sexual identity were: taking a rights-based position, experiences of homophobia and clinical context. Themes about access to primary health care were: diversity and heterogeneity, real or perceived discrimination, visual symbols and respect. Despite diversity, GLBTQ adults experience many barriers to accessing health care due to sexual identity. General practitioners and other primary health care providers have a role in ensuring equitable access to health care.
Zhou, Shang-Ming; Fernandez-Gutierrez, Fabiola; Kennedy, Jonathan; Cooksey, Roxanne; Atkinson, Mark; Denaxas, Spiros; Siebert, Stefan; Dixon, William G; O'Neill, Terence W; Choy, Ernest; Sudlow, Cathie; Brophy, Sinead
1) To use data-driven method to examine clinical codes (risk factors) of a medical condition in primary care electronic health records (EHRs) that can accurately predict a diagnosis of the condition in secondary care EHRs. 2) To develop and validate a disease phenotyping algorithm for rheumatoid arthritis using primary care EHRs. This study linked routine primary and secondary care EHRs in Wales, UK. A machine learning based scheme was used to identify patients with rheumatoid arthritis from primary care EHRs via the following steps: i) selection of variables by comparing relative frequencies of Read codes in the primary care dataset associated with disease case compared to non-disease control (disease/non-disease based on the secondary care diagnosis); ii) reduction of predictors/associated variables using a Random Forest method, iii) induction of decision rules from decision tree model. The proposed method was then extensively validated on an independent dataset, and compared for performance with two existing deterministic algorithms for RA which had been developed using expert clinical knowledge. Primary care EHRs were available for 2,238,360 patients over the age of 16 and of these 20,667 were also linked in the secondary care rheumatology clinical system. In the linked dataset, 900 predictors (out of a total of 43,100 variables) in the primary care record were discovered more frequently in those with versus those without RA. These variables were reduced to 37 groups of related clinical codes, which were used to develop a decision tree model. The final algorithm identified 8 predictors related to diagnostic codes for RA, medication codes, such as those for disease modifying anti-rheumatic drugs, and absence of alternative diagnoses such as psoriatic arthritis. The proposed data-driven method performed as well as the expert clinical knowledge based methods. Data-driven scheme, such as ensemble machine learning methods, has the potential of identifying the most
Weaver, Terri L; Gilbert, Louisa; El-Bassel, Nabila; Resnick, Heidi S; Noursi, Samia
Substance use and/or disorders (SUDs) have been identified as a significant correlate of intimate partner violence (IPV) exposure and present complex issues that intersect with the topography of IPV, attendant mental health, and physical co-morbidities and may pose barriers to primary care- and other agency-based screening and intervention efforts. Despite substantial research indicating significantly higher rates of all types and severity of IPV victimization among women with SUDs and bidirectional associations between partner or self-use of drugs or alcohol and IPV victimization, effective screening, brief interventions, coordinated systems of care, and treatment approaches to address these co-occurring problems remain very limited. We integrated select research examining the intersection of IPV victimization and SUDs and several comorbidities that have significant public health impact and provided recommendations for scaling up targeted interventions to redress these co-occurring problems among women in primary, emergency, and other care settings.
Maijala, Virpi; Tossavainen, Kerttu; Turunen, Hannele
The aims of this study were to identify and reach consensus among municipal primary health care participants on nurse practitioners' (NPs') required case management competencies in health promotion practices in eastern Finland. The NP's role as a case manager of patients with chronic conditions has been found to have positive outcomes in health promotion, such as reduced hospital lengths of stay and readmission rates. However, the challenging work of health promotion requires NPs to have multidimensional competencies in health promotion, including communication, advocacy, assessment, planning, consultation and implementation. A two-stage modified Delphi study. Round 1 semi-structured interviews were conducted among municipal primary health care participants (n = 42) in 11 health centres from April-July 2009, and the round 2 questionnaire survey was conducted in the same health centres in eastern Finland in January and March 2011. The questionnaire was answered by 64% of those surveyed (n = 56). Content analysis and descriptive statistics were used for data analysis. We identified a total of 18 required case management competencies for NPs' health promotion practices in municipal primary health care. In 17 of these competencies (such as knowledge, skills and ability to work independently in health promotion), a consensus was reached (51% or over). However, the need to be interested in municipal decision-making (44·6%) did not reach consensus. Consensus was clearly achieved for 17 competencies that NPs were required to have, and these indicated the knowledge or abilities of health promotion. Nevertheless, there was no agreement on the NPs' need to be interested in municipal decision-making. NPs need a variety of case management skills and abilities to realise health promotion in municipal primary health care and they need to be supported by primary health care leaders to develop health promotion activities. © 2015 John Wiley & Sons Ltd.
Weaver, Terri L.; Gilbert, Louisa; El-Bassel, Nabila; Resnick, Heidi S.; Noursi, Samia
Substance use and/or disorders (SUDs) have been identified as a significant correlate of intimate partner violence (IPV) exposure and present complex issues that intersect with the topography of IPV, attendant mental health, and physical co-morbidities and may pose barriers to primary care- and other agency-based screening and intervention efforts. Despite substantial research indicating significantly higher rates of all types and severity of IPV victimization among women with SUDs and bidire...
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.
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
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.
Lee, Theresa M; Tu, Karen; Wing, Laura L; Gershon, Andrea S
Little is known about using electronic medical records to identify patients with chronic obstructive pulmonary disease to improve quality of care. Our objective was to develop electronic medical record algorithms that can accurately identify patients with obstructive pulmonary disease. A retrospective chart abstraction study was conducted on data from the Electronic Medical Record Administrative data Linked Database (EMRALD ® ) housed at the Institute for Clinical Evaluative Sciences. Abstracted charts provided the reference standard based on available physician-diagnoses, chronic obstructive pulmonary disease-specific medications, smoking history and pulmonary function testing. Chronic obstructive pulmonary disease electronic medical record algorithms using combinations of terminology in the cumulative patient profile (CPP; problem list/past medical history), physician billing codes (chronic bronchitis/emphysema/other chronic obstructive pulmonary disease), and prescriptions, were tested against the reference standard. Sensitivity, specificity, and positive/negative predictive values (PPV/NPV) were calculated. There were 364 patients with chronic obstructive pulmonary disease identified in a 5889 randomly sampled cohort aged ≥ 35 years (prevalence = 6.2%). The electronic medical record algorithm consisting of ≥ 3 physician billing codes for chronic obstructive pulmonary disease per year; documentation in the CPP; tiotropium prescription; or ipratropium (or its formulations) prescription and a chronic obstructive pulmonary disease billing code had sensitivity of 76.9% (95% CI:72.2-81.2), specificity of 99.7% (99.5-99.8), PPV of 93.6% (90.3-96.1), and NPV of 98.5% (98.1-98.8). Electronic medical record algorithms can accurately identify patients with chronic obstructive pulmonary disease in primary care records. They can be used to enable further studies in practice patterns and chronic obstructive pulmonary disease management in primary care. NOVEL
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 ...
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.
Glidewell, Liz; Willis, Thomas A; Petty, Duncan; Lawton, Rebecca; McEachan, Rosemary R C; Ingleson, Emma; Heudtlass, Peter; Davies, Andrew; Jamieson, Tony; Hunter, Cheryl; Hartley, Suzanne; Gray-Burrows, Kara; Clamp, Susan; Carder, Paul; Alderson, Sarah; Farrin, Amanda J; Foy, Robbie
Interpreting evaluations of complex interventions can be difficult without sufficient description of key intervention content. We aimed to develop an implementation package for primary care which could be delivered using typically available resources and could be adapted to target determinants of behaviour for each of four quality indicators: diabetes control, blood pressure control, anticoagulation for atrial fibrillation and risky prescribing. We describe the development and prospective verification of behaviour change techniques (BCTs) embedded within the adaptable implementation packages. We used an over-lapping multi-staged process. We identified evidence-based, candidate delivery mechanisms-mainly audit and feedback, educational outreach and computerised prompts and reminders. We drew upon interviews with primary care professionals using the Theoretical Domains Framework to explore likely determinants of adherence to quality indicators. We linked determinants to candidate BCTs. With input from stakeholder panels, we prioritised likely determinants and intervention content prior to piloting the implementation packages. Our content analysis assessed the extent to which embedded BCTs could be identified within the packages and compared them across the delivery mechanisms and four quality indicators. Each implementation package included at least 27 out of 30 potentially applicable BCTs representing 15 of 16 BCT categories. Whilst 23 BCTs were shared across all four implementation packages (e.g. BCTs relating to feedback and comparing behaviour), some BCTs were unique to certain delivery mechanisms (e.g. 'graded tasks' and 'problem solving' for educational outreach). BCTs addressing the determinants 'environmental context' and 'social and professional roles' (e.g. 'restructuring the social and 'physical environment' and 'adding objects to the environment') were indicator specific. We found it challenging to operationalise BCTs targeting 'environmental context
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.
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
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.
Fuster, Daniel; Cheng, Debbie M; Wang, Na; Bernstein, Judith A; Palfai, Tibor P; Alford, Daniel P; Samet, Jeffrey H; Saitz, Richard
The use of brief intervention for decreasing frequent marijuana use holds potential, but its efficacy in primary care is not known. To assess the impact of 2 brief interventions on marijuana use among daily/or almost daily marijuana users. Subgroup analysis of a 3-arm randomized clinical trial of 2 brief counseling interventions compared with no brief intervention on daily marijuana use in a primary care setting (ASPIRE). ASPIRE study participants who both reported 21-30 days of marijuana use during the past month and identified marijuana as their drug of most concern. (1) brief negotiated interview (BNI), a 10-15-minute structured interview, and (2) an adaptation of motivational interviewing (MOTIV), a 30-45-minute intervention. Control group participants received only a list of substance use treatment resources. The primary outcome was number of days of marijuana use in the past 30 days at the 6-month follow-up. Secondary outcomes were (1) number of days of marijuana use at 6-week follow-up and (2) drug problems (Short Inventory of Problems-Drugs, SIP-D) at 6-week and 6-month follow-ups. Differences between intervention groups were analyzed using negative binomial regression models. Among the 167 eligible participants, we did not find any significant impact of either of the 2 interventions on past 30 days of marijuana use at 6 months (adjusted incidence rate ratio [aIRR]: 0.95, 95% confidence interval [CI]: 0.75-1.15, P = .82 for BNI vs. control; aIRR: 1.02, 95% CI: 0.85-1.23, P = .82 for MOTIV vs. control). There was no significant impact on drug-related problems at 6-month follow-up (aIRR: 1.12, 95% CI: 0.69-1.82, P = .66 and aIRR: 1.46, 95% CI: 0.89-2.38, P = .27 for BNI vs. control and MOTIV vs. control, respectively). Results were similar at 6 weeks. Brief intervention has no apparent impact on marijuana use or drug-related problems among primary care patients with frequent marijuana use identified by screening.
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.
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)
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...
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.
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...
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.
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...
Thompson, M.; Van den Bruel, A.; Verbakel, J.; Lakhanpaul, M.; Haj-Hassan, T.; Stevens, R.; Moll, HA; Buntinx, F.; Berger, M.; Aertgeerts, B.; Oostenbrink, R.; Mant, D.
Background: Although the vast majority of children with acute infections are managed at home, this is one of the most common problems encountered in children attending emergency departments (EDs) and primary care. Distinguishing children with serious infection from those with minor or self-limiting
M. Thompson (M.); A. van den Bruel (Ann); J. Verbakel (Johannes); M. Lakhanpaul (Monica); T. Haj-Hassan (Tanya); R. Stevens (Richard); H.A. Moll (Henriëtte); F. Buntinx (Frank); M.Y. Berger (Marjolein); B. Aertgeerts (Bert); R. Oostenbrink (Rianne); D. Mant (David)
textabstractBackground: Although the vast majority of children with acute infections are managed at home, this is one of the most common problems encountered in children attending emergency departments (EDs) and primary care. Distinguishing children with serious infection from those with minor or
Grimshaw, Jeremy M; Eccles, Martin P; Steen, Nick; Johnston, Marie; Pitts, Nigel B; Glidewell, Liz; Maclennan, Graeme; Thomas, Ruth; Bonetti, Debbie; Walker, Anne
Psychological models predict behaviour in a wide range of settings. The aim of this study was to explore the usefulness of a range of psychological models to predict the health professional behaviour 'referral for lumbar spine x-ray in patients presenting with low back pain' by UK primary care physicians. Psychological measures were collected by postal questionnaire survey from a random sample of primary care physicians in Scotland and north England. The outcome measures were clinical behaviour (referral rates for lumbar spine x-rays), behavioural simulation (lumbar spine x-ray referral decisions based upon scenarios), and behavioural intention (general intention to refer for lumbar spine x-rays in patients with low back pain). Explanatory variables were the constructs within the Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), Common Sense Self-Regulation Model (CS-SRM), Operant Learning Theory (OLT), Implementation Intention (II), Weinstein's Stage Model termed the Precaution Adoption Process (PAP), and knowledge. For each of the outcome measures, a generalised linear model was used to examine the predictive value of each theory individually. Linear regression was used for the intention and simulation outcomes, and negative binomial regression was used for the behaviour outcome. Following this 'theory level' analysis, a 'cross-theoretical construct' analysis was conducted to investigate the combined predictive value of all individual constructs across theories. Constructs from TPB, SCT, CS-SRM, and OLT predicted behaviour; however, the theoretical models did not fit the data well. When predicting behavioural simulation, the proportion of variance explained by individual theories was TPB 11.6%, SCT 12.1%, OLT 8.1%, and II 1.5% of the variance, and in the cross-theory analysis constructs from TPB, CS-SRM and II explained 16.5% of the variance in simulated behaviours. When predicting intention, the proportion of variance explained by individual
Lo, Clement; Teede, Helena; Ilic, Dragan; Russell, Grant; Murphy, Kerry; Usherwood, Timothy; Ranasinha, Sanjeeva; Zoungas, Sophia
Co-morbid diabetes and chronic kidney disease (CKD) are common in primary care but health care can be suboptimal. In this multi-centre mixed-methods study, we investigated GPs' perspectives on health service barriers in managing diabetes and CKD as an initial step towards health care improvement. Four focus groups were conducted among GPs in Australia's two largest cities. Transcripts underwent content analysis to inform development of a survey exploring health service barriers. This survey was then emailed/mailed to 840 GPs. Statistical analyses were performed using STATA v2.1. Responses were received from 13.7% of GPs (n = 115), mean (±SD) age 55.3 (10.1) years and mean duration of practice 26.6 (10.6). The majority (88.4%) reported wanting to manage diabetes and CKD in primary care with specialist assistance. However, 34.8% were unclear about the definition of CKD with 73.2% wanting more education. Access to specialist services was problematic with 39.3% and 28.2% reporting the process of referring patients to diabetes or CKD services, respectively, as hard. Coordination of care was also a problem with 35.6% unclear about each health care provider's role, 50.5% believing patients faced difficulties due to poor coordination across providers and 51.6% reporting duplication of tests. GPs expressed a clear interest in being the principal health care providers for patients with co-morbid diabetes and CKD. Supporting GPs and health care improvement focusing on overcoming reported barriers such as inadequate knowledge about CKD, access to specialist services and coordination of care may improve outcomes for people with co-morbid diabetes and CKD. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
Department of Community Medicine,. Ahmadu Bello University,Zaria. +234 803 705 3845. Email: email@example.com. Department of Community Medicine, Ahmadu Bello University, Zaria journal of. COMMUNITY MEDICINE. & PRIMARY HEALTH CARE. Journal of Community Medicine and Primary Health Care.
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...
Identifying patient-centred recommendations for improving patient safety in General Practices in England: a qualitative content analysis of free-text responses using the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire.
Ricci-Cabello, Ignacio; Saletti-Cuesta, Lorena; Slight, Sarah P; Valderas, Jose M
There is a growing interest in identifying strategies to achieve safer primary health-care provision. However, most of the research conducted so far in this area relies on information supplied by health-care providers, and limited attention has been paid to patients' perspectives. To explore patients' experiences and perceptions of patient safety in English general practices with the aim of eliciting patient-centred recommendations for improving patient safety. The Patient Reported Experiences and Outcomes of Safety in Primary Care questionnaire was sent to a random sample of 6736 primary care users registered in 45 English practices. We conducted a qualitative content analysis of responses to seven open-ended items addressing patients' experiences of safety problems, lessons learnt as a result of such experiences and recommendations for safer health care. A total of 1244 (18.4%) participants returned completed questionnaires. Of those, 678 (54.5%) responded to at least one open-ended question. Two main themes emerged as follows: (i) experiences of safety problems and (ii) good practices and recommendations to improve patient safety in primary care. Most frequent experiences of safety problems were related to appointments, coordination between providers, tests, medication and diagnosis. Patients' responses to these problems included increased patient activation (eg speaking up about concerns with their health care) and avoidance of unnecessary health care. Recommendations for safer health care included improvements in patient-centred communication, continuity of care, timely appointments, technical quality of care, active monitoring, teamwork, health records and practice environment. This study identified a number of patient-centred recommendations for improving patient safety in English general practices. © 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.
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.
Fergus, Thomas A; Kelley, Lance P; Griggs, Jackson O
Brief measures that are comparable across disparate groups are particularly likely to be useful in primary care settings. Prior research has supported a six-item short form of the Whiteley Index (WI), a commonly used measure of health anxiety, among English-speaking respondents. This study examined the measurement invariance of the WI-6 among Black ( n = 183), Latino ( n = 173), and White ( n = 177) respondents seeking treatment at a U.S. community health center. Results supported a bifactor model of the WI-6 among the composite sample ( N = 533), suggesting the presence of a general factor and two domain-specific factors. Results supported the incremental validity of one of the domain-specific factors in accounting for unique variance in somatic symptom severity scores beyond the general factor. Multiple-groups confirmatory factor analysis supported the configural, metric, ands scalar invariance of the bifactor WI-6 model across the three groups of respondents. Results provide support for the measurement invariance of the WI-6 among Black, Latino, and White respondents. The potential use of the WI-6 in primary care, and broader, settings is discussed.
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.
MAXimising Involvement in MUltiMorbidity (MAXIMUM) in primary care: protocol for an observation and interview study of patients, GPs and other care providers to identify ways of reducing patient safety failures.
Daker-White, Gavin; Hays, Rebecca; Esmail, Aneez; Minor, Brian; Barlow, Wendy; Brown, Benjamin; Blakeman, Thomas; Bower, Peter
Increasing numbers of older people are living with multiple long-term health conditions but global healthcare systems and clinical guidelines have traditionally focused on the management of single conditions. Having two or more long-term conditions, or 'multimorbidity', is associated with a range of adverse consequences and poor outcomes and could put patients at increased risk of safety failures. Traditionally, most research into patient safety failures has explored hospital or inpatient settings. Much less is known about patient safety failures in primary care. Our core aims are to understand the mechanisms by which multimorbidity leads to safety failures, to explore the different ways in which patients and services respond (or fail to respond), and to identify opportunities for intervention. We plan to undertake an applied ethnographic study of patients with multimorbidity. Patients' interactions and environments, relevant to their healthcare, will be studied through observations, diary methods and semistructured interviews. A framework, based on previous studies, will be used to organise the collection and analysis of field notes, observations and other qualitative data. This framework includes the domains: access breakdowns, communication breakdowns, continuity of care errors, relationship breakdowns and technical errors. Ethical approval was received from the National Health Service Research Ethics Committee for Wales. An individual case study approach is likely to be most fruitful for exploring the mechanisms by which multimorbidity leads to safety failures. A longitudinal and multiperspective approach will allow for the constant comparison of patient, carer and healthcare worker expectations and experiences related to the provision, integration and management of complex care. This data will be used to explore ways of engaging patients and carers more in their own care using shared decision-making, patient empowerment or other relevant models. Published by
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.
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.
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.
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.
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.
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.
Udedi, Michael; Swartz, Leslie; Stewart, Robert C; Kauye, Felix
There has been no study carried out to assess health service utilization by people with common mental disorder (CMD) in Malawi. The aim of the study was to evaluate health service utilization patterns of patients with CMD in primary health care (PHC) clinics. The study was conducted in two PHC clinics in one of the 28 districts in Malawi. Face-to-face interviews with the Self-Reporting Questionnaire (SRQ-20) were conducted in a sample of 323 PHC attendees aged 18 years and older who attended the PHC clinics for any reason. The prevalence of probable CMD in the sample was 20.1%. People with probable CMD had a higher mean number of health facility visits in the previous three months compared to those without probable CMD (1.6 vs 1.19, p = .02). The study reveals high utilization of health services for people with CMD in the PHC setting. There is a need for PHC workers to improve skills in diagnosing patients with CMD to make PHC services more effective by reducing re-attendance and improving patient outcomes. © The Author(s) 2013.
Overgaard Andersen, Ulla; Ibsen, Hans; Tobiassen, Minja
Many hypertensive patients are not treated to target and hence do not benefit fully from the blood pressure-related improvements in cardiovascular health. Hypertensive patients who had primarily been treated to a target goal in a nurse-led hypertension clinic were re-examined to evaluate whether their target goal blood pressure was maintained after their discharge from the hypertension clinic for further control in primary care, and to evaluate potential barriers to and factors acting against continuous hypertension control. The median observation time was 3.6 years (range 3 months to 7.9 years). Only 45.2% of the patients were well controlled at the time of re-examination. No patient-related factors (age, body mass index, gender, attitudes towards medication) predicted the outcome. Two factors were significant in the reduction in continuous hypertension control: the cooperation between the patient and health personnel and the shared commitment towards the target goal were discontinued; and many patients did not make control visits to the general practitioner's office. In conclusion, maintained strict control of hypertension requires both continued close collaboration between the patient and health personnel, with an emphasis on treatment goals, and systematic control visits.
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.
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...
Full Text Available 1 Abstract 1.1 Background Suicide is a leading cause of perinatal maternal deaths in industrialised countries but there has been little research to investigate prevalence or correlates of postpartum suicidality. The Edinburgh Postnatal Depression Scale is widely used in primary and maternity services to screen for perinatal depressive disorders, and includes a question on suicidal ideation (question 10. We aimed to investigate the prevalence, persistence and correlates of suicidal thoughts in postpartum women in the context of a randomised controlled trial of treatments for postnatal depression. 1.2 Methods Women in primary care were sent postal questionnaires at 6 weeks postpartum to screen for postnatal depression before recruitment into an RCT. The Edinburgh Postnatal Depression Scale (EPDS was used to screen for postnatal depression and in those with high levels of symptoms, a home visit with a standardised psychiatric interview was carried out using the Clinical Interview Schedule-Revised version (CIS-R. Other socio-demographic and clinical variables were measured, including functioning (SF12 and quality of the marital relationship (GRIMS. Women who entered the trial were followed up for 18 weeks. 1.3 Results 9% of 4,150 women who completed the EPDS question relating to suicidal ideation reported some suicidal ideation (including hardly ever; 4% reported that the thought of harming themselves had occurred to them sometimes or quite often. In women who entered the randomised trial and completed the EPDS question relating to suicidal ideation (n = 253, suicidal ideation was associated with younger age, higher parity and higher levels of depressive symptoms in the multivariate analysis. Endorsement of 'yes, quite often' to question 10 on the EPDS was associated with affirming at least two CIS-R items on suicidality. We found no association between suicidal ideation and SF-12 physical or mental health or the EPDS total score at 18 weeks. 1
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.
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
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)
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.
Randomized controlled trial of a primary care-based screening program to identify older women with prevalent osteoporotic vertebral fractures: Cohort for Skeletal Health in Bristol and Avon (COSHIBA).
Clark, Emma M; Gould, Virginia; Morrison, Leigh; Ades, A E; Dieppe, Paul; Tobias, Jon H
Approximately 12% of postmenopausal women have osteoporotic vertebral fractures (VFs); these are associated with excess morbidity and mortality and a high risk of future osteoporotic fractures. Despite this, less than one-third come to clinical attention, partly due to lack of clear clinical triggers for referral for spinal radiographs. The aim of this study was to investigate whether a novel primary care-based screening tool could be used to identify postmenopausal women with osteoporotic VFs and increase appropriate management of osteoporosis. A randomized controlled trial was undertaken in 15 general practices within the Bristol area of the UK. A total of 3200 women aged 65 to 80 years were enrolled, with no exclusion criteria. A simple screening tool was carried out by a nurse in primary care to identify women at high risk of osteoporotic VFs. All identified high-risk women were offered a diagnostic thoracolumbar radiograph. Radiographs were reported using standard National Health Service (NHS) reporting, with results sent back to each participant's general practitioner (GP). Participants in the control arm did not receive the screening tool or radiographs. The main outcome measure was self-reported prescription of medication for osteoporosis at 6 months with a random 5% subsample verified against electronic GP records. Secondary outcome was self-reported incidence of new fractures. Results showed that allocation to screening increased prescription of osteoporosis medications by 124% (odds ratio [OR] for prescription 2.24 at 6 months; 95% confidence interval [CI], 1.16 to 4.33). Allocation to screening also reduced fracture incidence at 12-month follow-up (OR for new fracture 0.60; 95% CI, 0.35-1.03; p = 0.063), although this did not reach statistical significance. This study supports the use of a simple screening tool administered in primary care to increase appropriate prescription of medications for osteoporosis in postmenopausal women in the UK. © 2012
Accuracy of the Audio Computer Assisted Self Interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ACASI ASSIST) for identifying unhealthy substance use and substance use disorders in primary care patients.
Kumar, Pritika C; Cleland, Charles M; Gourevitch, Marc N; Rotrosen, John; Strauss, Shiela; Russell, Linnea; McNeely, Jennifer
An Audio Computer-assisted Self Interview (ACASI) version of the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) could reduce barriers to substance use screening and assessment in primary care settings. This study evaluated the diagnostic accuracy of an ACASI ASSIST for identification of unhealthy substance use and substance use disorders (SUD). 399 adult patients were consecutively recruited from an urban safety-net primary care clinic. ACASI ASSIST scores for tobacco, alcohol, marijuana, and cocaine were compared against reference standard measures to assess the instrument's diagnostic accuracy for identifying unhealthy use and SUD, first using empirically-derived optimal cutoffs, and second using the currently recommended ASSIST cutoffs. For identifying any unhealthy use, at the empirically-derived cutoffs the ACASI ASSIST had 93.6% sensitivity and 85.8% specificity (AUC=0.90) for tobacco, 85.9% sensitivity and 60.3% specificity (AUC=0.73), for alcohol in men, 100% sensitivity and 62.4% specificity (AUC=0.81) for alcohol in women, 94.6% sensitivity and 81.6% specificity (AUC=0.88) for marijuana, and 86.1% sensitivity, 84.0% specificity (AUC=0.85) for cocaine. For SUD, sensitivity ranged from 79% (for alcohol in males), to 100% (for tobacco), and specificity was 83% or higher (AUCs ranged 0.83-0.91). For substances other than tobacco, empirically-derived cutoff scores were lower than the standard cutoffs, and resulted in higher sensitivity and lower specificity for identifying unhealthy substance use. The ACASI ASSIST is a valid measure of unhealthy use and SUD for substances that are commonly used by primary care patients, and could facilitate effective and efficient screening for substance use in medical settings. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
... 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...
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.
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.
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.
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
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.
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.
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 ...
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.
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
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.
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
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
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 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.
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...
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.
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 ...
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.
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.
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.
Shallcross, Laura J; Petersen, Irene; Rosenthal, Joe; Johnson, Anne M; Freemantle, Nick; Hayward, Andrew C
Using a primary care database, we identified a major increase in impetigo in the United Kingdom during 1995-2010. Despite a doubled rate of primary care consultations, this increase was not identified by routine surveillance. Primary care databases are a valuable and underused source of surveillance data on infectious diseases.
Petersen, Irene; Rosenthal, Joe; Johnson, Anne M.; Freemantle, Nick; Hayward, Andrew C.
Using a primary care database, we identified a major increase in impetigo in the United Kingdom during 1995–2010. Despite a doubled rate of primary care consultations, this increase was not identified by routine surveillance. Primary care databases are a valuable and underused source of surveillance data on infectious diseases. PMID:24047615
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
program was widespread even among physicians who are young, board-certified in family medicine, and salaried. Many physicians also reported that various problems had emerged to a great or very great extent: a heavier workload (65%, over-competitiveness (60%, excessive managerial pressure (48%, and distraction from other clinical issues (35%. In addition, there was some criticism of the quality of the measures themselves. Respondents also identified approaches to addressing these problems. Conclusions The findings provide perspective on the anecdotal reports of physician opposition to the monitoring program; they may well accurately reflect the views of the small number of physicians directly involved, but they do not reflect the views of primary care physicians as a whole, who are generally quite supportive of the program. At the same time, the study confirms the existence of several perceived problems. Some of these problems, such as excess managerial pressure, can probably best be addressed by the health plans themselves; while others, such as the need to refine the quality indicators, are probably best addressed at the national level. Cooperation between primary care physicians and health plan managers, which has been an essential component of the program's success thus far, can also play an important role in addressing the problems identified.
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 ...
on the patients and families for self-care and the leading to more effective counselling and better clinical decision-making responsibilities it .... about body image because of their weight. The responsibility of administering .... in the individual a negative effect on self- history of diabetes and were skipping meals as a esteem.
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.
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....
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.
those reported in Quatar and Kuwait and other. 30,34 developed countries. CONCLUSION. This study identified poor knowledge of cervical cancer and low practice of cervical screening among women of reproductive age. Finally, educational status and parity of respondents were identified as significant predictors that.
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
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
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.
Identifying strategies to maximise recruitment and retention of practices and patients in a multicentre randomised controlled trial of an intervention to optimise secondary prevention for coronary heart disease in primary care.
Leathem, Claire S
BACKGROUND: Recruitment and retention of patients and healthcare providers in randomised controlled trials (RCTs) is important in order to determine the effectiveness of interventions. However, failure to achieve recruitment targets is common and reasons why a particular recruitment strategy works for one study and not another remain unclear. We sought to describe a strategy used in a multicentre RCT in primary care, to report researchers\\' and participants\\' experiences of its implementation and to inform future strategies to maximise recruitment and retention. METHODS: In total 48 general practices and 903 patients were recruited from three different areas of Ireland to a RCT of an intervention designed to optimise secondary prevention of coronary heart disease. The recruitment process involved telephoning practices, posting information, visiting practices, identifying potential participants, posting invitations and obtaining consent. Retention involved patients attending reviews and responding to questionnaires and practices facilitating data collection. RESULTS: We achieved high retention rates for practices (100%) and for patients (85%) over an 18-month intervention period. Pilot work, knowledge of the setting, awareness of change in staff and organisation amongst participant sites, rapid responses to queries and acknowledgement of practitioners\\' contributions were identified as being important. Minor variations in protocol and research support helped to meet varied, complex and changing individual needs of practitioners and patients and encouraged retention in the trial. A collaborative relationship between researcher and practice staff which required time to develop was perceived as vital for both recruitment and retention. CONCLUSION: Recruiting and retaining the numbers of practices and patients estimated as required to provide findings with adequate power contributes to increased confidence in the validity and generalisability of RCT results. A
Identifying strategies to maximise recruitment and retention of practices and patients in a multicentre randomised controlled trial of an intervention to optimise secondary prevention for coronary heart disease in primary care.
Leathem, Claire S; Cupples, Margaret E; Byrne, Mary C; O'Malley, Mary; Houlihan, Ailish; Murphy, Andrew W; Smith, Susan M
Recruitment and retention of patients and healthcare providers in randomised controlled trials (RCTs) is important in order to determine the effectiveness of interventions. However, failure to achieve recruitment targets is common and reasons why a particular recruitment strategy works for one study and not another remain unclear. We sought to describe a strategy used in a multicentre RCT in primary care, to report researchers' and participants' experiences of its implementation and to inform future strategies to maximise recruitment and retention. In total 48 general practices and 903 patients were recruited from three different areas of Ireland to a RCT of an intervention designed to optimise secondary prevention of coronary heart disease. The recruitment process involved telephoning practices, posting information, visiting practices, identifying potential participants, posting invitations and obtaining consent. Retention involved patients attending reviews and responding to questionnaires and practices facilitating data collection. We achieved high retention rates for practices (100%) and for patients (85%) over an 18-month intervention period. Pilot work, knowledge of the setting, awareness of change in staff and organisation amongst participant sites, rapid responses to queries and acknowledgement of practitioners' contributions were identified as being important. Minor variations in protocol and research support helped to meet varied, complex and changing individual needs of practitioners and patients and encouraged retention in the trial. A collaborative relationship between researcher and practice staff which required time to develop was perceived as vital for both recruitment and retention. Recruiting and retaining the numbers of practices and patients estimated as required to provide findings with adequate power contributes to increased confidence in the validity and generalisability of RCT results. A continuous dynamic process of monitoring progress
Identifying strategies to maximise recruitment and retention of practices and patients in a multicentre randomised controlled trial of an intervention to optimise secondary prevention for coronary heart disease in primary care
Full Text Available Abstract Background Recruitment and retention of patients and healthcare providers in randomised controlled trials (RCTs is important in order to determine the effectiveness of interventions. However, failure to achieve recruitment targets is common and reasons why a particular recruitment strategy works for one study and not another remain unclear. We sought to describe a strategy used in a multicentre RCT in primary care, to report researchers' and participants' experiences of its implementation and to inform future strategies to maximise recruitment and retention. Methods In total 48 general practices and 903 patients were recruited from three different areas of Ireland to a RCT of an intervention designed to optimise secondary prevention of coronary heart disease. The recruitment process involved telephoning practices, posting information, visiting practices, identifying potential participants, posting invitations and obtaining consent. Retention involved patients attending reviews and responding to questionnaires and practices facilitating data collection. Results We achieved high retention rates for practices (100% and for patients (85% over an 18-month intervention period. Pilot work, knowledge of the setting, awareness of change in staff and organisation amongst participant sites, rapid responses to queries and acknowledgement of practitioners' contributions were identified as being important. Minor variations in protocol and research support helped to meet varied, complex and changing individual needs of practitioners and patients and encouraged retention in the trial. A collaborative relationship between researcher and practice staff which required time to develop was perceived as vital for both recruitment and retention. Conclusion Recruiting and retaining the numbers of practices and patients estimated as required to provide findings with adequate power contributes to increased confidence in the validity and generalisability of RCT
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.
Hantel, Andrew; Wroblewski, Kristen; Balachandran, Jay S.; Chow, Selina; DeBoer, Rebecca; Fleming, Gini F.; Hahn, Olwen M.; Kline, Justin; Liu, Hongtao; Patel, Bhakti K.; Verma, Anshu; Witt, Leah J.; Fukui, Mayumi; Kumar, Aditi; Howell, Michael D.; Polite, Blase N.
Purpose: Terminal oncology intensive care unit (ICU) hospitalizations are associated with high costs and inferior quality of care. This study identifies and characterizes potentially avoidable terminal admissions of oncology patients to ICUs. Methods: This was a retrospective case series of patients cared for in an academic medical center’s ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. An oncologist, intensivist, and hospitalist reviewed each patient’s electronic health record from 3 months preceding terminal hospitalization until death. The primary outcome was the proportion of terminal ICU hospitalizations identified as potentially avoidable by two or more reviewers. Univariate and multivariate analysis were performed to identify characteristics associated with avoidable terminal ICU hospitalizations. Results: Seventy-two patients met inclusion criteria. The majority had solid tumor malignancies (71%), poor performance status (51%), and multiple encounters with the health care system. Despite high-intensity health care utilization, only 25% had documented advance directives. During a 4-day median ICU length of stay, 81% were intubated and 39% had cardiopulmonary resuscitation. Forty-seven percent of these hospitalizations were identified as potentially avoidable. Avoidable hospitalizations were associated with factors including: worse performance status before admission (median 2 v 1; P = .01), worse Charlson comorbidity score (median 8.5 v 7.0, P = .04), reason for hospitalization (P = .006), and number of prior hospitalizations (median 2 v 1; P = .05). Conclusion: Given the high frequency of avoidable terminal ICU hospitalizations, health care leaders should develop strategies to prospectively identify patients at high risk and formulate interventions to improve end-of-life care. PMID:27601514
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.
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.
Simone Grativol Marchon
Full Text Available The aim of this study was to identify methodologies to evaluate incidents in primary health care, types of incidents, contributing factors, and solutions to make primary care safer. A systematic literature review was performed in the following databases: PubMed, Scopus, LILACS, SciELO, and Capes, from 2007 to 2012, in Portuguese, English, and Spanish. Thirty-three articles were selected: 26% on retrospective studies, 44% on prospective studies, including focus groups, questionnaires, and interviews, and 30% on cross-sectional studies. The most frequently used method was incident analysis from incident reporting systems (45%. The most frequent types of incidents in primary care were related to medication and diagnosis. The most relevant contributing factors were communication failures among member of the healthcare team. Research methods on patient safety in primary care are adequate and replicable, and they will likely be used more widely, thereby providing better knowledge on safety in this setting.
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.
Patients attending the sexually transmitted disease clinic of the Lagos State University Teaching Hospital,. Ikeja, Lagos were ... psychological disturbances and also work with mental health experts to provide psychological services for identified .... Another study from also facilitate change in risk behaviour.24 This. Pakistan ...
... 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...
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.
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.
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.
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.
Wholey, Douglas R; White, Katie M; Adair, Richard; Christianson, Jon B; Lee, Suhna; Elumba, Deborah
Improving the efficiency and effectiveness of primary care treatment of patients with chronic illness is an important goal in reforming the U.S. health care system. Reducing occupational conflicts and creating interdependent primary care teams is crucial for the effective functioning of new models being developed to reorganize chronic care. Occupational conflict, role interdependence, and resistance to change in a proof-of-concept pilot test of one such model that uses a new kind of employee in the primary care office, a "care guide," were analyzed. Care guides are lay individuals who help chronic disease patients and their providers achieve standard health goals. The aim of this study was to examine the development of occupational boundaries, interdependence of care guides and primary care team members, and acceptance by clinic employees of this new kind of health worker. A mixed methods, pilot study was conducted using qualitative analysis; clinic, provider, and patient surveys; administrative data; and multivariate analysis. Qualitative analysis examined the emergence of the care guide role. Administrative data and surveys were used to examine patterns of interdependence between care guides, physicians, team members, and clinic staff; obtain physician evaluations of the care guide role; and evaluate the effect of care guides on patient perceptions of care coordination and follow-up. Evaluation of implementation of the care guide model showed that (a) the care guide scope of practice was clearly defined; (b) interdependent relationships between care guides and providers were formed; (c) relational triads consisting of patient, care guide, and physician were created; (d) patients and providers were supported in managing chronic disease; and (e) resistance to this model among traditional employees was minimized. The feasibility of implementing a new care model for chronic disease management in the primary care setting, identifying factors associated with a positive
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.
Kriegel, Johannes; Rebhandl, Erwin; Hockl, Wolfgang; Stöbich, Anna-Maria
The primary health care in rural areas in Austria is currently determined by challenges such as ageing of the population, the shift towards chronic and age-related illnesses, the specialist medical and hospital-related education and training of physicians' as well growing widespread difficulty of staffing doctor's office. The objective is to realize a general practitioner centered and team-oriented primary health care (PHC) approach by establishing networked primary health care in rural areas of Austria. Using literature research, online survey, expert interviews and expert workshops, we identified different challenges in terms of primary health care in rural areas. Further, current resources and capacities of primary health care in rural areas were identified using the example of the district of Rohrbach. Twelve design dimensions and 51 relevant measurement indicators of a PHC network were delineated and described. Based on this, 12 design approaches of PHC concept for the GP-centered and team-oriented primary health care in rural areas have been developed.
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.
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.
Nash, Justin M; McKay, Kevin M; Vogel, Mark E; Masters, Kevin S
Psychologists are presented with unprecedented opportunities to integrate their work in primary care settings. Although some roles of psychologists in primary care overlap with those in traditional psychology practice settings, a number are distinct reflecting the uniqueness of the primary care culture. In this paper, we first describe the integrated primary care setting, with a focus on those settings that have components of patient centered medical home. We then describe functional roles and foundational characteristics of psychologists in integrated primary care. The description of functional roles emphasizes the diversity of roles performed. The foundational characteristics identified are those that we consider the 'primary care ethic,' or core characteristics of psychologists that serve as the basis for the various functional roles in integrated primary care. The 'primary care ethic' includes attitudes, values, knowledge, and abilities that are essential to the psychologist being a valued, effective, and productive primary care team member.
Drew, Peter; Jones, Brad; Norton, Douglas
Primary care networks (PCNs) are interdisciplinary programs in a geographical area that are designed to improve patient care, team collaboration and appropriate resource allocation. They are one of government's approaches to delivering quality healthcare with finite resources. The primary objective of this study was to explore the level of perceived team effectiveness in PCNs within three former health regions in Alberta. A descriptive, cross-sectional, exploratory, semi-structured questionnaire study design was employed. Respondents identified five themes for strategies to improve team effectiveness. Although many factors and strategies were identified, more work is needed to explore the study's findings.
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.
Chung, Christopher; Maisonneuve, Hubert; Pfarrwaller, Eva; Audétat, Marie-Claude; Birchmeier, Alain; Herzig, Lilli; Bischoff, Thomas; Sommer, Johanna; Haller, Dagmar M
Switzerland is facing an impending primary care workforce crisis since almost half of all primary care physicians are expected to retire in the next decade. Only a minority of medical students choose a primary care specialty, further deepening the workforce shortage. It is therefore essential to identify ways to promote the choice of a primary care career. The aim of the present study was to explore students' views about the undergraduate primary care teaching curriculum and different teaching formats, and to evaluate the possible impact of these views on students' perceptions of primary care. We surveyed fifth year medical students from the Medical Faculties in Geneva and Lausanne, Switzerland (n = 285) with a four sections electronic questionnaire. We carried out descriptive analyses presented as frequencies for categorical data, and means and/or medians for continuous data. The response rate was 43 %. Overall, primary care teaching had a positive impact on students' image of primary care. In Lausanne, primary care curricular components were rated more positively than in Geneva. Curricular components that were not part of the primary care teaching, but were nevertheless cited by some students, were frequently perceived as having a negative impact. The primary care curriculum at Lausanne and Geneva Universities positively influences students' perceptions of this discipline. However, there are shortcomings in both the structure and the content of both the primary care and hidden curriculum that may contribute to perpetuating a negative image of this specialization.
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.
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.
Evans, Lance; Trotter, David R M
Primary care is an endeavor marked by breadth, complexity, and more clinical uncertainty than all non-primary care specialties except psychiatry. This is significant, as uncertainty is associated with a variety of troublesome economic and clinical indicators. Researchers have identified the three types of cognitive resources needed to combat uncertainty (technical, personal, or conceptual), as well as the affective stress reactions physicians have when confronted with uncertainty. In this study, we explored the relationship between primary care physicians' stress reactions to uncertainty and the conceptual resource of epistemology. Using Likert-type measures of epistemology and stress reactions to uncertainty, we conducted a cross-sectional survey with 78 board-certified and resident physicians in primary care. A simple bivariate regression analysis was performed to identify the relationship between epistemology and stress reactions to uncertainty (Model 1), and a multivariate regression analysis was performed to test for the independent effect of epistemology on stress reactions to uncertainty while controlling for gender, specialty, and professional development status (Model 2). Physician epistemology and stress reactions to uncertainty were significantly related in both models. Among primary care physicians, a biopsychosocial epistemology is associated with less stress reactions to uncertainty, and a biomedical epistemology is associated with more stress reactions to uncertainty.
Valaitis, Ruta K; O'Mara, Linda; Wong, Sabrina T; MacDonald, Marjorie; Murray, Nancy; Martin-Misener, Ruth; Meagher-Stewart, Donna
AimThe aim of this paper is to examine Canadian key informants' perceptions of intrapersonal (within an individual) and interpersonal (among individuals) factors that influence successful primary care and public health collaboration. Primary health care systems can be strengthened by building stronger collaborations between primary care and public health. Although there is literature that explores interpersonal factors that can influence successful inter-organizational collaborations, a few of them have specifically explored primary care and public health collaboration. Furthermore, no papers were found that considered factors at the intrapersonal level. This paper aims to explore these gaps in a Canadian context. This interpretative descriptive study involved key informants (service providers, managers, directors, and policy makers) who participated in one h telephone interviews to explore their perceptions of influences on successful primary care and public health collaboration. Transcripts were analyzed using NVivo 9.FindingsA total of 74 participants [from the provinces of British Columbia (n=20); Ontario (n=19); Nova Scotia (n=21), and representatives from other provinces or national organizations (n=14)] participated. Five interpersonal factors were found that influenced public health and primary care collaborations including: (1) trusting and inclusive relationships; (2) shared values, beliefs and attitudes; (3) role clarity; (4) effective communication; and (5) decision processes. There were two influencing factors found at the intrapersonal level: (1) personal qualities, skills and knowledge; and (2) personal values, beliefs, and attitudes. A few differences were found across the three core provinces involved. There were several complex interactions identified among all inter and intra personal influencing factors: One key factor - effective communication - interacted with all of them. Results support and extend our understanding of what influences
Cerimele, Joseph M.; Halperin, Abigail C.; Spigner, Clarence; Ratzliff, Anna; Katon, Wayne J.
Objective To understand collaborative care psychiatric consultants’ views and practices on making the diagnosis of and recommending treatment for bipolar disorder in primary care using collaborative care. Method We conducted a focus group at the University of Washington in December 2013 with nine psychiatric consultants working in primary care-based collaborative care in Washington State. A grounded theory approach with open coding and the constant comparative method revealed categories where emergent themes were saturated and validated through member checking, and a conceptual model was developed. Results Three major themes emerged from the data including the importance of working as a collaborative care team, the strengths of collaborative care for treating bipolar disorder, and the need for psychiatric consultants to adapt specialty psychiatric clinical skills to the primary care setting. Other discussion topics included gathering clinical data from multiple sources over time, balancing risks and benefits of treating patients indirectly, tracking patient care outcomes with a registry, and effective care. Conclusion Experienced psychiatric consultants working in collaborative care teams provided their perceptions regarding treating patients with bipolar illness including identifying ways to adapt specialty psychiatric skills, developing techniques for providing team-based care, and perceiving the care delivered through collaborative care as high quality. PMID:25174762
Cerimele, Joseph M; Halperin, Abigail C; Spigner, Clarence; Ratzliff, Anna; Katon, Wayne J
To understand collaborative care psychiatric consultants' views and practices on making the diagnosis of and recommending treatment for bipolar disorder in primary care using collaborative care. We conducted a focus group at the University of Washington in December 2013 with nine psychiatric consultants working in primary-care-based collaborative care in Washington State. A grounded theory approach with open coding and the constant comparative method revealed categories where emergent themes were saturated and validated through member checking, and a conceptual model was developed. Three major themes emerged from the data including the importance of working as a collaborative care team, the strengths of collaborative care for treating bipolar disorder and the need for psychiatric consultants to adapt specialty psychiatric clinical skills to the primary care setting. Other discussion topics included gathering clinical data from multiple sources over time, balancing risks and benefits of treating patients indirectly, tracking patient care outcomes with a registry and effective care. Experienced psychiatric consultants working in collaborative care teams provided their perceptions regarding treating patients with bipolar illness including identifying ways to adapt specialty psychiatric skills, developing techniques for providing team-based care and perceiving the care delivered through collaborative care as high quality. Copyright © 2014 Elsevier Inc. All rights reserved.
Antônio Thomaz Gonzaga da Matta-Machado; Alaneir de Fátima dos Santos; Daisy Maria Xavier de Abreu; Alzira Oliveira Jorge; Clarice Magalhães Rodrigues dos Reis; Angela Maria de Lourdes Dayrell de Lima; Lucas Henrique Lobato de Araújo
Objective. To provide an overview of the distribution of institutional support in primary care in Brazil and to identify associations between the activities of institutional support and the outcome of the certification of the National Programme for Improving Access and Quality in Primary Health Care (PMAQ). Materials and methods. A cross-sectional study was conducted through interviews with 16 960 profes- sionals in Brazil in 2012. To examine the relationship between the received support and ...
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
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.
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
Benamore, R.E.; Wright, D.; Britton, I.
AIM: Primary care access to CT head examinations could enable common neurological conditions to be managed within primary care. Outcome data from the first 8 years of a local service were used to identify effective referral criteria. METHODS: Primary care head CT results from 1 March 1995 to 31 October 2003 were categorized as normal, incidental or significant findings. Normal reports were cross-referenced for referral to secondary care. Case notes with incidental or significant CT findings were reviewed for secondary care attendance and outcome. RESULTS: Records of 1403/1645 CT head examinations (85%) were available for review. Of these 1403, 951 (67.8%) returned normal findings, 317 (22.6%) incidental findings and 135 (9.6%) significant findings. The commonest indication for referral was investigation of headaches (46.6%). Of the total 533 patients under 50 years of age, 13 (2.4%) yielded significant findings and all 13 showed other features in addition to headache. Of 314 cases presenting with focal neurology, 83 (26.4%) showed significant findings. 314 patients were referred from primary to secondary care. 189 had normal scans and 74 had findings described as incidental. 60% of secondary care referrals were for normal CT scans. In patients with focal neurology, 90 of 314 were referred, allowing 71% to be managed in primary care. Yield was also 0% for headaches, dizziness, visual disturbance or nausea and vomiting. CONCLUSION: Primary care access to CT brain examinations is effective for patients with focal neurology, neurological symptoms or a known malignancy, but not for patients aged less than 50 years, or with uncomplicated headaches, dizziness or diplopia
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
Abcaya, Julien; Ștefan, Diana-Elena; Calvet-Montredon, Céline; Gentile, Stéphanie
Background: Homeless people have poorer health status than the general population. They need complex care management, because of associated medical troubles (somatic and psychiatric) and social difficulties. We aimed to describe the main characteristics of the primary care programs that take care of homeless people, and to identify which could be most relevant. Methods: We performed a literature review that included articles which described and evaluated primary care programs for homeless people. Results: Most of the programs presented a team-based approach, multidisciplinary and/or integrated care. They often proposed co-located services between somatic health services, mental health services and social support services. They also tried to answer to the specific needs of homeless people. Some characteristics of these programs were associated with significant positive outcomes: tailored primary care organizations, clinic orientation, multidisciplinary team-based models which included primary care physicians and clinic nurses, integration of social support, and engagement in the community’s health. Conclusions: Primary health care programs that aimed at taking care of the homeless people should emphasize a multidisciplinary approach and should consider an integrated (mental, somatic and social) care model. PMID:29439403
Jego, Maeva; Abcaya, Julien; Ștefan, Diana-Elena; Calvet-Montredon, Céline; Gentile, Stéphanie
Homeless people have poorer health status than the general population. They need complex care management, because of associated medical troubles (somatic and psychiatric) and social difficulties. We aimed to describe the main characteristics of the primary care programs that take care of homeless people, and to identify which could be most relevant. We performed a literature review that included articles which described and evaluated primary care programs for homeless people. Most of the programs presented a team-based approach, multidisciplinary and/or integrated care. They often proposed co-located services between somatic health services, mental health services and social support services. They also tried to answer to the specific needs of homeless people. Some characteristics of these programs were associated with significant positive outcomes: tailored primary care organizations, clinic orientation, multidisciplinary team-based models which included primary care physicians and clinic nurses, integration of social support, and engagement in the community's health. Primary health care programs that aimed at taking care of the homeless people should emphasize a multidisciplinary approach and should consider an integrated (mental, somatic and social) care model.
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...
The aim of this dissertation study was to identify and describe the use of electronic health records (EHRs) for information sharing between patients and clinicians in primary-care encounters and to understand work system factors influencing information sharing. Ultimately, this will promote better design of EHR technologies and effective training…
Nagham N. Alsafy
Jun 12, 2011 ... KEYWORDS. Domestic violence;. Primary care nurses;. Knowledge. Abstract Introduction: Domestic violence (DV) against women has been identified as a serious ... mate partner.1 DV, also known as intimate partner violence. (IPV), is ..... mate partner violence (IPV) from India, Bangladesh, Thailand,.
Introduction: Domestic violence (DV) against women has been identified as a serious public health problem. Primary care nurses usually play an important role in managing battered women. They must be equipped with the necessary knowledge, training and experience. Objective: The aim of this work was to study the ...
The aim of the studies described in this thesis was to analyze nutrition guidance practices of primary-care physicians (PCPs), their nutritional attitudes and knowledge and their interest in the role of nutrition in health and disease. A second objective was to identify the determinants
Fordwood, Samantha R.; Asarnow, Joan R.; Huizar, Diana P.; Reise, Steven P.
Although depression is strongly associated with suicide attempts and suicide deaths, most depressed youth do not make an attempt, indicating the need to identify additional risk factors. We examined suicide attempts among 451 depressed primary care patients, 13 to 21 years of age. In bivariate analyses, youth classified as suicide attempters…
Background: Higher maternal and neonatal deaths are common in low‑ and middle‑income countries; due to less access to skilled help. Adequate knowledge and skills on maternal and newborn care (MNC) of community health workers can improve maternal and newborn health. Aims: To identify the knowledge of primary ...
Background: Adequate diagnosis of Malaria is achieved by detection and identification of malaria parasites through examination of Giemsa's stained blood films by competent personnel. Objective: To identify the competency of laboratory personnel of the clinical laboratories attached to primary health care centres at ...
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.
Dennis, Sarah M; Zwar, Nicholas; Griffiths, Rhonda; Roland, Martin; Hasan, Iqbal; Powell Davies, Gawaine; Harris, Mark
To review the effectiveness of chronic disease management interventions for physical health problems in the primary care setting, and to identify policy options for implementing successful interventions in Australian primary care. We conducted a systematic review with qualitative data synthesis, using the Chronic Care Model as a framework for analysis between January 1990 and February 2006. Interventions were classified according to which elements were addressed: community resources, health care organisation, self-management support, delivery system design, decision support and/or clinical information systems. Our major findings were discussed with policymakers and key stakeholders in relation to current and emerging health policy in Australia. The interventions most likely to be effective in the context of Australian primary care were engaging primary care in self-management support through education and training for general practitioners and practice nurses, and including self-management support in care plans linked to multidisciplinary team support. The current Practice Incentives Payment and Service Incentives Payment programs could be improved and simplified to encourage guideline-based chronic disease management, integrating incentives so that individual patients are not managed as if they had a series of separate chronic diseases. The use of chronic disease registers should be extended across a range of chronic illnesses and used to facilitate audit for quality improvement. Training should focus on clear roles and responsibilities of the team members. The Chronic Care Model provides a useful framework for understanding the impact of chronic disease management interventions and highlights the gaps in evidence. Consultation with stakeholders and policymakers is valuable in shaping policy options to support the implementation of the National Chronic Disease Strategy in primary care.
Draper, Kevin; Gourevitch, Rebecca; Cross, Dori A.; Scholle, Sarah Hudson
Objective Consensus that enhanced teamwork is necessary for efficient and effective primary care delivery is growing. We sought to identify how electronic health records (EHRs) facilitate and pose challenges to primary care teams as well as how practices are overcoming these challenges. Methods Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size. Results EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time. Discussion Practices developed solutions for some of the challenges they faced when attempting to use EHRs to support teamwork but wanted more permanent vendor and policy solutions for other challenges. Conclusions EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time. PMID:25627278
O'Malley, Ann S; Draper, Kevin; Gourevitch, Rebecca; Cross, Dori A; Scholle, Sarah Hudson
Consensus that enhanced teamwork is necessary for efficient and effective primary care delivery is growing. We sought to identify how electronic health records (EHRs) facilitate and pose challenges to primary care teams as well as how practices are overcoming these challenges. Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size. EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time. Practices developed solutions for some of the challenges they faced when attempting to use EHRs to support teamwork but wanted more permanent vendor and policy solutions for other challenges. EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association.
Cláudia Rayanna Silva Mendes
Full Text Available Objective: to evaluate the practice of self-care performed by patients with systemic arterial hypertension in primary health care. Methods: this is a descriptive and cross-sectional study, conducted with 92 individuals with arterial hypertension in a primary care unit. The data collection occurred through script and data analyzed using descriptive statistics (frequency, mean and standard deviation and through the understanding of the adaption between capacity and self-care demand. Results: it was identified as a practice of self-care: adequate water intake, salt intake and restricted coffee, satisfactory sleep period, abstinence from smoking and alcoholism, continuing pharmacological treatment and attending medical appointments. As the demands: inadequate feeding, sedentary lifestyle, had no leisure activities, self-reported stress, and limited knowledge. Conclusion: although patients performed treatment a few years ago, still showed up self-care deficits, highlighting the need for nurses to advise and sensitize about the importance of self-care practice.
Bailey Kerry A
Full Text Available Abstract Background Antiretroviral treatment services delivered in hospital settings in Africa increasingly lack capacity to meet demand and are difficult to access by patients. We evaluate the effectiveness of nurse led primary care based antiretroviral treatment by comparison with usual hospital care in a typical rural sub Saharan African setting. Methods We undertook a prospective, controlled evaluation of planned service change in Lubombo, Swaziland. Clinically stable adults with a CD4 count > 100 and on antiretroviral treatment for at least four weeks at the district hospital were assigned to either nurse led primary care based antiretroviral treatment care or usual hospital care. Assignment depended on the location of the nearest primary care clinic. The main outcome measures were clinic attendance and patient experience. Results Those receiving primary care based treatment were less likely to miss an appointment compared with those continuing to receive hospital care (RR 0·37, p p = 0·001. Those receiving primary care based, nurse led care were more likely to be satisfied in the ability of staff to manage their condition (RR 1·23, p = 0·003. There was no significant difference in loss to follow-up or other health related outcomes in modified intention to treat analysis. Multilevel, multivariable regression identified little inter-cluster variation. Conclusions Clinic attendance and patient experience are better with nurse led primary care based antiretroviral treatment care than with hospital care; health related outcomes appear equally good. This evidence supports efforts of the WHO to scale-up universal access to antiretroviral treatment in sub Saharan Africa.
Creswell, John W; Fetters, Michael D; Ivankova, Nataliya V
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. We first identified criteria from the social and behavioral sciences to analyze mixed methods studies in primary care research. We then used the criteria to evaluate 5 mixed methods investigations published in primary care research journals. Of the 5 studies analyzed, 3 included a rationale for mixing based on the need to develop a quantitative instrument from qualitative data or to converge information to best understand the research topic. Quantitative data collection involved structured interviews, observational checklists, and chart audits that were analyzed using descriptive and inferential statistical procedures. Qualitative data consisted of semistructured interviews and field observations that were analyzed using coding to develop themes and categories. The studies showed diverse forms of priority: equal priority, qualitative priority, and quantitative priority. Data collection involved quantitative and qualitative data gathered both concurrently and sequentially. The integration of the quantitative and qualitative data in these studies occurred between data analysis from one phase and data collection from a subsequent phase, while analyzing the data, and when reporting the results. We recommend instrument-building, triangulation, and data transformation models for mixed methods designs as useful frameworks to add rigor to investigations in primary care. We also discuss the limitations of our study and the need for future research.
Lelli, Vanessa R; Hickman, Ronald L; Savrin, Carol L; Peterson, Rachel A
To examine if differences exist in the levels of autonomy and job satisfaction among primary care nurse practitioners (NPs) employed in retail clinics versus traditional primary care settings. Data were collected from 310 primary care NPs who attended the American Association of NP's 28th Annual Conference in June 2013. Participants completed a demographic form, the Misener NP Job Satisfaction Scale, and the Dempster Practice Behavior Scale. Overall, there were no differences in job satisfaction or autonomy among NPs by practice setting. Retail NPs felt less valued and were less satisfied with social interaction, but more satisfied with benefits compared to NPs in traditional settings. NPs working in retail clinics were less likely to have intentions to leave current position compared to NPs in traditional practice settings. The results of this study enhance our current understanding of the linkages between levels of autonomy, job satisfaction, and practice setting among primary care NPs. The findings of this descriptive study offer valuable insights for stakeholders devoted to the development of the primary care workforce and identify modifiable factors that may influence retention and turnover rates among NPs. ©2015 American Association of Nurse Practitioners.
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.
Kelly, Martina; Bennett, Deirdre; O'Flynn, Siun; Foley, Tony
Teamwork and patient centredness are frequently articulated concepts in medical education, but are not always explicit in the curriculum. In Ireland, recent government policy emphasises the importance of a primary care team approach to health care. We report on an appraisal of a newly introduced community-based student attachment, which focused on teamwork. To review students' experience of teamwork following a community clinical placement by examining student assignments: essays, poetry, music and art. Year-2 graduate-entry students (n = 45) spent 2 weeks with a primary care team. Attachments comprised placements with members of the primary care team, emphasising team dynamics, at the end of which students submitted a representative piece of work, which captured their learning. Essays (n = 22) were analysed using a thematic content analysis. Artwork consisted of painting, collage, photography, poetry and original music (n = 23). These were analysed using Gardner's entry points. Three core themes emerged in both written and visual work: patient centredness; communication; and an improved appreciation of the skills of other health care professionals. Students identified optimal team communication occurring when patient outcomes were prioritised. Metaphors relating to puzzles, hands and inter-connectedness feature strongly. The poems and artwork had a high impact when they were presented to tutors. Primary care team placements focus student attention on teamwork and patient centredness. Student artwork shows potential as a tool to evaluate student learning in medical education. © Blackwell Publishing Ltd 2013.
Halcomb, Elizabeth; Stephens, Moira; Bryce, Julianne; Foley, Elizabeth; Ashley, Christine
This paper reports an integrative review of the literature on nursing competency standards for nurses working in primary health care and, in particular, general practice. Internationally, there is growing emphasis on building a strong primary health care nursing workforce to meet the challenges of rising chronic and complex disease. However, there has been limited emphasis on examining the nursing workforce in this setting. Integrative review. A comprehensive search of relevant electronic databases using keywords (e.g. 'competencies', 'competen*' and 'primary health care', 'general practice' and 'nurs*') was combined with searching of the Internet using the Google scholar search engine. Experts were approached to identify relevant grey literature. Key websites were also searched and the reference lists of retrieved sources were followed up. The search focussed on English language literature published since 2000. Limited published literature reports on competency standards for nurses working in general practice and primary health care. Of the literature that is available, there are differences in the reporting of how the competency standards were developed. A number of common themes were identified across the included competency standards, including clinical practice, communication, professionalism and health promotion. Many competency standards also included teamwork, education, research/evaluation, information technology and the primary health care environment. Given the potential value of competency standards, further work is required to develop and test robust standards that can communicate the skills and knowledge required of nurses working in primary health care settings to policy makers, employers, other health professionals and consumers. Competency standards are important tools for communicating the role of nurses to consumers and other health professionals, as well as defining this role for employers, policy makers and educators. Understanding the content
Salvadó-Hernández, Cristina; Cosculluela-Torres, Pilar; Blanes-Monllor, Carmen; Parellada-Esquius, Neus; Méndez-Galeano, Carmen; Maroto-Villanova, Neus; García-Cerdán, Rosa Maria; Núñez-Manrique, M Pilar; Barrio-Ruiz, Carmen; Salvador-González, Betlem
To determine the attitudes, knowledge, and self-care practices in patients with heart failure (HF) in Primary Care, as well as to identify factors associated with better self-care. Cross-sectional and multicentre study. Primary Care. Subjects over 18 years old with HF diagnosis, attended in 10 Primary Health Care Centres in the Metropolitan Area of Barcelona. Self-care was measured using the European Heart Failure Self-Care Behaviour Scale. Sociodemographic and clinical characteristics, tests on attitudes (Self-efficacy Managing Chronic Disease Scale), knowledge (Patient Knowledge Questionnaire), level of autonomy (Barthel), and anxiety and depression screening (Goldberg Test), were also gathered in an interview. A multivariate mixed model stratified by centre was used to analyse the adjusted association of covariates with self-care. A total of 295 subjects (77.6%) agreed to participate, with a mean age of 75.6 years (SD: 11), 56.6% women, and 62% with no primary education. The mean self-care score was 28.65 (SD: 8.22), with 25% of patients scoring lower than 21 points. In the final stratified multivariate model (n=282; R 2 conditional=0.3382), better self-care was associated with higher knowledge (coefficient, 95% confidence interval: -1.37; -1.85 to -0.90), and coronary heart disease diagnosis (-2.41; -4.36: -0.46). Self-care was moderate. The correlation of better self-care with higher knowledge highlights the opportunity to implement strategies to improve self-care, which should consider the characteristics of heart failure patients attended in Primary Care. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.
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.
Rubinstein, Ellen B; Miller, William L; Hudson, Shawna V; Howard, Jenna; O'Malley, Denalee; Tsui, Jennifer; Lee, Heather Sophia; Bator, Alicja; Crabtree, Benjamin F
Despite a decade of effort by national stakeholders to bring cancer survivorship to the forefront of primary care, there is little evidence to suggest that primary care has begun to integrate comprehensive services to manage the care of long-term cancer survivors. To explain why primary care has not begun to integrate comprehensive cancer survivorship services. Comparative case study of 12 advanced primary care practices in the United States recruited from March 2015 to February 2017. Practices were selected from a national registry of 151 workforce innovators compiled for the Robert Wood Johnson Foundation. Practices were recruited to include diversity in policy context and organizational structure. Researchers conducted 10 to 12 days of ethnographic data collection in each practice, including interviews with practice personnel and patient pathways with cancer survivors. Fieldnotes, transcripts, and practice documents were analyzed within and across cases to identify salient themes. Description of cancer survivorship care delivery in advanced patient-centered medical homes, including identification of barriers and promotional factors related to that care. The 12 practices came from multiple states and policy contexts and had a mix of clinicians trained in family or internal medicine. All but 3 were recognized as National Committee on Quality Assurance level 3 patient-centered medical homes. None of the practices provided any type of comprehensive cancer survivorship services. Three interdependent explanatory factors emerged: the absence of a recognized, distinct clinical category of survivorship in primary care; a lack of actionable information to treat this patient population; and current information systems unable to support survivorship care. To increase the potential for primary care transformation efforts to integrate survivorship services into routine care, survivorship must become a recognized clinical category with actionable care plans supported by a
Bentham, Wayne D; Ratzliff, Anna; Harrison, David; Chan, Ya-Fen; Vannoy, Steven; Unützer, Jürgen
Primary care providers participating in a statewide implementation of an integrated mental health care program for "safety-net" patients in primary care clinics were surveyed to elicit their experiences and level of satisfaction. Quantitative analyses were performed to identify respondent characteristics and satisfaction with the program. Qualitative analyses were done to identify common themes in response to the question "How could psychiatric consultation [in the program] be improved?" Primary care providers were generally satisfied with the integrated mental health care program and raised several concerns that suggest important principles for successful future implementations of these types of programs.
Katerndahl, David A.; Bell, Iris R.; Palmer, Raymond F.; Miller, Claudia S.
intolerances in chemical intolerance, primary care clinicians could use the QEESI to identify patients for appropriate triage to comprehensive nonpharmacologic care. PMID:22778124
Beaulieu, Marie-Dominique; Haggerty, Jeannie; Tousignant, Pierre; Barnsley, Janet; Hogg, William; Geneau, Robert; Hudon, Éveline; Duplain, Réjean; Denis, Jean-Louis; Bonin, Lucie; Del Grande, Claudio; Dragieva, Natalyia
No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care. We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling. The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0-35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8-14.4), presence of allied health professionals (15.3; 95% CI 5.4-25.2) and/or specialist physicians (19.6; 95% CI 8.3-30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0-12.4) and average organizational access to the practice (4.9; 95% CI 2.6-7.2). The number of physicians (1.2; 95% CI 0.6-1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1-2.5) were modestly associated with high-quality care. We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.
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.
Bindels, J.; Cox, K.; De La Haye, J.; Mevissen, G.; Heijing, S.; van Schayck, O.C.P.; Widdershoven, G.; Abma, T.A.
Aims and objectives: The objective of this study was to evaluate whether care provided in the care programmes matched the needs of older people. Background: Care programmes were implemented in primary-care settings in the Netherlands to identify frail older people and to prevent further
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.
Bourgeois, Nicole; Brauer, Paula; Simpson, Janis Randall; Kim, Susie; Haines, Jess
Preventing childhood obesity is a public health priority, and primary care is an important setting for early intervention. Authors of a recent national guideline have identified a need for effective primary care interventions for obesity prevention and that parent perspectives on interventions are notably absent from the literature. Our objective was to determine the perspectives of primary care clinicians and parents of children 2-5 years of age on the implementation of an obesity prevention intervention within team-based primary care to inform intervention implementation. We conducted focus groups with interprofessional primary care clinicians (n = 40) and interviews with parents (n = 26). Participants were asked about facilitators and barriers to, and recommendations for implementing a prevention program in primary care. Data were recorded and transcribed, and we used directed content analysis to identify major themes. Barriers existed to addressing obesity-related behaviours in this age group and included a gap in well-child primary care between ages 18 months and 4-5 years, lack of time and sensitivity of the topic. Trust and existing relationships with primary care clinicians were facilitators to program implementation. Offering separate programs for parents and children, and addressing both general parenting topics and obesity-related behaviours were identified as desirable. Despite barriers to addressing obesity-related behaviours within well-child primary care, both clinicians and parents expressed interest in interventions in primary care settings. Next steps should include pilot studies to identify feasible strategies for intervention implementation.
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
Parker, Dianne; Wensing, Michel; Esmail, Aneez; Valderas, Jose M
ABSTRACT Background: There is little guidance available to healthcare practitioners about what tools they might use to assess the patient safety culture. Objective: To identify useful tools for assessing patient safety culture in primary care organizations in Europe; to identify those aspects of performance that should be assessed when investigating the relationship between safety culture and performance in primary care. Methods: Two consensus-based studies were carried out, in which subject matter experts and primary healthcare professionals from several EU states rated (a) the applicability to their healthcare system of several existing safety culture assessment tools and (b) the appropriateness and usefulness of a range of potential indicators of a positive patient safety culture to primary care settings. The safety culture tools were field-tested in four countries to ascertain any challenges and issues arising when used in primary care. Results: The two existing tools that received the most favourable ratings were the Manchester patient safety framework (MaPsAF primary care version) and the Agency for healthcare research and quality survey (medical office version). Several potential safety culture process indicators were identified. The one that emerged as offering the best combination of appropriateness and usefulness related to the collection of data on adverse patient events. Conclusion: Two tools, one quantitative and one qualitative, were identified as applicable and useful in assessing patient safety culture in primary care settings in Europe. Safety culture indicators in primary care should focus on the processes rather than the outcomes of care. PMID:26339832
Menear, Matthew; Gilbert, Michel; Fleury, Marie-Josée
Objective The objectives of this review were to identify and compare major international initiatives aiming to integrate mental health services in primary care and to summarize the lessons learned for similar integration efforts in the province of Quebec, Canada.Methods We conducted a narrative review of the literature guided by a conceptual framework drawn from the literature on integrated care. We identified relevant initiatives to support primary mental health care integration through Pubmed searches and through previous systematic reviews on this topic. We then selected those initiatives that provided sufficient details on their key characteristics, outcomes, and implementation issues (e.g. barriers, facilitators). We focused our analysis on large-scale initiatives as these offered the most potential for impacts on population mental health. This process resulted in the selection of 20 initiatives that were described in 153 articles and reports. Our synthesis was guided by our conceptual framework, which distinguishes between five types of integration, namely clinical, professional, organizational, systemic and functional integration.Results Of the 20 primary mental health care integration initiatives, 3 targeted youth, 14 targeted adults or multiple age groups, and 3 were targeted towards seniors. Most initiatives aimed to implement collaborative care models for common mental disorders in primary care. Other initiatives focused on co-locating mental health professionals in primary care, supporting the emergence of a diversity of integration projects led by community-based primary care practices, or the merger of primary care and mental health organizations. Most initiatives were based on clinical, professional and functional integration strategies. Across initiatives, a range of positive outcomes were reported, notably to the accessibility and quality of services, the satisfaction of patients and providers, the costs of services, and impacts on patients' health
Ellison, S; Lamb, J; Haines, A; O'Dell, S; Thomas, G; Sethi, S; Ratcliffe, J; Chisholm, S; Vaughan, J; Mahadevan, V S
Surgical and other advances in the treatment and care of congenital heart disease have resulted in a significant increase in the number of adults with congenital heart disease (ACHD), many of whom have no regular cardiology follow-up. Optimised care for ACHD patients requires continuity of specialist and shared care and education of practitioners and patients. The challenges for managing ACHD were identified by a Health Needs Assessment in the North West and are addressed within the UK Department of Health's ACHD Commissioning Guide. An ACHD model of care was recommended in the North West of England and developed by the three North West Cardiac & Stroke Networks. Within this, a Task Group focused on the role of primary care in the identification and continuing care of ACHD patients. A feasibility study demonstrated that existing diagnostic Read Codes can identify ACHD patients on general practice registers. An ACHD Toolkit was developed to provide algorithms to guide the appropriate management of ACHD patients through primary, secondary and/or specialist ACHD care and to improve education/knowledge amongst primary care staff about ACHD and its wider implications. Early findings during the development of this Toolkit illustrate a wide disparity of provision between current and optimal management strategies. Patients lost to follow-up have already been identified and their management modified. By focusing on identifying ACHD patients in primary care and organising/delivering ACHD services, the ACHD Toolkit could help to improve quality, timeliness of care, patient experience and wellbeing. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
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.
N Ann Scott
Full Text Available OBJECTIVE: To ascertain knowledge gaps in the diagnosis and treatment of acute and chronic low back pain (LBP in the primary care setting to prepare a scoping survey for identifying knowledge gaps in LBP management among Alberta’s primary care practitioners, and to identify potential barriers to implementing a multidisciplinary LBP guideline.
Yedidia, Michael J
Patients who heavily utilize hospitals and emergency departments frequently have complex needs requiring services spanning medical, behavioral, and social service sectors. This study identifies essential competencies for caring for high-needs patients and highlights their importance to primary care delivery. Transcripts of in-depth interviews with 30 clinical and administrative staff at 23 complex care programs across the United States were analyzed using standard qualitative techniques. Selected programs had several years of experience in serving patients with multiple chronic conditions, serious mental illness, substance use disorders, severe poverty, and homelessness. These programs exemplified diverse models (assertive community treatment, housing first, behavioral health, high utilizer), and all of them shared the common element of integrating primary care into their services. Competencies, including those known and taught in other fields, have distinctive application to informing delivery of high quality primary care to populations with complex needs, including: motivational interviewing for establishing patients' priorities and helping them improve their health on their own terms; trauma-informed care for modifying primary care procedures to mitigate the ill-effects of prior trauma prevalent in this population; and harm reduction for altering medical regimens to accommodate constraints on what patients are able or willing to do. Other capabilities, cultivated by these programs, include empathizing with patients, promoted by exposure to simulations of patient experiences (e.g., hearing voices); as well as withholding judgment and counteracting patient passivity to foster open discussion of treatment plans. Absence of deliberate attention to equipping providers with specific competencies for caring for high-needs patients may contribute to lack of patient engagement and sub-optimal outcomes, ultimately undermining the success of programs serving these
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.
Cavero, Victoria; Diez-Canseco, Francisco; Toyama, Mauricio; Flórez Salcedo, Gustavo; Ipince, Alessandra; Araya, Ricardo; Miranda, J Jaime
Background: This study aimed to understand the offer of mental health care at the primary care level, collecting the views of psychologists, primary health care providers (PHCPs), and patients, with a focus on health services in which patients attend regularly and who present a higher prevalence of mental disorders. Methods: A qualitative study was conducted in antenatal care, tuberculosis, HIV/AIDS, and chronic diseases services from six primary health care centers. Semi-structured interviews were conducted with psychologists, PHCPs, and patients working in or attending the selected facilities. Results: A total of 4 psychologists, 22 PHCPs, and 37 patients were interviewed. A high perceived need for mental health care was noted. PHCPs acknowledged the emotional impact physical health conditions have on their patients and mentioned that referral to psychologists was reserved only for serious problems. Their approach to emotional problems was providing emotional support (includes listening, talk about their patients' feelings, provide advice). PHCPs identified system-level barriers about the specialized mental health care, including a shortage of psychologists and an overwhelming demand, which results in brief consultations and lack in continuity of care. Psychologists focus their work on individual consultations; however, consultations were brief, did not follow a standardized model of care, and most patients attend only once. Psychologists also mentioned the lack of collaborative work among other healthcare providers. Despite these limitations, interviewed patients declared that they were willing to seek specialized care if advised and considered the psychologist's care provided as helpful; however, they recognized the stigmatization related to seeking mental health care. Conclusions: There is a perceived need of mental health care for primary care patients. To attend these needs, PHCPs provide emotional support and refer to psychology the most severe cases
Ab Rahman, Norazida; Sivasampu, Sheamini; Mohamad Noh, Kamaliah; Khoo, Ee Ming
The world population has become more globalised with increasing number of people residing in another country for work or other reasons. Little is known about the health profiles of foreign population in Malaysia. The aim of this study was to provide a detailed description of the health problems presented by foreigners attending primary care clinics in Malaysia. Data were derived from the 2012 National Medical Care Survey (NMCS), a cross sectional survey of primary care encounters from public and private primary care clinics sampled from five regions in Malaysia. Patients with foreign nationality were identified and analysed for demographic profiles, reasons for encounter (RFEs), diagnosis, and provision of care. Foreigners accounted for 7.7 % (10,830) of all patient encounters from NMCS. Most encounters were from private clinics (90.2 %). Median age was 28 years (IQR: 24.0, 34.8) and 69.9 % were male. Most visits to the primary care clinics were for symptom-based complaints (69.5 %), followed by procedures (23.0 %) and follow-up visit (7.4 %). The commonest diagnosis in public clinics was antenatal care (21.8 %), followed by high risk pregnancies (7.5 %) and upper respiratory tract infection (URTI) (6.8 %). Private clinics had more cases for general medical examination (13.5 %), URTI (13.1 %) and fever (3.9 %). Medications were prescribed to 76.5 % of these encounters. More foreigners were seeking primary medical care from private clinics and the encounters were for general medical examinations and acute minor ailments. Those who sought care from public clinics were for obstetric problems and chronic diseases. Medications were prescribed to two-thirds of the encounters while other interventions: laboratory investigations, medical procedures and follow-up appointment had lower rates in private clinics. Foreigners are generally of young working group and are expected to have mandatory medical checks. The preponderance of obstetrics seen in public
Maxey, Hannah L; Norwood, Connor W; Weaver, Donald L
Integrating oral health care and primary care is a priority for improving population health. Primary care physicians (PCP) are filling expanded roles within oral health care to secure strong overall health for their patients. This comparative case study examines the roles of PCPs at 5 federally qualified health centers that have integrated oral health care and primary care. Administrative data were obtained directly from the Health Resources and Services Administration. Key informant interviews were performed with administrators and clinical care team members at each of the health centers. Data were reviewed by 2 experts in oral health to identify emerging roles for physicians. PPCPs' roles in health centers' integration models vary, but 3 distinct roles emerged: (1) the physician as a champion, (2) the physician as a collaborator, and (3) the physician as a member of an interprofessional team. In addition, providing physicians with the necessary training to identify oral health issues was critical to preparing physicians to take on expanded roles in integrated health care delivery models. Regardless of the roles that they play, family physicians can contribute a great deal to the success of integration models. © Copyright 2017 by the American Board of Family Medicine.
Flinter, Margaret; Hsu, Clarissa; Cromp, DeAnn; Ladden, MaryJoan D; Wagner, Edward H
The years since the passage of the Affordable Care Act have seen substantial changes in the organization and delivery of primary care. These changes have emphasized greater team involvement in care and expansion of the roles of each team member including registered nurses (RNs). This study examined the roles of RNs in 30 exemplary primary care practices. We identified the emergence of new roles and activities for RNs characterized by greater involvement in face-to-face patient care and care management, their own daily schedule of patient visits and contacts, and considerable autonomy in the care of their patients.
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.
Gillies, Donna; Buykx, Penny; Parker, Alexandra G; Hetrick, Sarah E
Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary health care has been identified as essential to improving the delivery of mental health care. Consultation liaison is a model of mental health care where the primary care provider maintains the central role in the delivery of mental health care with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental health care in the primary care setting and in turn improve outcomes for people with a mental disorder. To identify whether consultation liaison can have beneficial effects for people with a mental disorder by improving the ability of primary care providers to provide mental health care. We searched the EPOC Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), and bibliographic databases: MEDLINE, EMBASE, CINAHL and PsycINFO, in March 2014. We also searched reference lists of relevant studies and reviews to identify any potentially relevant studies. We included randomised controlled trials (RCTs) which compared consultation liaison to standard care or other service models of mental health care in the primary setting. Included participants were people attending primary care practices who required mental health care or had a mental disorder, and primary care providers who had direct contact with people in need of mental health care. Two review authors independently screened the titles and abstracts of identified studies against the inclusion criteria and extracted details including the study design, participants and setting, intervention, outcomes and any risk of bias. We resolved any disagreements by discussion or referral to a third author. We contacted trial authors to obtain any missing information.We collected and
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.
Stringfellow, Erin J.; Kim, Theresa W.; Gordon, Adam J.; Pollio, David E.; Grucza, Richard A.; Austin, Erika L.; Johnson, N. Kay; Kertesz, Stefan G.
Background Community survey data suggest high prevalence of substance use disorders among currently homeless individuals. There is less data regarding illicit drug and alcohol use problems of homeless-experienced persons engaged in primary care. They may have less severe use and require different care responses from primary care teams. Methods We surveyed currently and formerly homeless, i.e., homeless-experienced, persons engaged in primary care at 5 federally-funded programs in the U.S., administering the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). We used the ASSIST definitions of lower, moderate, and high risk to assess a spectrum of lifetime and recent substance use, from any use to likely dependence, and to identify sociodemographic and health status characteristics associated with severity of use. Results Almost one-half of the sample (n = 601) had recently (within the past 3 months) used alcohol, and one-third had recently used an illicit drug. The most commonly used illicit drugs in the past 3 months were cannabis (19%), cocaine (16%), and opioids (7.5%). Over one-half (59%) of respondents had ASSIST-defined moderate or high risk substance use. A significant proportion (31%) of those identified as at moderate risk had no recent substance use, but did report past problematic use. Ten percent of the lower risk group had past problematic use of alcohol. Severity of use was associated with worse health status, but not with housing status or type of homelessness experienced. Conclusions Less severe (moderate risk) use and past problematic use, potentially indicative of remitted substance use disorders, were more common than high risk use in this primary care, homeless-experienced sample. Our findings highlight the urgency of identifying effective ways to reduce risky substance use and prevent relapse in homeless-experienced persons. PMID:26914448
Stringfellow, Erin J; Kim, Theresa W; Gordon, Adam J; Pollio, David E; Grucza, Richard A; Austin, Erika L; Johnson, N Kay; Kertesz, Stefan G
Community survey data suggest high prevalence of substance use disorders among currently homeless individuals. There are less data regarding illicit drug and alcohol use problems of homeless-experienced persons engaged in primary care. They may have less severe use and require different care responses from primary care teams. The authors surveyed currently and formerly homeless, i.e., homeless-experienced, persons engaged in primary care at five federally funded programs in the United States, administering the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). The ASSIST definitions of lower, moderate, and high risk were used to assess a spectrum of lifetime and recent substance use, from any use to likely dependence, and to identify sociodemographic and health status characteristics associated with severity of use. Almost one half of the sample (N = 601) had recently (within the past three months) used alcohol, and one third had recently used an illicit drug. The most commonly used illicit drugs in the past three months were cannabis (19%), cocaine (16%), and opioids (7.5%). Over one half (59%) of respondents had ASSIST-defined moderate- or high-risk substance use. A significant proportion (31%) of those identified as at moderate risk had no recent substance use, but did report past problematic use. Ten percent of the lower-risk group had past problematic use of alcohol. Severity of use was associated with worse health status, but not with housing status or type of homelessness experienced. Less severe (moderate-risk) use and past problematic use, potentially indicative of remitted substance use disorders, were more common than high-risk use in this primary care, homeless-experienced sample. These findings highlight the urgency of identifying effective ways to reduce risky substance use and prevent relapse in homeless-experienced persons.
Richards, David A; Hill, Jacqueline J; Gask, Linda; Lovell, Karina; Chew-Graham, Carolyn; Bower, Peter; Cape, John; Pilling, Stephen; Araya, Ricardo; Kessler, David; Bland, J Martin; Green, Colin; Gilbody, Simon; Lewis, Glyn; Manning, Chris; Hughes-Morley, Adwoa; Barkham, Michael
To compare the clinical effectiveness of collaborative care with usual care in the management of patients with moderate to severe depression. Cluster randomised controlled trial. 51 primary care practices in three primary care districts in the United Kingdom. 581 adults aged 18 years and older who met ICD-10 (international classification of diseases, 10th revision) criteria for a depressive episode on the revised Clinical Interview Schedule. We excluded acutely suicidal patients and those with psychosis, or with type I or type II bipolar disorder; patients whose low mood was associated with bereavement or whose primary presenting problem was alcohol or drug abuse; and patients receiving psychological treatment for their depression by specialist mental health services. We identified potentially eligible participants by searching computerised case records in general practices for patients with depression. Collaborative care, including depression education, drug management, behavioural activation, relapse prevention, and primary care liaison, was delivered by care managers. Collaborative care involved six to 12 contacts with participants over 14 weeks, supervised by mental health specialists. Usual care was family doctors' standard clinical practice. Depression symptoms (patient health questionnaire 9; PHQ-9), anxiety (generalised anxiety disorder 7; GAD-7), and quality of life (short form 36 questionnaire; SF-36) at four and 12 months; satisfaction with service quality (client satisfaction questionnaire; CSQ-8) at four months. 276 participants were allocated to collaborative care and 305 allocated to usual care. At four months, mean depression score was 11.1 (standard deviation 7.3) for the collaborative care group and 12.7 (6.8) for the usual care group. After adjustment for baseline depression, mean depression score was 1.33 PHQ-9 points lower (95% confidence interval 0.35 to 2.31, P=0.009) in participants receiving collaborative care than in those receiving usual
Interprofessional Relations; Primary Health Care/Organization & Administration; Diabetes Mellitus, Type 2/Prevention & Control; Primary Prevention/Methods; Risk Reduction Behavior; Randomized Controlled Trial; Life Style
Platonova, Elena A; Shewchuk, Richard M
The purpose of this paper is to examine how patient assessment of primary care physician (PCP) communication is related to patient satisfaction with the PCP, patient perception of PCP professional competence, patient assessment of the relationship with the doctor and patient demographic characteristics using a segmentation approach. The authors surveyed 514 adult patients waiting for appointments with their PCPs in two US primary care clinics. A latent class analysis was used to identify mutually exclusive unobserved homogeneous classes of patients. The authors identified three distinct classes/groups with regard to patient assessment of physician communication and the physician-patient relationship. The largest group (53 percent of the sample) assessed their PCP communication and other doctor-patient relationship aspects as excellent. However, 37 percent provided mostly negative assessments, expressed high general dissatisfaction with the physician and disagreed with the statement that their PCP was well qualified to manage their health problems. These patients were on average more educated and affluent and the group included more males. About 10 percent of patients expressed generally lower satisfaction with the PCP, though their dissatisfaction was not as extreme as in the highly dissatisfied group. Further studies are needed to help physicians develop skills to communicate with different patients. Patient segmentation can be an important tool for healthcare quality improvement particularly for emerging approaches to primary care such as patient-centered care.
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 ...
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 ...
Jung, H.P.; Baerveldt, C.; Olesen, F.; Grol, R.P.T.M.; Wensing, M.J.P.
OBJECTIVE: To identify associations between various cultural and demographic factors and patients' primary health care preferences. SEARCH STRATEGY: Searches were performed in MEDLINE (1966-December 2000), PsycINFO (1977-May 2001) and Sociological Abstracts (1963-December 2000). Identified papers
Ali, Parveen Azam; Watson, Roger; Albutt, Gary
This study explored the role of nurses in primary care and nurses' level of preparedness to work in the primary care sector in United Kingdom. The study was conducted in three primary care trusts (PCTs) in the north of England and participants were selected using a modified snowball sampling technique. Data were collected through telephone interviews. Fourteen nurses working at various levels in PCTs were interviewed. Data were analysed using thematic analysis. Participants believed that nurses work in a variety of roles in primary care including care provider, autonomous practitioner, health educator and patient's advocate. With regard to preparedness to work in primary care, a mixed response was identified. Some nurses believed that the pre-registration nursing curriculum generally prepares nurses well for the role; others believed it did not prepare them at all. A common perception was that the pre-registration nursing curriculum is generally acute care focused and does not educate nurses about the structure of the primary care setting. Participants recommended more emphasis on primary care, longer placements in community and primary care, increased involvement of the nurses working in primary care in the pre-registration nursing curriculum and preceptorship and mentorship programmes for novice nurses in primary care. Copyright © 2011 Elsevier Ltd. All rights reserved.
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.
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
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
Chapman, Susan A; Blash, Lisel K
To identify and describe new roles for medical assistants (MAs) in innovative care models that improve care while providing training and career advancement opportunities for MAs. Primary data collected at 15 case study sites; 173 key informant interviews and de-identified secondary data on staffing, wages, patient satisfaction, and health outcomes. Researchers used snowball sampling and screening calls to identify 15 organizations using MAs in new roles. Conducted site visits from 2010 to 2012 and updated information in 2014. Thematic analysis explored key topics: factors driving MA role innovation, role description, training required, and wage gains. Categorized outcome data in patient and staff satisfaction, quality of care, and efficiency. New MA roles included health coach, medical scribe, dual role translator, health navigator, panel manager, cross-trained flexible role, and supervisor. Implementation of new roles required extensive training. MA incentives and enhanced compensation varied by role type. New MA roles are part of a larger attempt to reform workflow and relieve primary care providers. Despite some evidence of success, spread has been limited. Key challenges to adoption included leadership and provider resistance to change, cost of additional MA training, and lack of reimbursement for nonbillable services. © Health Research and Educational Trust.
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
A multicenter, primary care-based, open-label study to identify behaviors related to prescription opioid misuse, abuse, and diversion in opioid-experienced patients with chronic moderate-to-severe pain.
Setnik, Beatrice; Roland, Carl L; Sommerville, Kenneth W; Pixton, Glenn C; Berke, Robert; Calkins, Anne; Goli, Veeraindar
To compare the investigator assessment of patient risk for prescription opioid misuse, abuse, and diversion with patient self-reports of these activities in a population with chronic pain. As a secondary objective of an open-label, multicenter, primary care-based clinical study to evaluate the success of converting opioid-experienced patients with chronic pain to morphine sulfate with sequestered naltrexone hydrochloride, risk for misuse, abuse, and diversion was assessed using two nonvalidated questionnaires: one was completed by the investigator and another by the patient (Self-Reported Misuse, Abuse, and Diversion [SR-MAD]). In addition, the validated Current Opioid Misuse Measure (COMM) test and urine drug test were used. Of the 684 patients assessed by the investigators, 537 returned the self-assessment, SR-MAD. Most patients were assigned by the investigator as low risk for misuse (84.2%), abuse (89.3%), and diversion (94.3%). Of the patients who returned SR-MAD, 60% indicated having taken more opioids than prescribed and 10.9% reported chewing or crushing their opioids in the past. Of the patients who completed COMM, 40.6% were deemed as having aberrant behaviors. COMM results correlated with the risk levels from the investigator assessment. One-third of patients (33.8%) had at least one abnormal urine drug test result. More research is needed to better understand the gap between the investigator assessment of potential risk for misuse, abuse, and diversion and the actual extent of these behaviors among patients with chronic pain.
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.
Hernandez, Johnanna; Anderson, Stoerm
The purpose of this study was to explore the nurse practitioner (NP) experience with caring for prehypertensive patients. Lifestyle modifications are the primary recommendation for management of prehypertension. Given the historical foundation of health promotion and disease prevention as a fundamental component of NP professional identity, gaining insight into the experience of caring for prehypertensive patients in the current healthcare environment is valuable to the profession, patients, and communities. Therefore, the NP role in health promotion and disease prevention related to prehypertension was explored as well. Narrative inquiry was the chosen methodology to gather narrative accounts of eight NPs caring for prehypertensive patients in primary care. The three-dimensional narrative inquiry space was used to guide the researcher during data analysis. Three themes emerged from the NPs' narratives: realities of practice, ambiguous role identity, and bridging models. Time constraints, financial considerations, and bridging the nursing and medical models while adapting to practice environments were barriers identified as components of the NP experience caring for patients with prehypertension. This study revealed that caring for prehypertensive patients is a complex and multilayered experience. ©2011 The Author(s) Journal compilation ©2011 American Academy of Nurse Practitioners.
Shreve, Marilou; Scott, Allison; Vowell Johnson, Kelly
To assess the challenges primary care providers encounter when providing counseling for pediatric patients identified as obese. A survey assessed the current challenges and barriers to the screening and treatment of pediatric obesity for providers in northwest Arkansas who provide care to families. The survey consisted of 15 Likert scale questions and 4 open-ended questions. Time, resources, comfort, and cultural issues were reported by providers as the biggest barriers in screening and the treatment of pediatric obesity. All providers reported lack of time as a barrier to providing the care needed for obese children. Cultural barriers of both the provider and client were identified as factors, which negatively affect the care and treatment of obese children. Primary care providers continue to experience challenges when addressing pediatric obesity. In this study, a lack of adequate time to address obesity was identified as the most significant current barrier and may likely be tied to physician resources. Although reimbursement for obesity is increasing, the level of reimbursement does not support the time or the resources needed to treat patients. Many providers reported their patients' cultural view of obesity influenced how they counsel their patients. Increasing providers' knowledge concerning differences in how weight is viewed or valued may assist them in the assessment and care of obese pediatric patients. The challenges identified in previous research continue to limit providers when addressing obesity. Although progress has been made regarding knowledge of guidelines, continuing effort is needed to tackle the remaining challenges. This will allow for earlier identification and intervention, resulting in improved outcomes in pediatric obesity.
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
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. METHODS We first identified criteria from the social and behavioral sciences to analyze mixed methods studies in primary care research. We then used the criteria to evaluate 5 mixed methods investigations published in primary care research journals. RESULTS Of the 5 studies analyzed, 3 included a rationale for mixing based on the need to develop a quantitative instrument from qualitative data or to converge information to best understand the research topic. Quantitative data collection involved structured interviews, observational checklists, and chart audits that were analyzed using descriptive and inferential statistical procedures. Qualitative data consisted of semistructured interviews and field observations that were analyzed using coding to develop themes and categories. The studies showed diverse forms of priority: equal priority, qualitative priority, and quantitative priority. Data collection involved quantitative and qualitative data gathered both concurrently and sequentially. The integration of the quantitative and qualitative data in these studies occurred between data analysis from one phase and data collection from a subsequent phase, while analyzing the data, and when reporting the results. DISCUSSION We recommend instrument-building, triangulation, and data transformation models for mixed methods designs as useful frameworks to add rigor to investigations in primary care. We also discuss the limitations of our study and the need for future research. PMID:15053277
Krass, I; Hebing, R; Mitchell, B; Hughes, J; Peterson, G; Song, Y J C; Stewart, K; Armour, C L
Worldwide studies have shown that significant proportions of patients with type 2 diabetes (T2DM) do not meet targets for glycaemic control, blood pressure (BP) and lipids, putting them at higher risk of developing complications. However, little is known about medicines management in Australian primary care populations with T2DM. The aim of this study was to (i) describe the management of a large group of patients in primary care, (ii) identify areas for improvement in management and (iii) determine any relationship between adherence and glycaemic, BP and lipid control. This was a retrospective, epidemiological study of primary care patients with T2DM diabetes, with HbA(1c) of >7%, recruited in 90 Australian community pharmacies. Data collected included demographic details, diabetes history, current medication regimen, height, weight, BP, physical activity and smoking status. Of the 430 patients, 98% used antidiabetics, 80% antihypertensives, 73% lipid lowering drugs and 38% aspirin. BP and all lipid targets were met by only 21% and 14% of the treated patients and 21% and 12% of the untreated patients respectively. Medication adherence was related to better glycaemic control (P = 0.04). An evidence-base prescribing practice gap was seen in this Australian primary care population of T2DM patients. Patients were undertreated with antihypertensive and lipid lowering medication, and several subgroups with co-morbidities were not receiving the recommended pharmacotherapy. Interventions are required to redress the current evidence-base prescribing practice gap in disease management in primary care. © 2011 Blackwell Publishing Ltd.
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.
Cassio Batista Alves
Full Text Available In Brazil, Occupational Therapy (OT was legislated in 1969, and was introduced into the Primary Health Care (PHC in the 90s. At this level of care, the OT serves various stages of human development, including aging, in a perspective of care and active aging line, seeks to optimize opportunities for health, participation and safety, using clinical reasoning in order to plan, guide, conduct and reflect their actions in producing the line of care. This career considers human activities as part of the construction of the man himself as an expertise area and seeks to understand the relationships that the active human establishes in its life and health. This study aimed to verify the actions and identify the occupational therapy line of care with the elderly in APS. This is a qualitative study that used a semi-structured interview applied during April to May 2013 with six occupational therapists that cared for older people in the APS at Uberaba-MG. The data was analyzed using the Collective Subject Discourse (CSD technique. We observed that the OT actions to produce line of care for the elderly happen according to the general public care, whether individual or group, with the team during case discussions, referrals or work management and the territory during the territorial diagnosis and networks formation, all permeated by the principles of fairness, integrity, intersectoriality and clinical reasoning in OT.
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
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
Poghosyan, Lusine; Norful, Allison A.; Martsolf, Grant R.
Developing team-based care models and expanding nurse practitioner (NP) workforce in primary care are recommended by policy makers to meet demand. Little is known how to promote interprofessional teamwork. Using a mixed-methods design, we analyzed qualitative interview and quantitative survey data from primary care NPs to explore practice characteristics important for teamwork. The Interprofessional Teamwork for Health and Social Care Framework guided the study. We identified NP-physician and...
Santuzza Arreguy Silva VITORINO
Full Text Available ABSTRACT Objective: To describe the modeling stages of food and nutrition surveillance in the Primary Health Care of the Unified Health Care System, considering its activities, objectives, and goals Methods: Document analysis and semi-structured interviews were used for identifying the components, describe the intervention, and identify potential assessment users. Results: The results include identification of the objectives and goals of the intervention, the required inputs, activities, and expected effects. The intervention was then modeled based on these data. The use of the theoretical logic model optimizes times, resources, definition of the indicators that require monitoring, and the aspects that require assessment, identifying more clearly the contribution of the intervention to the results Conclusion: Modeling enabled the description of food and nutrition surveillance based on its components and may guide the development of viable plans to monitor food and nutrition surveillance actions so that modeling can be established as a local intersectoral planning instrument.
Zhang, Yi; Zhao, Shengli; Rodriguez, Erica; Takatoh, Jun; Han, Bao-Xia; Zhou, Xiang; Wang, Fan
Primary pain and touch sensory neurons not only detect internal and external sensory stimuli, but also receive inputs from other neurons. However, the neuronal derived inputs for primary neurons have not been systematically identified. Using a monosynaptic rabies viruses-based transneuronal tracing method combined with sensory-specific Cre-drivers, we found that sensory neurons receive intraganglion, intraspinal, and supraspinal inputs, the latter of which are mainly derived from the rostroventral medulla (RVM). The viral-traced central neurons were largely inhibitory but also consisted of some glutamatergic neurons in the spinal cord and serotonergic neurons in the RVM. The majority of RVM-derived descending inputs were dual GABAergic and enkephalinergic (opioidergic). These inputs projected through the dorsolateral funiculus and primarily innervated layers I, II, and V of the dorsal horn, where pain-sensory afferents terminate. Silencing or activation of the dual GABA/enkephalinergic RVM neurons in adult animals substantially increased or decreased behavioral sensitivity, respectively, to heat and mechanical stimuli. These results are consistent with the fact that both GABA and enkephalin can exert presynaptic inhibition of the sensory afferents. Taken together, this work provides a systematic view of and a set of tools for examining peri- and extrasynaptic regulations of pain-afferent transmission.
Hall, Jennifer; Cohen, Deborah J; Davis, Melinda; Gunn, Rose; Blount, Alexander; Pollack, David A; Miller, William L; Smith, Corey; Valentine, Nancy; Miller, Benjamin F
To identify how organizations prepare clinicians to work together to integrate behavioral health and primary care. Observational cross-case comparison study of 19 U.S. practices, 11 participating in Advancing Care Together, and 8 from the Integration Workforce Study. Practices varied in size, ownership, geographic location, and experience delivering integrated care. Multidisciplinary teams collected data (field notes from direct practice observations, semistructured interviews, and online diaries as reported by practice leaders) and then analyzed the data using a grounded theory approach. Organizations had difficulty finding clinicians possessing the skills and experience necessary for working in an integrated practice. Practices newer to integration underestimated the time and resources needed to train and organizationally socialize (onboard) new clinicians. Through trial and error, practices learned that clinicians needed relevant training to work effectively as integrated care teams. Training efforts exclusively targeting behavioral health clinicians (BHCs) and new employees were incomplete if primary care clinicians (PCCs) and others in the practice also lacked experience working with BHCs and delivering integrated care. Organizations' methods for addressing employees' need for additional preparation included hiring a consultant to provide training, sending employees to external training programs, hosting residency or practicum training programs, or creating their own internal training program. Onboarding new employees through the development of training manuals; extensive shadowing processes; and protecting time for ongoing education, mentoring, and support opportunities for new and established clinicians and staff were featured in these internal training programs. Insufficient training capacity and practical experience opportunities continue to be major barriers to supplying the workforce needed for effective behavioral health and primary care integration
Dysinger, Wayne S; King, Valerie; Foster, Tina C; Geffken, Dominic
Expanded competencies in population health and systems-based medicine have been identified as a need for primary care physicians. Incorporating formal training in preventive medicine is one method of accomplishing this objective. We identified three family medicine residencies that have developed formal integrated pathways for residents to also complete preventive medicine residency requirements during their training period. Although there are differences, each pathway incorporates a structured approach to dual residency training and includes formal curriculum that expands resident competencies in population health and systems-based medicine. A total of 26 graduates have completed the formally combined family and preventive medicine residencies. All are board certified in family medicine, and 22 are board certified in preventive medicine. Graduates work in a variety of academic, quality improvement, community, and international settings utilizing their clinical skills as well as their population medicine competencies. Dual training has been beneficial in job acquisition and satisfaction. Incorporation of formal preventive medicine training into family medicine education is a viable way to use a structured format to expand competencies in population medicine for primary care physicians. This type of training, or modifications of it, should be part of the debate in primary care residency redesign.
Kennedy, Norelee; Armstrong, Claire; Woodward, Oonagh; Cullen, Walter
Team working is an integral aspect of primary care, but barriers to effective team working can limit the effectiveness of a primary care team (PCT). The establishment of new PCTs in Ireland provides an excellent opportunity to explore team working in action. The aim of this qualitative study was to explore the experiences of team members working in a PCT. Team members (n = 19) from two PCTs were interviewed from May to June 2010 using a semi-structured interview guide. All interviews were audio-recorded and transcribed. Data were analysed using NVivo (version 8). Thematic analysis was used to explore the data. We identified five main themes that described the experiences of the team members. The themes were support for primary care, managing change, communication, evolution of roles and benefits of team working. Team members were generally supportive of primary care and had experienced benefits to their practice and to the care of their patients from participation in the team. Regular team meetings enabled communication and discussion of complex cases. Despite the significant scope for role conflict due to the varied employment arrangements of the team members, neither role nor interpersonal conflict was evident in the teams studied. In addition, despite the unusual team structure in Irish PCTs - where there is no formally appointed team leader or manager - general issues around team working and its benefits and challenges were very similar to those found in other international studies. This suggests, in contrast to some studies, that some aspects of the leadership role may not be as important in successful PCT functioning as previously thought. Nonetheless, team leadership was identified as an important issue in the further development of the teams. © 2014 John Wiley & Sons Ltd.
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.
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.
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.
Banas, David A; Redfern, Roberta; Wanjiku, Stephen; Lazebnik, Rina; Rome, Ellen S
The ability to diagnose eating disorders (ED) is important and difficult for primary care physicians (PCPs). Previous reports suggest that PCPs feel their training is inadequate. To explore residents' interest and comfort diagnosing and treating ED. An internet survey was sent to primary care residencies. Logistic regression models were fitted to identify factors correlated with residents' interest and comfort in diagnosing and treating ED. Family Medicine and Internal Medicine residents had higher interest in ED than Pediatric residents, as did female residents and residents exposed to teenagers with unexplained weight loss. Residents in programs with an ED program and faculty interested in ED were more comfortable diagnosing ED. Interest in, and comfort diagnosing and treating ED are associated with specialty type, presence of an ED program, presence of faculty interested in ED, and resident exposure to ED outpatients and teenagers with unexplained weight loss.
Davis, T C; Crouch, M A; Long, S W; Jackson, R H; Bates, P; George, R B; Bairnsfather, L E
Health education materials, medical instructions, consent forms, and self-report questionnaires are often given to patients with little regard for their ability to read them. Reading ability is rarely tested in medical settings. The Rapid Estimate of Adult Literacy in Medicine (REALM) was developed as a quick screening tool to assist physicians in identifying patients with limited reading skills and in estimating patient reading levels. This information can be used to tailor materials and instructions to patients' abilities. The REALM and the reading sections of the Peabody Individual Achievement Test-Revised and the Slosson Oral Reading Test were used to test reading ability in 207 adults in six public and private primary care clinics. REALM scores correlated highly with those of the standardized reading tests. The REALM, which takes three to five minutes to administer and score, appears to be a practical instrument to estimate patient literacy in primary care, patient education, and medical research.
Andressa Jacondino Pires
Full Text Available Objective: To identify the association between panic disorder and licit and illicit substance use in the population provided with primary care in the southern Brazil. Methods: This is a cross-sectional study with patients from three primary care centers. We used the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST to evaluate substance use and the Mini International Neuropsychiatric Interview (MINI to diagnose panic disorder. Results: A total of 1,081 subjects were evaluated. The prevalence of panic disorder was 5.6%. Panic disorder was associated with using marijuana (p = 0.001, tobacco (p = 0.001, cocaine (p < 0.001, and other illicit substances (p < 0.001. Conclusion: A significant association is noticed between panic disorder and licit and illicit substance use, thus, it is interesting to rethink the approach to treatment/intervention in patients with dual diagnosis.
Full Text Available The management of requests for diagnostic exams presents its own inherent characteristics in primary health care and reflects the specific nature of the physician-patient relationship. The scope of the study was to identify the reasons for requesting an electrocardiogram (ECG in primary health care. A cross-sectional study was conducted in an urban region in Portugal, establishing the motives to ask for an ECG consecutively over two years, starting on 01/03/2007 using data retrieved from structured forms filled out by the physician at the moment of requesting the exam. A total of 870 ECGs of 817 patients were included. Symptoms manifested during the patient visit justified 48.5% of the ECGs, and follow-up of cardiovascular risk factors motivated 25.2%. A global health examination accounted for 22.8% of the requests. Multivariate analysis showed that the presence of symptoms (p
Antônio Thomaz Gonzaga da Matta-Machado
Full Text Available Objective. To provide an overview of the distribution of institutional support in primary care in Brazil and to identify associations between the activities of institutional support and the outcome of the certification of the National Programme for Improving Access and Quality in Primary Health Care (PMAQ. Materials and methods. A cross-sectional study was conducted through interviews with 16 960 profes- sionals in Brazil in 2012. To examine the relationship between the received support and the quality of health care it was made a multiple binary logistic regression. Results. A positive relationship between high-level support and certification in the sub-dimensions analyzed was observed: women and child care, diabetes mellitus/ hypertension and mental health. The support activities which contributed most were: self-assessment, shared assessment, targeted workshops and training. Conclusion. Institutional support activities have helped to improve the quality and access of the population to healthcare in the country.
A multicenter, primary care-based, open-label study to identify behaviors related to prescription opioid misuse, abuse, and diversion in opioid-experienced patients with chronic moderate-to-severe pain
Full Text Available Beatrice Setnik,1 Carl L Roland,1 Kenneth W Sommerville,1,2 Glenn C Pixton,1 Robert Berke,3,4 Anne Calkins,5 Veeraindar Goli1,2 1Pfizer Inc, 2Duke University Medical Center, Durham, NC, 3Family Health Medical Services PLLC, Mayville, NY, 4Department of Social and Preventive Medicine, State University of New York at Buffalo, Buffalo, NY, 5New York Spine & Wellness Center, Syracuse, NY, USA Objective: To compare the investigator assessment of patient risk for prescription opioid misuse, abuse, and diversion with patient self-reports of these activities in a population with chronic pain. Methods: As a secondary objective of an open-label, multicenter, primary care-based clinical study to evaluate the success of converting opioid-experienced patients with chronic pain to morphine sulfate with sequestered naltrexone hydrochloride, risk for misuse, abuse, and diversion was assessed using two nonvalidated questionnaires: one was completed by the investigator and another by the patient (Self-Reported Misuse, Abuse, and Diversion [SR-MAD]. In addition, the validated Current Opioid Misuse Measure (COMM test and urine drug test were used. Results: Of the 684 patients assessed by the investigators, 537 returned the self-assessment, SR-MAD. Most patients were assigned by the investigator as low risk for misuse (84.2%, abuse (89.3%, and diversion (94.3%. Of the patients who returned SR-MAD, 60% indicated having taken more opioids than prescribed and 10.9% reported chewing or crushing their opioids in the past. Of the patients who completed COMM, 40.6% were deemed as having aberrant behaviors. COMM results correlated with the risk levels from the investigator assessment. One-third of patients (33.8% had at least one abnormal urine drug test result. Conclusion: More research is needed to better understand the gap between the investigator assessment of potential risk for misuse, abuse, and diversion and the actual extent of these behaviors among patients with
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.
Saitz, Richard; Palfai, Tibor P. A.; Cheng, Debbie M.; Alford, Daniel P.; Bernstein, Judith A.; Lloyd-Travaglini, Christine A.; Meli, Seville M.; Chaisson, Christine E.; Samet, Jeffrey H.
IMPORTANCE The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy. OBJECTIVE To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)—a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)—compared with no brief intervention. DESIGN, SETTING, AND PARTICIPANTS This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of $4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts. INTERVENTIONS Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master’s-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources. MAIN OUTCOMES AND MEASURES Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization. RESULTS At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for
Nebot Adell, Carme; Pasarin Rua, Maribel; Canela Soler, Jaume; Sala Alvarez, Clara; Escosa Farga, Alex
To describe the process of development of community health in a territory where the Primary Health Care board decided to include it in its roadmap as a strategic line. Evaluative research using qualitative techniques, including SWOT analysis on community health. Two-steps study. Primary care teams (PCT) of the Catalan Health Institute in Barcelona city. The 24 PCT belonging to the Muntanya-Dreta Primary Care Service in Barcelona city, with 904 professionals serving 557,430 inhabitants. Application of qualitative methodology using SWOT analysis in two steps (two-step study). Step 1: Setting up a core group consisting of local PCT professionals; collecting the community projects across the territory; SWOT analysis. Step 2: From the needs identified in the previous phase, a plan was developed, including a set of training activities in community health: basic, advanced, and a workshop to exchange experiences from the PCTs. A total of 80 team professionals received specific training in the 4 workshops held, one of them an advanced level. Two workshops were held to exchange experiences with 165 representatives from the local teams, and 22 PCTs presenting their practices. In 2013, 6 out of 24 PCTs have had a community diagnosis performed. Community health has achieved a good level of development in some areas, but this is not the general situation in the health care system. Its progression depends on the management support they have, the local community dynamics, and the scope of the Primary Health Care. Copyright Â© 2016 Elsevier España, S.L.U. All rights reserved.
Objective: Mental health has been identified as a major priority in the Ugandan Health Sector Strategic Plan. Efforts are currently underway to integrate mental health services into the Primary Health Care system. In this study, we report aspects of the integration of mental health into primary health care in one rural district in ...
Bulc, M.; Kersnik, J.; Boerma, W.; Pellny, M.
Background: The article summarizes the main results of the WHO Primary Care Quality Management project, which has been implemented as a pilot study to identify and support mechanisms for quality management in primary health care. Material and methods: The project was commissioned by WHO Europe and
van Ierland, Yvette; Elshout, Gijs; Berger, Marjolein Y.; Vergouwe, Yvonne; de Wilde, Marcel; van der Lei, Johan; Mol, Henritte A.; Oostenbrink, Rianne
Background Clinical prediction rules (CPRs) to identify children with serious infections lack validation in low-prevalence populations, which hampers their implementation in primary care practice. Aim To evaluate the diagnostic value of published CPRs for febrile children in primary care. Design and
Warmelink, J.C.; Hoijtink, K.; Noppers, M.; Wiegers, T.A.; de Cock, T.P.; Klomp, T.; Hutton, E.K.
Objective: the main objectives of our study was to gain an understanding of how primary care midwives in the Netherlands feel about their work and to identify factors associated with primary care midwives' job satisfaction and areas for improvement. Design: a qualitative analysis was used, based on
Warmelink, J.C.; Hoijtink, K.; Noppers, M.; Wiegers, T.A.; Cock, T.P. de; Klomp, T.; Hutton, E.K.
Objective: the main objectives of our study was to gain an understanding of how primary care midwives in the Netherlands feel about their work and to identify factors associated with primary care midwives׳ job satisfaction and areas for improvement. Design: a qualitative analysis was used, based on
Gaal, S.; Verstappen, W.H.J.M.; Wensing, M.J.P.
BACKGROUND: Although it has been increasingly recognised that patient safety in primary care is important, little is known about the feasibility and effectiveness of different strategies to improve patient safety in primary care. In this study, we aimed to identify the most important strategies by
Jones, Caroline H D; Howick, Jeremy; Roberts, Nia W; Price, Christopher P; Heneghan, Carl; Plüddemann, Annette; Thompson, Matthew
Point-of-care blood tests are becoming increasingly available and could replace current venipuncture and laboratory testing for many commonly used tests. However, at present very few have been implemented in most primary care settings. Understanding the attitudes of primary care clinicians towards these tests may help to identify the barriers and facilitators to their wider adoption. We aimed to systematically review qualitative studies of primary care clinicians' attitudes to point-of-care blood tests. We systematically searched Medline, Embase, ISI Web of Knowledge, PsycINFO and CINAHL for qualitative studies of primary care clinicians' attitudes towards point-of-care blood tests in high income countries. We conducted a thematic synthesis of included studies. Our search identified seven studies, including around two hundred participants from Europe and Australia. The synthesis generated three main themes: the impact of point-of-care testing on decision-making, diagnosis and treatment; impact on clinical practice more broadly; and impact on patient-clinician relationships and perceived patient experience. Primary care clinicians believed point-of-care testing improved diagnostic certainty, targeting of treatment, self-management of chronic conditions, and clinician-patient communication and relationships. There were concerns about test accuracy, over-reliance on tests, undermining of clinical skills, cost, and limited usefulness. We identified several perceived benefits and barriers regarding point-of-care tests in primary care. These imply that if point-of-care tests are to become more widely adopted, primary care clinicians require evidence of their accuracy, rigorous testing of the impact of introduction on patient pathways and clinical practice, and consideration of test funding.
Hone, Thomas; Lee, John Tayu; Majeed, Azeem; Conteh, Lesong; Millett, Christopher
Policy-makers are increasingly considering charging users different fees between primary and secondary care (differential user charges) to encourage utilisation of primary health care in health systems with limited gate keeping. A systematic review was conducted to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published in MEDLINE, EMBASE, the Cochrane library, EconLIT, HMIC, and WHO library databases from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively. Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care. Overall, the impact of introducing differential user-charges on primary care utilisation remains uncertain. Further research is required to understand their impact as a demand side intervention, including implications for health system costs and on utilisation among low-income patients. © The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
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...
Full Text Available Abstract Background Collaboration between providers of conventional care and complementary therapies (CTs has gained in popularity but there is a lack of conceptualised models for delivering such care, i.e. integrative medicine (IM. The aim of this paper is to describe some key findings relevant to the development and implementation of a proposed model for IM adapted to Swedish primary care. Methods Investigative procedures involved research group and key informant meetings with multiple stakeholders including general practitioners, CT providers, medical specialists, primary care administrators and county council representatives. Data collection included meeting notes which were fed back within the research group and used as ongoing working documents. Data analysis was made by immersion/crystallisation and research group consensus. Results were categorised within a public health systems framework of structures, processes and outcomes. Results The outcome was an IM model that aimed for a patient-centered, interdisciplinary, non-hierarchical mix of conventional and complementary medical solutions to individual case management of patients with pain in the lower back and/or neck. The IM model case management adhered to standard clinical practice including active partnership between a gate-keeping general practitioner, collaborating with a team of CT providers in a consensus case conference model of care. CTs with an emerging evidence base included Swedish massage therapy, manual therapy/naprapathy, shiatsu, acupuncture and qigong. Conclusion Despite identified barriers such as no formal recognition of CT professions in Sweden, it was possible to develop a model for IM adapted to Swedish primary care. The IM model calls for testing and refinement in a pragmatic randomised controlled trial to explore its clinical effectiveness.
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 ...
Flokstra - de Blok BMJ
Full Text Available Bertine MJ Flokstra - de Blok,1,2 Thys van der Molen,1,2 Wianda A Christoffers,3 Janwillem WH Kocks,1,2 Richard L Oei,4 Joanne NG Oude Elberink,2,4 Emmy M Roerdink,5 Marie Louise Schuttelaar,3 Jantina L van der Velde,1,2 Thecla M Brakel,1,6 Anthony EJ Dubois2,5 1Department of General Practice, 2GRIAC Research Institute, 3Department of Dermatology, 4Department of Allergology, 5Department of Pediatric Pulmonology and Pediatric Allergy, University of Groningen, University Medical Center Groningen, 6Teaching Unit, Department of Social Psychology, University of Groningen, Groningen, The Netherlands Background: Management of allergic patients in the population is becoming more difficult because of increases in both complexity and prevalence. Although general practitioners (GPs are expected to play an important role in the care of allergic patients, they often feel ill-equipped for this task. Therefore, the aim of this study was to develop an allergy management support system (AMSS for primary care. Methods: Through literature review, interviewing and testing in secondary and primary care patients, an allergy history questionnaire was constructed by allergists, dermatologists, GPs and researchers based on primary care and specialists’ allergy guidelines and their clinical knowledge. Patterns of AMSS questionnaire responses and specific immunoglobulin E (sIgE-test outcomes were used to identify diagnostic categories and develop corresponding management recommendations. Validity of the AMSS was investigated by comparing specialist (gold standard and AMSS diagnostic categories. Results: The two-page patient-completed AMSS questionnaire consists of 12 (mainly multiple choice questions on symptoms, triggers, severity and medication. Based on the AMSS questionnaires and sIgE-test outcome of 118 patients, approximately 150 diagnostic categories of allergic rhinitis, asthma, atopic dermatitis, anaphylaxis, food allergy, hymenoptera allergy and other
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 ...
Brouwers, Melissa C; Vukmirovic, Marija; Tomasone, Jennifer R; Grunfeld, Eva; Urquhart, Robin; O'Brien, Mary Ann; Walker, Melanie; Webster, Fiona; Fitch, Margaret
To report on the findings of the CanIMPACT (Canadian Team to Improve Community-Based Cancer Care along the Continuum) Casebook project, which systematically documented Canadian initiatives (ie, programs and projects) designed to improve or support coordination and continuity of cancer care between primary care providers (PCPs) and oncology specialists. Pan-Canadian environmental scan. Canada. Individuals representing the various initiatives provided data for the analysis. Initiatives included in the Casebook met the following criteria: they supported coordination and collaboration between PCPs and oncology specialists; they were related to diagnosis, treatment, survivorship, or personalized medicine; and they included breast or colorectal cancer or both. Data were collected on forms that were compiled into summaries (ie, profiles) for each initiative. Casebook initiatives were organized based on the targeted stage of the cancer care continuum, jurisdiction, and strategy (ie, model of care or type of intervention) employed. Thematic analysis identified similarities and differences among employed strategies, the level of primary care engagement, implementation barriers and facilitators, and initiative evaluation. The CanIMPACT Casebook profiles 24 initiatives. Eleven initiatives targeted the survivorship stage of the cancer care continuum and 15 focused specifically on breast or colorectal cancer or both. Initiative teams implemented the following strategies: nurse patient navigation, multidisciplinary care teams, electronic communication or information systems, PCP education, and multicomponent initiatives. Initiatives engaged PCPs at various levels. Implementation barriers included lack of care standardization across jurisdictions and incompatibility among electronic communication systems. Implementation facilitators included having clinical and program leaders publicly support the initiative, repurposing existing resources, receiving financial support, and
Full Text Available Background A critical need exists for effective electronic tools that facilitate multidisciplinary care for complex patients in patient-centered medical homes. Objective To identify the essential components of a primary care (PC based electronic care plan (ECP tool that facilitates coordination of care for complex patients. Methods Three focus groups and nine semi-structured interviews were conducted at an academic PC practice in order to identify the ideal components of an ECP. Results Critical components of an ECP identified included: 1 patient background information, including patient demographics, care team member designation and key patient contacts, 2 user- and patient-centric task management functionalities, 3 a summary of a patient’s care needs linked to the responsible member of the care team and 4 integration with the electronic medical record. We then designed an ECP mockup incorporating these components. Conclusion Our investigation identified key principles that healthcare software developers can integrate into PC and patient-centered ECP tools.
Neergaard, Mette Asbjørn; Olesen, Frede; Jensen, Anders Bonde
Background: Knowledge about the quality and organisation of care to terminally ill cancer patients with a relatives' view in a primary health care setting is limited. The aim of the study is to analyse experiences and preferences of bereaved relatives to terminally ill cancer patients in a primary...... care setting to explore barriers and facilitators for delivery of good palliative home care. Methods: Three focus group interviews with fourteen bereaved relatives in Aarhus County, Denmark. Results: Three main categories of experience were identified: 1) The health professionals' management, where...... a need to optimize was found. 2) Shared care, which was lacking. 3) The relatives' role, which needs an extra focus. Conclusion: Relatives experience insufficient palliative care mainly due to organizational and cultural problems among professionals. Palliative care in primary care in general needs...
Carter, Yvonne H; Shaw, Sara; Macfarlane, Fraser
College of General Practitioners (RCGP) to develop a scheme to accredit UK general practices undertaking primary care R&D. The pilot began with initial consultation on the development of the process, as well as the standards and criteria for assessment. The resulting assessment schedule allowed for assessment at one of two levels: Collaborative Research Practice (Level I), with little direct experience of gaining project or infrastructure funding Established Research Practice (Level II), with more experience of research funding and activity and a sound infrastructure to allow for growth in capacity. The process for assessment of practices involved the assessment of written documentation, followed by a half-day assessment visit by a multidisciplinary team of three assessors. IMPLEMENTATION--THE PILOT PROJECT: Pilot practices were sampled in two regions. Firstly, in the NHS Executive South West Region, where over 150 practices expressed an interest in participating. From these a purposive sample of 21 practices was selected, providing a range of research and service activity. A further seven practices were identified and included within the project through the East London and Essex Network of Researchers (ELENoR). Many in this latter group received funding and administrative support and advice from ELENoR in order to prepare written submissions for assessment. Some sample loss was encountered within the pilot project, which was attributable largely to conflicting demands on participants' time. Indeed, the preparation of written submissions within the South West coincided with the introduction of primary care groups (PCGs) in April 1999, which several practices cited as having a major impact on their participation in the pilot project. A final sample of 15 practices (nine in the South West and six through ELENoR) underwent assessment through the pilot project. A formal evaluation of the Primary Care Research Team Assessment (PCRTA) pilot was undertaken by an independent
Carey, Mariko; Noble, Natasha; Mansfield, Elise; Waller, Amy; Henskens, Frans; Sanson-Fisher, Rob
Modifiable health risk behaviors such as smoking, overweight and obesity, risky alcohol consumption, physical inactivity, and poor nutrition contribute to a substantial proportion of the world's morbidity and mortality burden. General practitioners (GPs) play a key role in identifying and managing modifiable health risk behaviors. However, these are often underdetected and undermanaged in the primary care setting. We describe the potential of eHealth to help patients and GPs to overcome some of the barriers to managing health risk behaviors. In particular, we discuss (1) the role of eHealth in facilitating routine collection of patient-reported data on lifestyle risk factors, and (2) the role of eHealth in improving clinical management of identified risk factors through provision of tailored feedback, point-of-care reminders, tailored educational materials, and referral to online self-management programs. Strategies to harness the capacity of the eHealth medium, including the use of dynamic features and tailoring to help end users engage with, understand, and apply information need to be considered and maximized. Finally, the potential challenges in implementing eHealth solutions in the primary care setting are discussed. In conclusion, there is significant potential for innovative eHealth solutions to make a contribution to improving preventive care in the primary care setting. However, attention to issues such as data security and designing eHealth interfaces that maximize engagement from end users will be important to moving this field forward.
Brauer, Paula; Royall, Dawna; Dwyer, John; Edwards, A Michelle; Hussey, Tracy; Kates, Nick; Smith, Heidi; Kirkconnell, Ross
Aim We report on a formative project to develop an organization-level planning framework for obesity prevention and management services. It is common when developing new services to first develop a logic model outlining expected outcomes and key processes. This can be onerous for single primary care organizations, especially for complex conditions like obesity. The initial draft was developed by the research team, based on results from provider and patient focus groups in one large Family Health Team (FHT) in Ontario. This draft was reviewed and activities prioritized by 20 FHTs using a moderated electronic consensus process. A national panel then reviewed the draft. Findings Providers identified five main target groups: pregnancy to 2, 3-12, 13-18, 18+ years at health risk, and 18+ with complex care needs. Desired outcomes were identified and activities were prioritized under categories: raising awareness (eg, providing information and resources on weight-health), identification and initial management (eg, wellness care), follow-up management (eg, group programs), expanded services (eg, availability of team services), and practice initiatives (eg, interprofessional education). Overall, there was strong support for raising awareness by providing information on the weight-health connection and on community services. There was also strong support for growth assessment in pediatric care. In adults, there was strong support for wellness care/health check visits and episodic care to identify people for interventions, for group programs, and for additional provider education. Joint development by different teams proved useful for consensus on outcomes and for ensuring relevancy across practices. While priorities will vary depending on local context, the basic descriptions of care processes were endorsed by reviewers. Key next steps are to trial the use of the framework and for further implementation studies to find optimally effective approaches for obesity prevention
Cancer Survivorship Care Plan Utilization and Impact on Clinical Decision-Making at Point-of-Care Visits with Primary Care: Results from an Engineering, Primary Care, and Oncology Collaborative for Survivorship Health.
Donohue, SarahMaria; Haine, James E; Li, Zhanhai; Feldstein, David A; Micek, Mark; Trowbridge, Elizabeth R; Kamnetz, Sandra A; Sosman, James M; Wilke, Lee G; Sesto, Mary E; Tevaarwerk, Amye J
Every cancer survivor and his/her primary care provider should receive an individualized survivorship care plan (SCP) following curative treatment. Little is known regarding point-of-care utilization at primary care visits. We assessed SCP utilization in the clinical context of primary care visits. Primary care physicians and advanced practice providers (APPs) who had seen survivors following provision of an SCP were identified. Eligible primary care physicians and APPs were sent an online survey, evaluating SCP utilization and influence on decision-making at the point-of-care, accompanied by copies of the survivor's SCP and the clinic note. Eighty-eight primary care physicians and APPs were surveyed November 2016, with 40 (45%) responding. Most respondents (60%) reported discussing cancer or related issues during the visit. Information needed included treatment (66%) and follow-up visits, and the cancer team was responsible for (58%) vs primary care (58%). Respondents acquired this information by asking the patient (79%), checking oncology notes (75%), the SCP (17%), or online resources (8%). Barriers to SCP use included being unaware of the SCP (73%), difficulty locating it (30%), and finding needed information faster via another mechanism (15%). Despite largely not using the SCP for the visit (90%), most respondents (61%) believed one would be quite or very helpful for future visits. Most primary care visits included discussion of cancer or cancer-related issues. SCPs may provide the information necessary to deliver optimal survivor care but efforts are needed to reduce barriers and design SCPs for primary care use.
Stewart, Simon; Carrington, Melinda J; Swemmer, Carla; Kurstjens, Nicol; Jennings, Garry L
The Valstartan Intensified Primary CarE Reduction of Blood Pressure Study (VIPER-BP) Study is an open-label, randomised controlled trial comparing usual primary care management with an intensive BP management strategy using three forms of valsartan-based therapy (mono-therapy, thiazide diuretic or calcium channel blocker combinations) to achieve individualised BP control. To identify the features of General Practitioner (GP) management of hypertension in Australia, we analyse the response to a case scenario-based survey of 500 GPs. We subsequently recruited a national cohort of GP Investigators to enrol up to 2500 patients into the VIPER-BP Study. GP responses clearly demonstrated that, compared to the VIPER-BP intervention, a heterogeneous approach to the primary care management of hypertension persists in Australia. By November 2010, 2157 hypertensive patients from 272 actively recruiting GP Investigators were enrolled into the study. Of these, 1965 (91%) patients were entered into a standardised "run-in" phase of 28 days of valsartan 80 mg/day. Subsequently, 1285 patients were randomised to usual care (n=435) or the VIPER-BP intervention (n=850). There was a predominance of males (62%), whilst 55% had pre-existing diabetes or cardiovascular disease and 63% had been previously treated for hypertension. Mean systolic and diastolic BP on randomisation for men and women, respectively, was 148 ± 15/88 ± 11 and 148 ± 18/87 ± 10 mm Hg. In contrast to typical primary care management of hypertension, VIPER-BP combines more intensive and aggressive therapies with structured management to more rapidly attain and sustain individualised BP targets in hypertensive patients. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
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
Gunn, Jane M; Palmer, Victoria J; Dowrick, Christopher F; Herrman, Helen E; Griffiths, Frances E; Kokanovic, Renata; Blashki, Grant A; Hegarty, Kelsey L; Johnson, Caroline L; Potiriadis, Maria; May, Carl R
Depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting. We used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development. Five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how
U.S. Department of Health & Human Services — The establishment in recent years of a National Provider Identifier (NPI) offers a new method for counting and categorizing physicians and other health care...
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.
AbdulRahman, Aminatu Ali; Rabiu, Mansur Muhammad; Alhassan, Mahmoud Babanini
To assess knowledge and practice of primary eye care among primary healthcare workers known as community health extension workers in Funtua district of Nigeria. Cross-sectional mixed method study among health workers employed in government-owned primary healthcare facilities. Quantitative data were obtained using self-administered questionnaires and checklists, while qualitative data by modified Delphi technique, role plays and observation. A score of 1 was given for each correct answer, while a total score of ≥60% was considered 'good'. Eighty three of 88 health workers participated (94%) in the questionnaire survey; while 16 of them were selected for the qualitative survey. Good scores regarding the knowledge of common eye diseases were obtained by 68.7%, but only 26.4% of them could identify their most important features. Participants could undertake 3 of 5 steps in visual acuity testing. Skills in recognising common eye diseases and their management were weak; while practice was often not according to the guidelines. Community health extension workers displayed good knowledge of common eye diseases. Areas of weakness are recognition and interpretation of eye signs, and practice rarely follows the guidelines. Preventive medicine was neglected; community health extension workers require practical retraining and supervision to achieve integration of primary eye care into primary healthcare services. © 2015 John Wiley & Sons Ltd.
Aldulaimi, Sommer; Mora, Francisco E
Ecuador is a country with few resources to spend on health care. Historically, Ecuador has struggled to find a model for health care that is efficient, effective, and available to all people in the country, even those in underserved and rural communities. In 2000, the Ecuador Ministry of Public Health implemented a new system of health care that used primary care as its platform. Since then, Ecuador has been able to increase its health care efficiency, increasing its ranking from 111 of 211 countries worldwide in 2000, to 20 of 211 countries in 2014. This article briefly reviews the new components of the system implemented in Ecuador and examines the tools used to accomplish this. The discussion also compares and contrasts the Ecuador and US systems, and identifies concepts and policies from Ecuador that could improve the US system. © Copyright 2017 by the American Board of Family Medicine.
Full Text Available Abstract Background Despite the increasing usage and popularity of chiropractic care, there has been limited research conducted to examine the professional relationships between conventional trained primary care physicians (PCPs and chiropractors (DCs. The objectives of our study were to contrast the intra-professional referral patterns among PCPs with referral patterns to DCs, and to identify predictors of PCP referral to DCs. Methods We mailed a survey instrument to all practicing PCPs in the state of Iowa. Descriptive statistics were used to summarize their responses. Multivariable logistic regression analyses were conducted to identify demographic factors associated with inter-professional referral behaviors. Results A total of 517 PCPs (33% participated in the study. PCPs enjoyed strong intra-professional referral relationships with other PCPs. Although patients exhibited a great deal of interest in chiropractic care, PCPs were unlikely themselves to make formal referral relationships with DCs. PCPs in a private practice arrangement were more likely to exhibit positive referral attitudes towards DCs (p = 0.01. Conclusion PCPs enjoy very good professional relationships with other PCPs. However, the lack of direct formalized referral relationships between PCPs and chiropractors has implications for efficiency, continuity, quality, and patient safety in the health care delivery system. Future research must focus on identifying facilitators and barriers for developing positive relationships between PCPs and chiropractors.
Klemp, Kerstin; Zwart, Dorien; Hansen, Jørgen; Hellebek, Torben; Luettel, Dagmar; Verstappen, Wim; Beyer, Martin; Gerlach, Ferdin M.; Hoffmann, Barbara; Esmail, Aneez
Background: Incident reporting is widely used in both patient safety improvement programmes, and in research on patient safety.Objective: To identify the key requirements for incident reporting systems in primary care; to develop an Internet-based incident reporting and learning system for primary
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.
Donato, Ronald; Segal, Leonie
A strong primary care sector is widely acknowledged as a fundamental component of a well functioning health system and thus has been the focus of strategic reforms in a number of countries. This paper provides an economic analysis of primary healthcare reform, with the aim of identifying the key structural elements that are necessary to support enhanced models of primary health in the Australian context. This paper utilises economic theory, and draws upon empirical evidence and international experience to analyse primary healthcare reform to identify the structural elements necessary for an enhanced primary care sector. The aim of which is to improve health system performance. These structural elements are then critically examined in the Australian health system setting. For enhanced models of primary healthcare to promote efficiency, they must incorporate a number of key structural elements; notably: governance and purchasing responsibilities for primary care devolved to a meso-level organisational structure through capitated single fundholding arrangements; blended payment methods for reimbursing providers; the establishment of a national quality and performance framework; and the development of primary care infrastructure. As the Federal government attempts to address recommendations of the National Health and Hospital Reform Commission, a window of opportunity now exists to pursue long overdue structural reforms to deal with the challenges facing the Australian health system. The paper advances the important structural features to primary healthcare that need to be embraced as the government attempts to pursue its health reform agenda. © 2010 The Authors. ANZJPH © 2010 Public Health Association of Australia.
Mansell, Gemma; Shapley, Mark; Jordan, Joanne L; Jordan, Kelvin
Reducing delay in the primary care part of the cancer care pathway is likely to improve cancer survival. Identifying effective interventions in primary care would allow action by primary healthcare professionals and local commissioners to reduce delay. To identify interventions that reduce primary care delay in the referral of patients with cancer to secondary care. Systematic review in primary care. Eight electronic databases were searched using terms for primary care, cancer, and delay. Exclusion criteria included screening and the 2-week-wait referral system. Reference lists of relevant papers were hand searched. The quality of each paper was assessed using predefined criteria, and checked by a second reviewer. Searches identified 1798 references, of which 22 papers were found to meet the criteria. Interventions concerning education, audit and feedback, decision support software and guideline use, diagnostic tools, and other specific skills training were identified. Most studies reported a positive effect on their specified outcomes, although no study measured a direct effect on reducing delay. There was no evidence that any intervention directly reduced primary care delay in the diagnosis of cancer. Limited evidence suggests that complex interventions, including audit and feedback and specific skills training, have the potential to do so.
Full Text Available Billy M Tsima,1 Vincent Setlhare,1 Oathokwa Nkomazana2 1Department of Family Medicine and Public Health, 2Department of Surgery, Faculty of Medicine, University of Botswana, Gaborone, Botswana Background: Botswana’s health care system is based on a primary care model. Various national guidelines exist for specific diseases. However, most of the guidelines address management at a tertiary level and often appear nonapplicable for the limited resources in primary care facilities. An integrated symptom-based guideline was developed so as to translate the Botswana national guidelines to those applicable in primary care. The Botswana Primary Care Guideline (BPCG integrates the care of communicable diseases, including HIV/AIDS and noncommunicable diseases, by frontline primary health care workers.Methods: The Department of Family Medicine, Faculty of Medicine, University of Botswana, together with guideline developers from the Knowledge Translation Unit (University of Cape Town collaborated with the Ministry of Health to develop the guideline. Stakeholder groups were set up to review specific content of the guideline to ensure compliance with Botswana government policy and the essential drug list.Results: Participants included clinicians, academics, patient advocacy groups, and policymakers from different disciplines, both private and public. Drug-related issues were identified as necessary for implementing recommendations of the guideline. There was consensus by working groups for updating the essential drug list for primary care and expansion of prescribing rights of trained nurse prescribers in primary care within their scope of practice. An integrated guideline incorporating common symptoms of diseases seen in the Botswana primary care setting was developed.Conclusion: The development of the BPCG took a broad consultative approach with buy in from relevant stakeholders. It is anticipated that implementation of the BPCG will translate into better
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
Full Text Available Patients with heart failure have a significant symptom burden and other palliative care needs often over a longer period than patients with cancer. It is acknowledged that this need may be unmet but by how much has not been quantified in primary care data at the population level.This was the first use of Clinical Practice Research Datalink, the world's largest primary care database to explore recognition of the need for palliative care. Heart failure and cancer patients who had died in 2009 aged 18 or over and had at least one year of primary care records were identified. A palliative approach to care among patients with heart failure was compared to that among patients with cancer using entry onto a palliative care register as a marker for a palliative approach to care.Among patients with heart failure, 7% (234/3 122 were entered on the palliative care register compared to 48% (3 669/7 608 of cancer patients. Of heart failure patients on the palliative care register, 29% (69/234 were entered onto the register within a week of their death.This confirms that the stark inequity in recognition of palliative care needs for people with heart failure in a large primary care dataset. We recommend a move away from prognosis based criteria for palliative care towards a patient centred approach, with assessment of and attention to palliative needs including advance care planning throughout the disease trajectory.
Oliveira, Cátia Martins; Casanova, Angela Oliveira
This paper discusses the possibilities of re-orienting work processes at the primary care level in the light of the concepts and pre-suppositions of the health surveillance system. In addition, it presents some key concepts that could help putting into operation a health surveillance system at the local level. One of these concepts is the idea of the territory as a privileged space of primary care, helping to define and identify health needs. The study further emphasizes the heuristic value of integrating knowledge and practices in the various fields of health care so as to ensure a broader vision of problems and comprehensive health care. Finally, it analyzes the contributions from epidemiological, environmental, and health surveillance for consolidating health surveillance into a system not only limited to these three areas of action. Integrated actions of epidemiological, sanitary, and environmental surveillance can favor risk management and allow for innovative and more effective answers to the demands emerging from the health area. In addition, the local teams can acquire practical experience in internal and inter-sectorial actions which, though their importance is recognized in theory, were rarely put into practice.
O'Kelly, C M
BACKGROUND: In 2001, a primary care-based health needs assessment (HNA) in South Inner City of Dublin identified high levels of morbidity and widespread and frequent use of primary care and specialist hospital services as particular concerns. AIMS: This study aims to determine the primary care health needs of a local community, from the perspective of service users and service providers. METHODS: A similar methodology to our 2001 HNA was adopted, involving semi-structured interviews with a convenience sample of patients attending two general practices and key informants regarding local health issues and health service utilisation. RESULTS: High levels of morbidity and chronic illness were found. A correlation between the local environment and ill-health was identified, as well as high utilisation of primary care services in the area. CONCLUSION: The establishment of a Primary Care Team would begin to address the health needs of the community.
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.
Mishori, Ranit; Aleinikoff, Shoshana; Davis, Dawn
Since 1975, more than 3 million refugees have settled in the United States, fleeing unrest, conflict, and persecution. Refugees represent diverse ethnic, cultural, religious, socioeconomic, and educational backgrounds. Despite this heterogeneity, there are commonalities in the refugee experience. Before resettlement, all refugees must undergo an overseas medical screening to detect conditions that pose a potential health threat in the United States. On arrival, they should undergo an examination to detect diseases with high prevalence in their country of origin or departure. Refugees have higher rates of chronic pain compared with the general population, and their mental health and wellbeing are strongly influenced by their migration history. Refugees have higher rates of mood disorders, posttraumatic stress disorder, and anxiety than the general population. Some refugees have been tortured, which contributes to poorer health. Chronic noncommunicable diseases, such as diabetes mellitus and hypertension, are also prevalent among refugees. Many refugees may be missing routine immunizations and screenings for cancer and chronic diseases. Attention to reproductive health, oral health, and vision care will help identify and address previously unmet needs. Refugees face barriers to care as a result of cultural, language, and socioeconomic factors.
Sifaki-Pistolla, Dimitra; Chatzea, Vasiliki-Eirini; Markaki, Adelais; Kritikos, Kyriakos; Petelos, Elena; Lionis, Christos
Despite several countrywide attempts to strengthen and standardise the primary healthcare (PHC) system, Greece is still lacking a sustainable, policy-based model of integrated services. The aim of our study was to identify operational integration levels through existing patient care pathways and to recommend an alternative PHC model for optimum integration. The study was part of a large state-funded project, which included 22 randomly selected PHC units located across two health regions of Greece. Dimensions of operational integration in PHC were selected based on the work of Kringos and colleagues. A five-point Likert-type scale, coupled with an algorithm, was used to capture and transform theoretical framework features into measurable attributes. PHC services were grouped under the main categories of chronic care, urgent/acute care, preventive care, and home care. A web-based platform was used to assess patient pathways, evaluate integration levels and propose improvement actions. Analysis relied on a comparison of actual pathways versus optimal, the latter ones having been identified through literature review. Overall integration varied among units. The majority (57%) of units corresponded to a basic level. Integration by type of PHC service ranged as follows: basic (86%) or poor (14%) for chronic care units, poor (78%) or basic (22%) for urgent/acute care units, basic (50%) for preventive care units, and partial or basic (50%) for home care units. The actual pathways across all four categories of PHC services differed from those captured in the optimum integration model. Certain similarities were observed in the operational flows between chronic care management and urgent/acute care management. Such similarities were present at the highest level of abstraction, but also in common steps along the operational flows. Existing patient care pathways were mapped and analysed, and recommendations for an optimum integration PHC model were made. The developed web
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...
Llobera, Joan; Sansó, Noemí; Ruiz, Amador; Llagostera, Merce; Serratusell, Estefania; Serrano, Carlos; Roselló, María Luisa Martín; Benito, Enric; Castaño, Eusebio J; Leiva, Alfonso
The objective of the Balearic Islands Palliative Care (PC) Program is to improve the quality of PC through a shared model consisting of primary health care professionals, home-based PC teams, and PC units in hospitals. According to the World Health Organization (WHO), patients with advanced cancer and other terminal diseases benefit from early identification and proactive PC. We will evaluate the effectiveness of an intervention in which a PC leader is established in the primary health care center, and assess the effect of this intervention on the early identification of patients in need of PC, the efficient use of health care services, and direct health care costs. Design: A two-arm cluster randomized clinical trial of 30 Primary Health Care Centers (PHCC) in Mallorca (Spain), in which each center was randomized to an intervention arm or a usual care arm. We expect that the number of patients identified as suitable for PC (including non-oncological PC) is at least 5% greater in the intervention arm. A total of 4640 deceased patients. Outcomes will be assessed by a blinded external review of the electronic records. General practitioners (GPs) and nurse leaders in PC for each PHCC will be appointed. These leaders will help promote PC training of colleagues, improve symptom management and psychological support of patients, and evaluate the complexity of individual cases so that these cases receive assistance from PC home-based teams. Early identification (>90 days before death), evaluation of case complexity, level of case complexity (with referral to a home-based PC team), use and cost of hospital and primary care services, and quality of life during the last month of life (≥2 emergency room visits, ≥2 hospital admissions, ≥14 days of hospitalization). PC leaders in primary care teams will improve the early identification of patients eligible for PC. This initiative could improve the quality of end-of-life care and utilization of hospital resources. ISRCTN
Halley, M D; Little, A W
Although hospital-owned primary care practices have been unprofitable for most hospitals, some hospitals are achieving competitive advantage and sustainable practice operations. A key to the success of some has been a net income reporting tool that separates practice operating expenses from the costs of creating and operating a network of practices to help healthcare organization managers, physicians, and staff to identify opportunities to improve the network's financial performance. This "Net One, Net Two" reporting allows operations leadership to be held accountable for Net One expenses and strategic leadership to be held accountable for Net Two expenses.
Hinton, Ladson; Franz, Carol E; Reddy, Geetha; Flores, Yvette; Kravitz, Richard L; Barker, Judith C
To examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care. Cross-sectional qualitative interview study of primary care physicians. Physicians' offices. Forty primary care physicians in Northern California. Open-ended interviews lasted 30-60 minutes and were structured by an interview guide covering clinician background and practice setting, clinical care of a particular patient, and general approach to managing patients with AD or dementia. Interviews were transcribed and themes reflecting constraints of practice were identified through a systematic coding process. Recurring themes (i.e., those present in > or = 25% of physician interviews) included insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams. Physician narratives suggest that these constraints may lead to delayed detection of behavior problems, "reactive" as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches. Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers. Our results suggest that more effective educational interventions (for families and physicians) and broader structural changes are needed to better meet the needs of the elderly with dementia and their families now and in the future. Without these changes, dementia care is likely to continue to fall short.
Camila Eugenia Roseira
Full Text Available ABSTRACT Objective: identify the compliance of health care product processing in Primary Health Care and assess possible differences in the compliance among the services characterized as Primary Health Care Service and Family Health Service. Method: quantitative, observational, descriptive and inferential study with the application of structure, process and outcome indicators of the health care product processing at ten services in an interior city of the State of São Paulo - Brazil. Results: for all indicators, the compliance indices were inferior to the ideal levels. No statistically significant difference was found in the indicators between the two types of services investigated. The health care product cleaning indicators obtained the lowest compliance index, while the indicator technical-operational resources for the preparation, conditioning, disinfection/sterilization, storage and distribution of health care products obtained the best index. Conclusion: the diagnosis of compliance of health care product processing at the services assessed indicates that the quality of the process is jeopardized, as no results close to ideal levels were obtained at any service. In addition, no statistically significant difference in these indicators was found between the two types of services studied.
Elias, Sjoerd G; Kok, Liselotte; Witteman, Ben J M; Goedhard, Jelle G; Romberg-Camps, Mariëlle J L; Muris, Jean W M; de Wit, Niek J; Moons, Karel G M
OBJECTIVE: To validate published diagnostic models for their ability to safely reduce unnecessary endoscopy referrals in primary care patients suspected of significant colorectal disease. STUDY DESIGN AND SETTING: Following a systematic literature search, we independently validated the identified
Conclusion: The sub-group of people with diabetes identified to have worse tensional control should have a different and more intensive approach in primary care. We recommend further longitudinal and population based confirmatory research.
Holtman, Gea A.; Kranenberg, Justin J.; Blanker, Marco H.; Ott, Alewijn; Lisman-van Leeuwen, Yvonne; Berger, Marjolein Y.
Background. Dientamoeba fragilis is commonly identified in children in primary care and is suspected to cause gastrointestinal disease. Objective. To determine the association between D. fragilis colonization and gastrointestinal symptoms in children. Methods. We performed a cross-sectional study
Oude Nijeweme-d'Hollosy, Wendeline; van Velsen, Lex Stefan; Huygens, Martine; Hermens, Hermanus J.
Despite eHealth technology's rapid growth, eHealth applications are rarely embedded within primary care, mostly because systems lack interoperability. This article identifies requirements for, and barriers towards, interoperable eHealth technology from healthcare professionals' perspective -- the
Sinnige, J.; Korevaar, J.C.; Westert, G.P.; Spreeuwenberg, P.; Schellevis, F.G.; Braspenning, J.C.C.
BACKGROUND: To support the management of multimorbid patients in primary care, evidence is needed on prevalent multimorbidity patterns. OBJECTIVE: To identify the common and distinctive multimorbidity patterns. METHODS: Clinical data of 120480 patients (>/=55 years) were extracted from 158 general
Conclusion: Our study identified that follow-up by GPs after RP is insufficient. Accordingly, there is a requirement for formal educational programs if primary care is to take a greater role in follow-up of these patients.
Conclusion: The prevalence of both depressive symptomatology and impairment of quality of life is significant and primary care with simple, validated tools can be the setting for identifying and helping such patients.
Lindbloom, Erik J; Ewigman, Bernard G; Hickner, John M
Medical research has traditionally been based in academic centers, and the findings are frequently not applicable in community primary care settings. The result is a large gap between the possible and the practical in delivering high-quality primary medical care in the United States. Practice-based research networks (PBRNs), laboratories for primary care clinical research, are the appropriate vehicles for uniting the worlds of community primary care practice and clinical research. Although they have received little attention in the mainstream of clinical and health services research, PBRNs have already reported a variety of findings useful for primary care providers, and these networks have helped to identify key issues in healthcare delivery that affect important outcomes. In this report, we outline the rationale for and history of PBRNs. We describe the organization and work of several productive PBRNs, giving examples of their studies that have changed the standards of modern primary care practice. Finally, we describe a developing electronic process for identifying research questions obtained directly from primary care providers that can be used to focus the national primary care research agenda on questions of clinical relevance and importance. As electronic technologies are fully developed and tested, they will facilitate communication between clinicians and researchers, thereby improving the effectiveness and efficiency of practice-based research.
Bailie, Jodie; Matthews, Veronica; Laycock, Alison; Schultz, Rosalie; Burgess, Christopher P; Peiris, David; Larkins, Sarah; Bailie, Ross
Like other colonised populations, Indigenous Australians experience poorer health outcomes than non-Indigenous Australians. Preventable chronic disease is the largest contributor to the health differential between Indigenous and non-Indigenous Australians, but recommended best-practice preventive care is not consistently provided to Indigenous Australians. Significant improvement in health care delivery could be achieved through identifying and minimising evidence-practice gaps. Our objective was to use clinical audit data to create a framework of the priority evidence-practice gaps, strategies to address them, and drivers to support these strategies in the delivery of recommended preventive care. De-identified preventive health clinical audit data from 137 primary health care (PHC) centres in five jurisdictions were analysed (n = 17,108 audited records of well adults with no documented major chronic disease; 367 system assessments; 2005-2014), together with stakeholder survey data relating to interpretation of these data, using a mixed-methods approach (n = 152 responses collated in 2015-16). Stakeholders surveyed included clinicians, managers, policy officers, continuous quality improvement (CQI) facilitators and academics. Priority evidence-practice gaps and associated barriers, enablers and strategies to address the gaps were identified and reported back through two-stages of consultation. Further analysis and interpretation of these data were used to develop a framework of strategies and drivers for health service improvement. Stakeholder identified priorities were: following-up abnormal test results; completing cardiovascular risk assessments; timely recording of results; recording enquiries about living conditions, family relationships and substance use; providing support for clients identified with emotional wellbeing risk; enhancing systems to enable team function and continuity of care. Drivers identified for improving care in these areas included
A Retrospective Study of the Incidence of Missed Opportunities in Identifying, Managing and Referring At-Risk of Overweight and Overweight Children and Adolescents in an Outpatient Primary Care Setting
A descriptive study of the incidence of missed opportunities in identifying, managing and referring children and adolescents at-risk of overweight and overweight were conducted using a retrospective...
Full Text Available INTRODUCTION: International research consistently shows that sole mothers experience poorer health and suboptimal health care access. New Zealand studies on sole mothers' health report similar findings. The aim of this exploratory research was to better understand the experiences of Maori sole mothers' access to health services, particularly primary health care, for personal health needs. METHODS: This qualitative study employed a general inductive design informed by a Kaupapa Maori approach, providing guidance on appropriate cultural protocols for recruiting and engaging Maori participants. Distributing written information and snowballing techniques were used to purposively recruit seven Maori sole mothers. Data collection involved semi-structured interviews which were digitally recorded and transcribed verbatim. Data were analysed using general inductive thematic analysis to identify commonalities and patterns in participants' experiences. FINDINGS: The dominant themes that emerged captured and described participants' experiences in accessing health care. The major barrier to access reported was cost. Compounding cost, transport difficulties and location or scheduling of services were additional barriers to health service accessibility. Child-related issues also posed a barrier, including prioritising children's needs and childcare over personal health needs. CONCLUSION: The findings illuminate Maori sole mothers' experiences of accessing health care and the complex socioeconomic inequalities affecting access options and uptake of services. Further investigation of barriers to access is needed. The study has implications for addressing barriers to access at policy, funding and practice levels to improve health outcomes and equitable health care access for Maori sole mothers.
People who are homeless encounter barriers to primary care despite having greater needs for health care, on average, than people who are not homeless. We evaluated the effectiveness of interventions to improve access to primary care for people who are homeless. We performed a systematic review to identify studies in English published between January 1, 1995, and July 8, 2015, comparing interventions to improve access to a primary care provider with usual care among people who are homeless. The outcome of interest was access to a primary care provider. The risk of bias in the studies was evaluated, and the quality of the evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. From a total of 4,047 citations, we identified five eligible studies (one randomized controlled trial and four observational studies). With the exception of the randomized trial, the risk of bias was considered high in the remaining studies. In the randomized trial, people who were homeless, without serious mental illness, and who received either an outreach intervention plus clinic orientation or clinic orientation alone, had improved access to a primary care provider compared with those receiving usual care. An observational study that compared integration of primary care and other services for people who are homeless with usual care did not observe any difference in access to a primary care provider between the two groups. A small observational study showed improvement among participants with a primary care provider after receiving an intervention consisting of housing and supportive services compared with the period before the intervention. The quality of the evidence was considered moderate for both the outreach plus clinic orientation and clinic orientation alone, and low to very low for the other interventions. Despite limitations, the literature identified reports of interventions developed to overcome
Modell, Vicki; Quinn, Jessica; Ginsberg, Grant; Gladue, Ron; Orange, Jordan; Modell, Fred
This study seeks to generate analytic insights into risk management and probability of an identifiable primary immunodeficiency defect. The Jeffrey Modell Centers Network database, Jeffrey Modell Foundation's 10 Warning Signs, the 4 Stages of Testing Algorithm, physician-reported clinical outcomes, programs of physician education and public awareness, the SPIRIT® Analyzer, and newborn screening, taken together, generates P values of less than 0.05%. This indicates that the data results do not occur by chance, and that there is a better than 95% probability that the data are valid. The objectives are to improve patients' quality of life, while generating significant reduction of costs. The advances of the world's experts aligned with these JMF programs can generate analytic insights as to risk management and probability of an identifiable primary immunodeficiency defect. This strategy reduces the uncertainties related to primary immunodeficiency risks, as we can screen, test, identify, and treat undiagnosed patients. We can also address regional differences and prevalence, age, gender, treatment modalities, and sites of care, as well as economic benefits. These tools support high net benefits, substantial financial savings, and significant reduction of costs. All stakeholders, including patients, clinicians, pharmaceutical companies, third party payers, and government healthcare agencies, must address the earliest possible precise diagnosis, appropriate intervention and treatment, as well as stringent control of healthcare costs through risk assessment and outcome measurement. An affected patient is entitled to nothing less, and stakeholders are responsible to utilize tools currently available. Implementation offers a significant challenge to the entire primary immunodeficiency community.
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.
Behrens, Garance; Bocherens, Astrid; Senn, Nicolas
Esophageal candidiasis is one of the most common opportunistic infections in patients infected by human immunodeficiency virus (HIV). This pathology is also found in patients without overt immunodeficiency. Other risk factors are known to be associated with this disease like inhaled or systemic corticosteroid treatment or proton-pump inhibitors and H2 receptor antagonists. In the absence of identified risk factors, a primary immune deficiency should be sought. Prevention of esophageal candidiasis is based primarily on the identification of risk factors, and a better control of them. This article presents a review of the physiopathology, clinical presentation and management of esophageal candidiasis by primary care physicians. We will also discuss ways of preventing esophageal candidiasis when necessary.
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
Manzar, Shabih; Nair, Arun K; Pai, Mangalore G; Al-Khusaiby, Saleh M
Caring for infants born with lesions that are either incompatible with life or conditions that will not allow meaningful survival is an ethical dilemma. Provision of intensive ineffective care to these infants may be labeled as "futile care" which can consume a major proportion of total hospital expenditure. We conducted the present study to look at the extent of futility in a neonatal intensive care unit (NICU) setting. All neonates with lesion either incompatible with life or conditions that will not allow meaningful survival admitted during April 2003 to September 2003 in the Neonatal Intensive Care Unit, Royal Hospital, Muscat, Sultanate of Oman, were reviewed to identify futility. Bed days were used as surrogate for extent of futile care and resource consumption. A total of 355 infants were admitted to the NICU during the study period representing 4452 consecutive patient bed days. Twenty-five infants fulfilled the criteria of futility. Total length of stay of futile group was 317 (7.1%) days as compared to 4153 (92.8%) days in the non-futile group. The bed occupancy for futile care cases was less than 8% of all the NICU beds suggesting only a small proportion of resource consumption. Based on this, expecting cost savings from further limiting futile care in neonates is not warranted and is negligible. Ethically, we are assured that the majority of the care provided to our sick neonates are appropriate.
Berenson, Robert A; Burton, Rachel A; McGrath, Megan
Many view advanced primary care models such as the patient-centered medical home as foundational for accountable care organizations (ACOs), but it remains unclear how these two delivery reforms are complementary and how they may produce conflict. The objective of this study was to identify how joining an ACO could help or hinder a primary care practice's efforts to deliver high-quality care. This qualitative study involved interviews with a purposive sample of 32 early adopters of advanced primary care and/or ACO models, drawn from across the U.S. and conducted in mid-2014. Interview notes were coded using qualitative data analysis software, permitting topic-specific queries which were then summarized. Respondents perceived many potential benefits of joining an ACO, including care coordination staff, data analytics, and improved communication with other providers. However, respondents were also concerned about added "bureaucratic" requirements, referral restrictions, and a potential inability to recoup investments in practice improvements. Interviewees generally thought joining an ACO could complement a practice's efforts to deliver high-quality care, yet noted some concerns that could undermine these synergies. Both the advantages and disadvantages of joining an ACO seemed exacerbated for small practices, since they are most likely to benefit from additional resources yet are most likely to chafe under added bureaucratic requirements. Our identification of the potential pros and cons of joining an ACO may help providers identify areas to examine when weighing whether to enter into such an arrangement, and may help ACOs identify potential areas for improvement. Copyright © 2016 Elsevier Inc. All rights reserved.
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.
Parker, D.; Wensing, M.; Esmail, A.; Valderas, J.M.
BACKGROUND: There is little guidance available to healthcare practitioners about what tools they might use to assess the patient safety culture. OBJECTIVE: To identify useful tools for assessing patient safety culture in primary care organizations in Europe; to identify those aspects of performance
Randall, C S; Bergus, G R; Schlechte, J A; McGuinness, G; Mueller, C W
Satisfaction is known to impact work performance, learning, recruitment, and retention. This study identifies the factors associated with primary care residents' satisfaction with their training. We used a cross-sectional survey based on the Price-Mueller model of job satisfaction. The model included 14 job characteristics, four personal characteristics, and four demographic factors. Data were collected in February and March 1996 from residents in three primary care training programs (family practice, pediatrics, and internal medicine) at a large academic medical center. The same standardized, self-administered questionnaires were used in all three departments. Seventy-five percent (n = 119) of the residents returned questionnaires. Five job characteristics were positively associated with resident satisfaction: continuity of care, autonomy, collegiality, work that encourages professional growth, and work group loyalty. Role conflict, a sixth job characteristic, was negatively associated with satisfaction. The personal characteristic of having an optimistic outlook on life was also positively associated with satisfaction. The model explained 66% of the variation in self-reported satisfaction. The satisfaction of the residents was significantly associated with six job characteristics and one personal factor. Interventions based on these job characteristics may increase resident satisfaction and may lead to better patient outcomes, better work performance, greater patient satisfaction, and more success in recruiting top students into a residency.
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 ...
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 ...
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…
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
Thomas, Celeste C; Zeytinoglu, Meltem
Diabetes mellitus, thyroid disorders, and osteoporosis are endocrine conditions affecting a significant proportion of women presenting to the obstetrician-gynecologist. Obstetrician-gynecologists are often the first health-care providers that young women see in adulthood, and thus, have a critical opportunity to identify women at risk for gestational and overt diabetes and manage the condition in those who have developed it. The obstetrician-gynecologist should be aware of the appropriate therapeutic options and treatment goals (eg, hemoglobin A1c) for women with diabetes. Thyroid disorders often present with menstrual irregularities or infertility, can affect pregnancy outcomes, and contribute to cardiovascular and bone disorders as women age. Finally, osteoporosis and low bone mineral density affect a substantial proportion of older women and some younger women with risk factors for secondary osteoporosis. The morbidity and mortality of osteoporotic fractures is substantial. There are many lifestyle interventions and therapeutic options available for these conditions, and the gynecologist plays a key role in optimizing risk factor assessment, screening, and providing treatment when appropriate. Copyright © 2016 Elsevier Inc. All rights reserved.
McIntyre, Meredith; Francis, Karen; Chapman, Ysanne
in 2009 the Australian government announced a programme of reform that will change the way maternity services have traditionally been delivered. A shift to a primary maternity care model has occurred despite strong challenges from medicine and a general public that has embraced high technology in all aspects of life including childbirth. a critical analysis was undertaken for the purpose of identifying discourses that have influenced the direction of the Australian maternity care reform agenda. within a critical discourse analysis framework data were collected from state, territory and commonwealth government policy documents, and selected written submissions from national key stakeholder organisations to the National Review of Maternity Services 2008. three discourses influencing the direction of the reform are described, these include the following: 'Australia is one of the safest place to give birth or to be born, but not for everyone'; 'maternity care is primarily about mothers and babies, not about the service or the health professionals' and 'government must ensure provision of safe and sustainable maternity services'. the Australian government has strong support for the primary maternity care reform backed by a strong key stakeholder alliance involving consumers, midwives and rural doctors. On the contrary to the position of the key stakeholder alliance, the obstetric position has been unable to provide government with solutions to escalating costs and workforce deficits in the delivery of safe and sustainable maternity services. Consumers, rural doctors, midwives and government all agree on the need to safeguard excellent safety and quality standards whilst at the same time reducing high levels of medical intervention and providing options for care in a reformed maternity service designed to meet the needs of all Australian women. Crown Copyright © 2011. Published by Elsevier Ltd. All rights reserved.
Rahul M. Prasad
Full Text Available Over the past decade, primary cilia have emerged as the premier means by which cells sense and transduce mechanical stimuli. Primary cilia are sensory organelles that have been shown to be vitally involved in the mechanosensation of urine in the renal nephron, bile in the hepatic biliary system, digestive fluid in the pancreatic duct, dentin in dental pulp, lacunocanalicular fluid in bone and cartilage, and blood in vasculature. The prevalence of primary cilia among mammalian cell types is matched by the tremendously varied disease states caused by both structural and functional defects in cilia. In the process of delineating the mechanisms behind these disease states, calcium fluorimetry has been widely utilized as a means of quantifying ciliary function to both fluid flow and pharmacological agents. In this review, we will discuss the approaches used in associating calcium levels to cilia function.
Full Text Available Human health has became a topic that is required exploration and development since the existence of humanity. Many of the diseases out of during the human life and with the miscellaneous invention; solution ways were sought. Development of antibiotics and vaccines are featured inventions in this warfare. Vaccine is known as the best alternative and may be primarily preferred method. Study was conducted to determine of costs and comparison of estimates of the families. In order to investigate the prediction of family about cost and vaccine applications a survey prepared that is reached with a link to the survey on the internet and 170 people participated. According to 2013 childhood immunization schedule; 21 doses of vaccine are administered for 13 varieties of disease. While in the market price of vaccines were identified as TL1094.54 Ministry of Health vaccine price is TL320.22 for a child. Families vaccinated or have been vaccinated their 98% of children to the family physicians or health care facilities. Primarialy reasons of families to prefer primary health care as a priority are vaccines stored in safer conditions and better monitoring of the vaccination time in family physician system. When the cost of immunization that is primary of protective health services analysed significant differences between the ministry prices with the market price is present, families are not aware enough about these costs have been identified.
Bluestein, Daniel; Rutledge, Carolyn M; Healey, Amanda C
Insomnia is a substantive primary care issue that leads to adverse outcomes. These can be improved by addressing factors that accentuate insomnia severity. Accordingly, this study identifies correlates of insomnia severity and determines whether these relationships vary with sociodemographic attributes. This correlational cross-sectional study was conducted in a hospital-sponsored primary care clinic and 2 urban, academic family practice centers. Participants consisted of 236 patients 18 years old or older with clinically significant insomnia (Insomnia Severity Index scores of 7 or more). Surveys instruments included the Insomnia Severity Index, SF-8 (Medical Outcomes Study SF-8 global health status measure), CES-D (Center for Epidemiologic Studies-Depression Scale), DBAS (Dysfunctional Beliefs about Sleep scale), SE-S (Self-Efficacy for Sleep Scale), and a researcher-designed demographic survey. Analytic techniques included descriptive statistics to characterize the study sample, Pearson or Spearman Correlation Coefficients to examine individual associations with insomnia severity, and step-wise linear regression to identify net predictors. Insomnia severity was significantly correlated with health status, depression, self-efficacy, and dysfunctional beliefs (P insomnia severity was best predicted by low self-efficacy and high depression scores. These findings indicate that clinicians treating insomnia should not only manage comorbid depression but also facilitate self-efficacy for sleep-inducing behavioral change.
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...
locations in time and space through semiotic texts is presented, and subsequently applied as a method of analyzing and evaluating the communicative effect of an electronic care record in home care in Denmark. Paradoxes of communication are identified and discussed in relation to the practice...... and organizational development with the electronic record. Identifying errors of communicating through IT providesa crucial opportunity for the organization to reflect on its own working conditions and to educate clinicians to become co-authors and co-designers of ICT-devices....
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
Sanchez-Piedra, Carlos Alberto; Jaruseviciene, Lina; Prado-Galbarro, Francisco Javier; Liseckiene, Ida; Sánchez-Alonso, Fernando; García-Pérez, Sonia; Sarria Santamera, Antonio
Given the importance of primary care to healthcare systems and population health, it seems crucial to identify factors that contribute to the quality of primary care. Professional satisfaction has been linked with quality of primary care. Physician dissatisfaction is considered a risk factor for burnout and leaving medicine. This study explored factors associated with professional satisfaction in seven European countries. A survey was conducted among primary care physicians. Estonia, Finland, Germany and Hungary used a web-based survey, Italy and Lithuania a telephone survey, and Spain face to face interviews. Sociodemographic information (age, sex), professional experience and qualifications (years since graduation, years of experience in general practice), organizational variables related to primary care systems and satisfaction were included in the final version of the questionnaire. A logistic regression analysis was performed to assess the factors associated with satisfaction among physicians. A total of 1331 primary care physicians working in primary care services responded to the survey. More than half of the participants were satisfied with their work in primary care services (68.6%). We found significant associations between satisfaction and years of experience (OR = 1.01), integrated network of primary care centres (OR = 2.8), patients having direct access to specialists (OR = 1.3) and professionals having access to data on patient satisfaction (OR = 1.3). Public practice, rather than private practice, was associated with lower primary care professional satisfaction (OR = 0.8). Elements related to the structure of primary care are associated with professional satisfaction. At the individual level, years of experience seems to be associated with higher professional satisfaction.
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
Leung, Lucinda B; Yoon, Jean; Rubenstein, Lisa V; Post, Edward P; Metzger, Maureen E; Wells, Kenneth B; Sugar, Catherine A; Escarce, José J
Aiming to foster timely, high-quality mental health care for Veterans, VA's Primary Care-Mental Health Integration (PC-MHI) embeds mental health specialists in primary care and promotes care management for depression. PC-MHI and patient-centered medical home providers work together to provide the bulk of mental health care for primary care patients with low-to-moderate-complexity mental health conditions. This study examines whether increasing primary care clinic engagement in PC-MHI services is associated with changes in patient health care utilization and costs. We performed a retrospective longitudinal cohort study of primary care patients with identified mental health needs in 29 Southern California VA clinics from October 1, 2008 to September 30, 2013, using electronic administrative data (n = 66,638). We calculated clinic PC-MHI engagement as the proportion of patients receiving PC-MHI services among all primary care clinic patients in each year. Capitalizing on variation in PC-MHI engagement across clinics, our multivariable regression models predicted annual patient use of 1) non-primary care based mental health specialty (MHS) visits, 2) total mental health visits (ie, the sum of MHS and PC-MHI visits), and 3) health care utilization and costs. We controlled for year- and clinic-fixed effects, other clinic interventions, and patient characteristics. Median clinic PC-MHI engagement increased by 8.2 percentage points over 5 years. At any given year, patients treated at a clinic with 1 percentage-point higher PC-MHI engagement was associated with 0.5% more total mental health visits (CI, 0.18% to 0.90%; P = .003) and 1.0% fewer MHS visits (CI, -1.6% to -0.3%; P = .002); this is a substitution rate, at the mean, of 1.5 PC-MHI visits for each MHS visit. There was no PC-MHI effect on other health care utilization and costs. As intended, greater clinic engagement in PC-MHI services seems to increase realized accessibility to mental health care for primary care
Batista, Ricardo; Pottie, Kevin; Bouchard, Louise; Ng, Edward; Tanuseputro, Peter; Tugwell, Peter
To examine two healthcare models, specifically "Primary Medical Care" (PMC) and "Primary Health Care" (PHC) in the context of immigrant populations' health needs. We conducted a systematic scoping review of studies that examined primary care provided to immigrants. We categorized studies into two models, PMC and PHC. We used subjects of access barriers and preventive interventions to analyze the potential of PMC/PHC to address healthcare inequities. From 1385 articles, 39 relevant studies were identified. In the context of immigrant populations, the PMC model was found to be more oriented to implement strategies that improve quality of care of the acute and chronically ill, while PHC models focused more on health promotion and strategies to address cultural and access barriers to care, and preventive strategies to address social determinants of health. Primary Health Care models may be better equipped to address social determinants of health, and thus have more potential to reduce immigrant populations' health inequities.
Bazemore, Andrew; Phillips, Robert L.; Etz, Rebecca S.; Stange, Kurt C.
Objectives. We sought to understand how national policy key informants perceive the value and changing role of primary care in the context of emerging political opportunities. Methods. We conducted 13 semistructured interviews in May 2011 with leaders of federal agencies, think tanks, nonprofits, and quality standard–defining organizations with influence over health care reform policies and implementation. We recorded the interviews and used an editing and immersion–crystallization analysis approach to identify themes. Results. We identified 4 themes: (1) affirmation of primary care as the foundation of a more effective health care system, (2) the patient-centered medical home as a transitional step to foster practice innovation and payment reform, (3) the urgent need for an increased focus on community and population health in primary care, and (4) the ongoing need for advocacy and research efforts to keep primary care on public and policy agendas. Conclusions. Current efforts to reform primary care are only intermediate steps toward a system with a greater focus on community and population health. Transformed and policy-enabled primary care is an essential link between personalized care and population health. PMID:22690969
Bower, Peter; Knowles, Sarah; Coventry, Peter A; Rowland, Nancy
The prevalence of mental health and psychosocial problems in primary care is high. Counselling is a potential treatment for these patients, but there is a lack of consensus over the effectiveness of this treatment in primary care. To assess the effectiveness and cost effectiveness of counselling for patients with mental health and psychosocial problems in primary care. To update the review, the following electronic databases were searched: the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers (to December 2010), MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials (to May 2011). Randomised controlled trials of counselling for mental health and psychosocial problems in primary care. Data were extracted using a standardised data extraction sheet by two reviewers. Trials were rated for quality by two reviewers using Cochrane risk of bias criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. There was no assessment of adverse events. Nine trials were included in the review, involving 1384 randomised participants. Studies varied in risk of bias, although two studies were identified as being at high risk of selection bias because of problems with concealment of allocation. All studies were from primary care in the United Kingdom and thus comparability was high. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in terms of mental health outcomes in 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...
PRImary care Streptococcal Management (PRISM) study: identifying clinical variables associated with Lancefield group A β-haemolytic streptococci and Lancefield non-Group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat
Little, Paul; Moore, Michael; Hobbs, F D R; Mant, David; McNulty, Cliodna; Williamson, Ian; Cheng, Edith; Stuart, Beth; Kelly, Joanne; Barnett, Jane; Mullee, Mark
Objective To assess the association between features of acute sore throat and the growth of streptococci from culturing a throat swab. Design Diagnostic cohort. Setting UK general practices. Participants Patients aged 5 or over presenting with an acute sore throat. Patients were recruited for a second cohort (cohort 2, n=517) consecutively after the first (cohort 1, n=606) from similar practices. Main outcome Predictors of the presence of Lancefield A/C/G streptococci. Results The clinical score developed from cohort 1 had poor discrimination in cohort 2 (bootstrapped estimate of area under the receiver operator characteristic (ROC) curve (0.65), due to the poor validity of the individual items in the second data set. Variables significant in multivariate analysis in both cohorts were rapid attendance (prior duration 3 days or less; multivariate adjusted OR 1.92 cohort, 1.67 cohort 2); fever in the last 24 h (1.69, 2.40); and doctor assessment of severity (severely inflamed pharynx/tonsils (2.28, 2.29)). The absence of coryza or cough and purulent tonsils were significant in univariate analysis in both cohorts and in multivariate analysis in one cohort. A five-item score based on Fever, Purulence, Attend rapidly (3 days or less), severely Inflamed tonsils and No cough or coryza (FeverPAIN) had moderate predictive value (bootstrapped area under the ROC curve 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection (38% in cohort 1, 36% in cohort 2 scored ≤1, associated with a streptococcal percentage of 13% and 18%, respectively). A Centor score of ≤1 identified 23% and 26% of participants with streptococcal percentages of 10% and 28%, respectively. Conclusions Items widely used to help identify streptococcal sore throat may not be the most consistent. A modified clinical scoring system (FeverPAIN) which requires further validation may be clinically helpful in identifying individuals who are
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
Al Sayah, Fatima; Szafran, Olga; Robertson, Sandra; Bell, Neil R; Williams, Beverly
This study investigated nurses' roles and their perspectives on the factors that influence interdisciplinary teamwork within Canadian primary care setting. Interdisciplinary teams have shown to lead to better system- and patient-level outcomes and, accordingly, have became important aspects of healthcare systems especially within primary care settings. Nurses play a key role in these primary care teams, particularly with respect to chronic disease management. A focused ethnography design using semi-structured individual interviews was conducted. Interviews were conducted with 20 primary care nurses between July 2010-May 2011. Interviews were recorded, transcribed, and content and thematic analysis was performed. Nurses experienced increasing scope of practice and professional responsibility as they transitioned into the primary care setting. Nine major roles of primary care nurses were identified. Several factors that facilitate or hinder teamwork were identified and categorised under four theme areas: (1) organisation/leadership (e.g. having common goals and mandate, unclear descriptions of team members' roles); (2) team relationships (e.g. closed loop of communication, trust, respect); (3) process/support (e.g. unclear referral process and reporting structure, large patient panels); and (4) physical environment (e.g. decentralised model of care). Nurses' roles within primary care setting appear to be focused mainly on case management. Minimal orientation and lack of preparation of nurses for their roles, vagueness of these roles among the interdisciplinary primary care team members and lack of communication appeared to be among the most important factors that influence teamwork and nurses' functioning within these teams. Given that nurses play a key role in interdisciplinary primary care teams, particularly in managing chronic disease patients, approaches to improve chronic disease management and care of these patients should incorporate strategies to ensure
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…
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...
Full Text Available Abstract Background Attention Deficit Hyperactivity Disorder (ADHD is a common childhood psychiatric disorder. The management of ADHD has recently been highlighted. The National Institute of Clinical Excellence (NICE and Scottish Intercollegiate Guidelines network (SIGN have both produced management guidelines. Doctors working within Primary Care in countries such as the United States play an important role in the management of ADHD. In the United Kingdom however the role of doctors in primary care in the management of ADHD, both individually and within shared care protocols, is only now being identified and defined. Is this role for Primary Care likely to be acceptable and effective? Discussion There is some evidence that doctors working within Primary Care in the United Kingdom are willing to follow up children on medication for ADHD and carry out monitoring of physical status. However many feel unconfident in the management of ADHD and most have received little or no training in child psychiatry. There are also concerns that adverse media reports will have an undue influence on the attitudes of doctors within primary care to families with children suffering from ADHD. Summary There are important barriers to be tackled before shared care protocols for ADHD can be successfully implemented in the United Kingdom. Tailored information about ADHD needs to be provided to doctors in primary care. Clear dialogue between planners and healthcare professionals from both primary and secondary care is essential to ensure that service delivery is acceptable to healthcare providers, tailored to their skills and is adequately resourced.
Shen, J; Eyaid, W; Mochida, G; Al-Moayyad, F; Bodell, A; Woods, C; Walsh, C
Background: Human autosomal recessive primary microcephaly (MCPH) is a heterogeneous disorder with at least six genetic loci (MCPH1–6), with MCPH5, caused by ASPM mutation, being the most common. Despite the high prevalence of epilepsy in microcephaly patients, microcephaly with frequent seizures has been excluded from the ascertainment of MCPH. Here, we report a pedigree with multiple affected individuals with microcephaly and seizures.
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.
Porras-Javier, Lorena; Bromley, Elizabeth; Lopez, Maria; Coker, Tumaini R
Publicly insured children needing referral to mental health (MH) services often do not access or receive services. The objective of this study was to identify gaps in communication and coordination between primary care providers (PCPs) and MH providers during the MH referral and care process for publicly insured children. Thirteen semi-structured interviews were conducted with 10 PCPs and staff from a federally qualified health center (FQHC) and 6 MH providers and staff from two local MH clinics. Interview participants identified multiple gaps in communication throughout the care process and different phases as priorities for improvement. PCPs described primary care-MH communication challenges during early phases, while MH providers described coordination challenges in transferring patients back to primary care for ongoing mental health management. Strategies are needed to improve primary care-specialty MH communication and coordination throughout all phases of the referral and care process, particularly at initial referral and transfer back to primary care.
Vives-Relats, Carme; Ferré-Grau, Carme; Rodero-Sánchez, Virtudes; Cid-Buera, Dolors
This case discussion starts from the Uncertainty Theory of illness of Merle Mishel, who raised the idea that even without a solution to the uncertainty, a person should accept it as a part of their life and reinterpret it as an opportunity to promote a new view of life governed by probability. The author proposes theoretical concepts that allow the phenomena experienced by family caregivers to be approached from the perspective of their experiences and stress. It establishes uncertainty and indecisiveness as contradictions that should not create anxiety permanently. This can be released gradually, if we create lines of flight though the care. Among these lines are located the Problem Solving Method as a strategy useful in primary health care to reduce the uncertainty of the caregivers. This article describes the outcome of Isabel, a 63- year-old female family caregiver of her dependent mother and her daughter with anorexia. The primary care nurse identifies the problem of weariness of the care-givers role and that of conflict of decisions during home visits. It describes the assessment made from the main concepts of the theory and the work with the care-givers by the problem solving method in order to reduce anxiety and help to mobilize internal resources and increase their welfare. Copyright © 2010 Elsevier España, S.L. All rights reserved.
Johnson, Heather M; Thorpe, Carolyn T; Bartels, Christie M; Schumacher, Jessica R; Palta, Mari; Pandhi, Nancy; Sheehy, Ann M; Smith, Maureen A
Young adults meeting hypertension diagnostic criteria have a lower prevalence of a hypertension diagnosis than middle-aged and older adults. The purpose of this study was to compare the rates of a new hypertension diagnosis for different age groups and identify predictors of delays in the initial diagnosis among young adults who regularly use primary care. A 4-year retrospective analysis included 14 970 patients, at least 18 years old, who met clinical criteria for an initial hypertension diagnosis in a large, Midwestern, academic practice from 2008 to 2011. Patients with a previous hypertension diagnosis or prior antihypertensive medication prescription were excluded. The probability of diagnosis at specific time points was estimated by Kaplan-Meier analysis. Cox proportional hazard models (hazard ratio; 95% confidence interval) were fit to identify predictors of delays to an initial diagnosis, with a subsequent subset analysis for young adults (18-39 years old). After 4 years, 56% of 18-24-year-olds received a diagnosis compared with 62% (25-31-year-olds), 68% (32-39-year-olds), and more than 70% (≥40-year-olds). After adjustment, 18-31-year-olds had a 33% slower rate of receiving a diagnosis (18-24 years hazard ratio 0.66, 0.53-0.83; 25-31 years hazard ratio 0.68, 0.58-0.79) compared with adults at least 60 years. Other predictors of a slower diagnosis rate among young adults were current tobacco use, white ethnicity, and non-English primary language. Young adults with diabetes, higher blood pressures, or a female provider had a faster diagnosis rate. Provider and patient factors are critical determinants of poor hypertension diagnosis rates among young adults with regular primary care use.
Stall, Nathan; Nowaczynski, Mark; Sinha, Samir K
To describe the effect of home-based primary care for homebound older adults on individual, caregiver, and systems outcomes. A systematic review of home-based primary care interventions for community-dwelling older adults (aged ≥65) using the Cochrane, PubMed, and MEDLINE databases from the earliest available date through March 15, 2014. Studies were included if the house calls visitor was the ongoing primary care provider and if the intervention measured emergency department visits, hospitalizations, hospital beds days of care, long-term care admissions, or long-term care bed days of care. Home-based primary care programs. Homebound community-dwelling older adults (N = 46,154). Emergency department visits, hospitalizations, hospital bed days of care, long-term care admissions, long-term care bed days of care, costs, program design, and individual and caregiver quality of life and satisfaction with care. Of 357 abstracts identified, nine met criteria for review. The nine interventions were all based in North America, with five emerging from the Veterans Affairs system. Eight of nine programs demonstrated substantial effects on at least one inclusion outcome, with seven programs affecting two outcomes. Six interventions shared three core program components: interprofessional care teams, regular interprofessional care meetings, and after-hours support. Specifically designed home-based primary care programs may substantially affect individual, caregiver and systems outcomes. Adherence to the core program components identified in this review could guide the development and spread of these programs. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.
Costa, Ediná Alves; Araújo, Patrícia Sodré; Penaforte, Thais Rodrigues; Barreto, Joslene Lacerda; Guerra, Augusto Afonso; Acurcio, Francisco de Assis; Guibu, Ione Aquemi; Alvares, Juliana; Costa, Karen Sarmento; Karnikowski, Margô Gomes de Oliveira; Soeiro, Orlando Mario; Leite, Silvana Nair
To identify and discuss the conceptions of pharmaceutical services in Brazilian Primary Health Care, according to different subjects. This study 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), which is composed of an information survey in a representative sample of cities, stratified according to Brazilian regions, and a subsample of primary health care services. Municipal secretaries of health, those responsible for pharmaceutical services, and those responsible for medicine delivery in pharmacies/dispensing units of the selected services were interviewed. The questionnaires included one question about the understanding of the interviewee regarding pharmaceutical services. The content analysis technique was used to apprehend, in the statements, the meanings attributed to pharmaceutical services, which were subsequently classified into categories according to their main conceptions. Among the wide diversity of conceptions on pharmaceutical services (PS), we highlight the ones focused on 1) logistic control of medicines with activities concerning guidance or information on their use and 2) guidance or information to users on the use of medicine. The findings reveal a shifting tendency from a medicine-focused conception to one that considers the users and their needs as the final recipient of these actions. However, the lack of references to conceptions regarding care management and integrality point out the slowness of this change; after all, this is a social and historical process that comprises the production of meanings that transcend legal, logistic, and technical arrangements in pharmaceutical services. The diversity of conceptions expresses the several meanings attributed to pharmaceutical services; we also identified, in their reorientation process, a movement that reflects a gradual
Ediná Alves Costa
Full Text Available ABSTRACT OBJECTIVE To identify and discuss the conceptions of pharmaceutical services in Brazilian Primary Health Care, according to different subjects. METHODS This study 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, which is composed of an information survey in a representative sample of cities, stratified according to Brazilian regions, and a subsample of primary health care services. Municipal secretaries of health, those responsible for pharmaceutical services, and those responsible for medicine delivery in pharmacies/dispensing units of the selected services were interviewed. The questionnaires included one question about the understanding of the interviewee regarding pharmaceutical services. The content analysis technique was used to apprehend, in the statements, the meanings attributed to pharmaceutical services, which were subsequently classified into categories according to their main conceptions. RESULTS Among the wide diversity of conceptions on pharmaceutical services (PS, we highlight the ones focused on 1 logistic control of medicines with activities concerning guidance or information on their use and 2 guidance or information to users on the use of medicine. The findings reveal a shifting tendency from a medicine-focused conception to one that considers the users and their needs as the final recipient of these actions. However, the lack of references to conceptions regarding care management and integrality point out the slowness of this change; after all, this is a social and historical process that comprises the production of meanings that transcend legal, logistic, and technical arrangements in pharmaceutical services. CONCLUSIONS The diversity of conceptions expresses the several meanings attributed to pharmaceutical services; we also identified
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.
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.
Virani, Salim S; Akeroyd, Julia M; Ramsey, David J; Deswal, Anita; Nasir, Khurram; Rajan, Suja S; Ballantyne, Christie M; Petersen, Laura A
Although effectiveness of diabetes or cardiovascular disease (CVD) care delivery between physicians and advanced practice providers (APPs) has been shown to be comparable, health care resource utilization between these 2 provider types in primary care is unknown. This study compared health care resource utilization between patients with diabetes or CVD receiving care from APPs or physicians. Diabetes (n = 1,022,588) or CVD (n = 1,187,035) patients with a primary care visit between October 2013 and September 2014 in 130 Veterans Affairs facilities were identified. Using hierarchical regression adjusting for covariates including patient illness burden, the authors compared number of primary or specialty care visits and number of lipid panels and hemoglobinA1c (HbA1c) tests among diabetes patients, and number of primary or specialty care visits and number of lipid panels and cardiac stress tests among CVD patients receiving care from physicians and APPs. Physicians had significantly larger patient panels compared with APPs. In adjusted analyses, diabetes patients receiving care from APPs received fewer primary and specialty care visits and a greater number of lipid panels and HbA1c tests compared with patients receiving care from physicians. CVD patients receiving care from APPs received more frequent lipid testing and fewer primary and specialty care visits compared with those receiving care from physicians, with no differences in the number of stress tests. Most of these differences, although statistically significant, were numerically small. Health care resource utilization among diabetes or CVD patients receiving care from APPs or physicians appears comparable, although physicians work with larger patient panels.
O'Sullivan, M; Cullen, W; MacFarlane, A
The Irish government published its primary care strategy, Primary Care: A New Direction in 2001. Progress with the implementation of Primary care teams is modest. The aim of this paper is to map the Irish grey literature and peer-reviewed publications to determine what research has been carried out in relation to primary care teams, the reform process and interdisciplinary working in primary care in Ireland. This scoping review employed three methods: a review of Web of Science, Medline and Embase databases, an email survey of researchers across academic institutions, the HSE and independent researchers and a review of Lenus and the Health Well repository. N = 123 outputs were identified. N = 14 were selected for inclusion. A thematic analysis was undertaken. Common themes identified were resources, GP participation, leadership, clarity regarding roles in primary care teams, skills and knowledge for primary care team working, communication and community. There is evidence of significant problems that disrupt team formation and functioning that warrants more comprehensive research.
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
Denneson, Lauren M; Williams, Holly B; Kaplan, Mark S; McFarland, Bentson H; Dobscha, Steven K
We describe Veterans Affairs (VA) primary care received by veterans with mental health symptoms in the year prior to suicide to identify opportunities to improve care. Death certificate data from 11 states were linked to VA national patient care data for veterans who died by suicide in 2009 and had received VA care. We identified 118 age-, sex- and clinician-matched case-control pairs (suicide decedents and living controls) with mental health symptoms. Using McNemar's chi-square and paired t tests, we compare primary care follow-up received during the year prior to death. Cases and controls received similar primary care clinician follow-up and treatment for mental health symptoms. Cases were less likely than controls to fill 90 or more total days of an antidepressant during the year (P=.02), despite no differences in prescription orders from clinicians (P=.05). Cases and controls were equally likely to fill 90 or more consecutive days of an antidepressant (P=.47). Across both groups, 48% (n=113) received assessment for suicidal ideation in primary care. We identified two areas to improve primary care for veterans at risk for suicide: monitoring antidepressant treatment adherence and improving suicidal ideation assessment and follow-up for veterans with mental health symptoms. Published by Elsevier Inc.
Heras-Mosteiro, Julio; Otero-García, Laura; Sanz-Barbero, Belén; Aranaz-Andrés, Jesús María
To address the current economic crisis, governments have promoted austerity measures that have affected the taxpayer-funded health system. We report the findings of a study exploring the perceptions of primary care physicians in Madrid (Spain) on measures implemented in the Spanish health system. We carried out a qualitative study in two primary health care centres located in two neighbourhoods with unemployment and migrant population rates above the average of those in Madrid. Interviews were conducted with 12 primary health care physicians. Interview data were analysed by using thematic analysis and by adopting some elements of the grounded theory approach. Two categories were identified: evaluation of austerity measures and evaluation of decision-making in this process. Respondents believed there was a need to promote measures to improve the taxpayer-funded health system, but expressed their disagreement with the measures implemented. They considered that the measures were not evidence-based and responded to the need to decrease public health care expenditure in the short term. Respondents believed that they had not been properly informed about the measures and that there was adequate professional participation in the prioritization, selection and implementation of measures. They considered physician participation to be essential in the decision-making process because physicians have a more patient-centred view and have first-hand knowledge of areas requiring improvement in the system. It is essential that public authorities actively involve health care professionals in decision-making processes to ensure the implementation of evidence-based measures with strong professional support, thus maintaining the quality of care. Copyright © 2016 SESPAS. Published by Elsevier Espana. All rights reserved.
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.
Lefbom, Bonnie K; Peckens, Neal K
OBJECTIVE To assess the effects of in-person collaborative care by primary care veterinarians (pcDVMs) and board-certified veterinary cardiologists (BCVCs) on survival time of dogs after onset of congestive heart failure (CHF) and on associated revenue for the attending pcDVMs. DESIGN Retrospective cohort study. ANIMALS 26 small-breed dogs treated for naturally occurring CHF secondary to myxomatous mitral valve disease at a multilocation primary care veterinary hospital between 2008 and 2013. PROCEDURES Electronic medical records were reviewed to identify dogs with confirmed CHF secondary to myxomatous mitral valve disease and collect information on patient care, survival time, and pcDVM revenue. Data were compared between dogs that received collaborative care from the pcDVM and a BCVC and dogs that received care from the pcDVM alone. RESULTS Dogs that received collaborative care had a longer median survival time (254 days) than did dogs that received care from the pcDVM alone (146 days). A significant positive correlation was identified between pcDVM revenue and survival time for dogs that received collaborative care (ie, the longer the dog survived, the greater the pcDVM revenue generated from caring for that patient). CONCLUSIONS AND CLINICAL RELEVANCE Findings suggested that collaborative care provided to small-breed dogs with CHF by a BCVC and pcDVM could result in survival benefits for affected dogs and increased revenue for pcDVMs, compared with care provided by a pcDVM alone.
Gerlack, Letícia Farias; Karnikowski, Margô Gomes de Oliveira; Areda, Camila Alves; Galato, Dayani; Oliveira, Aline Gomes de; Álvares, Juliana; Leite, Silvana Nair; Costa, Ediná Alves; Guibu, Ione Aquemi; Soeiro, Orlando Mario; Costa, Karen Sarmento; Guerra, Augusto Afonso; Acurcio, Francisco de Assis
To identify limiting factors in the management of pharmaceutical services in the primary health care provided by the Brazilian Unified Health System (SUS). This study was based on the data from the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil (PNAUM - National Survey on Access, Use and Promotion of Rational Use of Medicines), and it was conducted by interviews with professionals responsible for pharmaceutical services in Brazilian cities, in 2015. To identify the management limiting factors, we considered the organizational, operational, and sustainability indicators of the management. For the analyses, we included the weights and structure of analysis plan for complex samples. The results were expressed by frequencies and measures of central tendency with 95% confidence interval, considering the Brazilian geographic regions. We identified the following limiting factors: lack of pharmaceutical services in the Municipal Health Secretariat organization chart (24%) and in the health plan (18%); lack of participation of managers in the Health Board and the absence of reference to this topic in the agenda of meetings (58.4%); lack of financial autonomy (61.5%) and lack of knowledge on the available values (81.7%); lack of adoption of operational procedures (about 50%) for selection, scheduling, and acquisition; and the fact that most professionals evaluate the organization of pharmaceutical services as good and great (58.8%), despite the worrisome indicators. Pharmaceutical services management is currently supported by a legal and political framework that should guide and contribute to improve the pharmaceutical services in the Brazilian Unified Health System primary health care. However, there is a mismatch between the goals established by these guidelines and what is actually happening.
The present work also proposes a simpleunsupervised learning-based novel approach to identify mis-assemblies in the contigs which was found performingreasonably well when compared to the already existing tools to report mis-assembled contigs. It was observed that theproposed methodology may work as a ...
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.
Imbus, Joseph R; Randle, Reese W; Pitt, Susan C; Sippel, Rebecca S; Schneider, David F
20%-25% of patients with primary hyperparathyroidism will have multigland disease (MGD). Preoperatative imaging can be inaccurate or unnecessary in MGD. Identification of MGD could direct the need for imaging and inform operative approach. The purpose of this study is to use machine learning (ML) methods to predict MGD. Retrospective review of a prospective database. The ML platform, Waikato Environment for Knowledge Analysis, was used, and we selected models for (1) overall accuracy and (2) preferential identification of MGD. A review of imaging studies was performed on a cohort predicted to have MGD. 2010 patients met inclusion criteria: 1532 patients had single adenoma (SA) (76%) and 478 had MGD (24%). After testing many algorithms, we selected two different models for potential integration as clinical decision-support tools. The best overall accuracy was achieved using a boosted tree classifier, RandomTree: 94.1% accuracy; 94.1% sensitivity, 83.8% specificity, 94.1% positive predictive value, and 0.984 area under the receiver operating characteristics curve. To maximize positive predictive value of MGD prediction, a rule-based classifier, JRip, with cost-sensitive learning was used and achieved 100% positive predictive value for MGD. Imaging reviewed from the cohort of 34 patients predicted to have MGD by the cost-sensitive model revealed 39 total studies performed: 28 sestamibi scans and 11 ultrasounds. Only 8 (29%) sestamibi scans and 4 (36%) ultrasounds were correct. ML methods can help distinguish MGD early in the clinical evaluation of primary hyperparathyroidism, guiding further workup and surgical planning. Copyright © 2017 Elsevier Inc. All rights reserved.
The European Alcohol Action Plan stresses that health care systems, traditionally involved in the management of alcohol problems, must play a greater role in the detection and prevention of alcohol-related harm. Primary health care is seen as an important setting for identifying individuals at risk from heavy drinking and helping them to reduce…
Wagemakers, Harry P. A.; Luijsterburg, Pim A. J.; Heintjes, Edith M.; Berger, Marjolein Y.; Verhaar, Jan A. N.; Koes, Bart W.; Bierma-Zeinstra, Sita M. A.
Background: Prognosis of persistent complaints after knee injury is based on secondary care populations. In a primary care setting, however, no studies have addressed this issue. Aim: To identify possible predictors of persistent complaints 1 year after a knee injury. These predictors are important
Norful, Allison Andreno; Swords, Kyleen; Marichal, Mickaela; Cho, Hwayoung; Poghosyan, Lusine
The U.S. primary care system is under tremendous strain to deliver care to an increased volume of patients with a concurrent primary care physician shortage. Nurse practitioner (NP)-physician comanagement of primary care patients has been proposed by some policy makers to help alleviate this strain. To date, no collective evidence demonstrates the effects of NP-physician comanagement in primary care. This is the first review to synthesize all available studies that compare the effects of NP-physician comanagement to an individual physician managing primary care. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) framework guided the conduct of this systematic review. Five electronic databases were searched. Titles, abstracts, and full texts were reviewed, and inclusion/exclusion criteria were applied to narrow search results to eligible studies. Quality appraisal was performed using Downs and Black's quality checklist for randomized and nonrandomized studies. Six studies were identified for synthesis. Three outcome categories emerged: (a) primary care provider adherence to recommended care guidelines, (b) empirical changes in clinical patient outcomes, and (c) patient/caregiver quality of life. Significantly more recommended care guidelines were completed with NP-physician comanagement. There was variability of clinical patient outcomes with some findings favoring the comanagement model. Limited differences in patient quality of life were found. Across all studies, the NP-physician comanagementcare delivery model was determined to produce no detrimental effect on measured outcomes and, in some cases, was more beneficial in reaching practice and clinical targets. The use of NP-physician comanagement of primary care patients is a promising delivery care model to improve the quality of care delivery and alleviate organizational strain given the current demands of increased patient panel sizes and primary care physician shortages. Future
Turner, Helen E; Peake, Roy W A; Allison, James J
Spurious hyperkalaemia is a relatively common occurrence in samples originating from primary care. Failure to identify spurious hyperkalaemia carries a significant risk of patient mismanagement. We have carried out a retrospective evaluation to review the impact of the use of centrifuges in primary care for biochemistry blood samples on the management of hyperkalaemia. Serum potassium concentrations in samples received from primary care were reviewed for six months prior to and after the implementation of on-site centrifugation. Samples exhibiting significant hyperkalaemia (serum potassium >6.0 mmol/L) were further investigated to ascertain the degree of patient follow-up. There was a significant decrease in the number of samples exhibiting marked hyperkalaemia following the implementation (2244 versus 524; P centrifugation of serum samples in primary care improves the sample quality and the integrity of the potassium results reported. We have also demonstrated evidence of an improvement in patient management and quality of care.
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.
Aljuburi, Ghida; Phekoo, Karen J; Okoye, Nv Ogo; Anie, Kofie; Green, Stuart A; Nkohkwo, Asaah; Ojeer, Patrick; Ndive, Comfort; Banarsee, Ricky; Oni, Lola; Majeed, Azeem
To assess sickle cell disease (SCD) patient and carer perspectives on the primary care services related to SCD that they receive from their general practitioner (GP). A focus group discussion was used to elicit the views of patients about the quality of care they receive from their primary health-care providers and what they thought was the role of primary care in SCD management. The focus group discussion was video recorded. The recording was then examined by the project team and recurring themes were identified. A comparison was made with notes made by two scribes also present at the discussion. Sickle Cell Society in Brent, UK. Ten participants with SCD or caring for someone with SCD from Northwest London, UK. Patients' perceptions about the primary care services they received, and a list of key themes and suggestions. Patients and carers often bypassed GPs for acute problems but felt that GPs had an important role to play around repeat prescriptions and general health care. These service users believed SCD is often ignored and deemed unimportant by GPs. Participants wanted the health service to support primary health-care providers to improve their knowledge and understanding of SCD. Key themes and suggestions from this focus group have been used to help develop an educational intervention for general practice services that will be used to improve SCD management in primary care.
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
M. de Wet
Full Text Available In the effort to stem the HIV pandemic, the promotion of the correct and consistent use of condoms has to be a priority in the primary health care sector. This study, concentrating on the southern Free State, sought to identify obstacles to condom usage and to develop strategies to encourage condom usage. Both primary health care workers and their clients served as respondents in the study.
Poghosyan, Lusine; Norful, Allison A; Martsolf, Grant R
Developing team-based care models and expanding nurse practitioner (NP) workforce in primary care are recommended by policy makers to meet demand. Little is known how to promote interprofessional teamwork. Using a mixed-methods design, we analyzed qualitative interview and quantitative survey data from primary care NPs to explore practice characteristics important for teamwork. The Interprofessional Teamwork for Health and Social Care Framework guided the study. We identified NP-physician and NP-administration relationships; organizational support and governance; time and space for teamwork; and regulations and economic impact as important. Practice and policy change addressing these factors is needed for effective interprofessional teamwork.
Justin K. Benzer
Full Text Available Objective. There is limited theory regarding the real-world implementation of mental health care in the primary care setting: a type of organizational coordination intervention. The purpose of this study was to develop a theory to conceptualize the potential causes of barriers and facilitators to how local sites responded to this mandated intervention to achieve coordinated mental health care. Methods. Data from 65 primary care and mental health staff interviews across 16 sites were analyzed to identify how coordination was perceived one year after an organizational mandate to provide integrated mental health care in the primary care setting. Results. Standardized referral procedures and communication practices between primary care and mental health were influenced by the organizational factors of resources, training, and work design, as well as provider-experienced organizational boundaries between primary care and mental health, time pressures, and staff participation. Organizational factors and provider experiences were in turn influenced by leadership. Conclusions. Our emergent theory describes how leadership, organizational factors, and provider experiences affect the implementation of a mandated mental health coordination intervention. This framework provides a nuanced understanding of the potential barriers and facilitators to implementing interventions designed to improve coordination between professional groups.
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.
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
Telepaediatrics, which has the potential to improve paediatric care if expert knowledge is not locally available, involves transfer of information between two or more locations, to aid diagnosis or management and/or to allow continuing professional development and education. Developed nations first introduced telemedicine ...
Primary health care facility infrastructure and services and the nutritional status of children 0 to 71 months old and their caregivers attending these facilities in four rural districts in the Eastern Cape and KwaZulu-Natal provinces, South Africa.
Knowledge and attitude of primary health care providers regarding domestic violence. A validation study. Shaikha S Al-Hajeri, Eman Y Al-Otibie, Tahani K Habib, Medhat El-Shazly, Mohamed I Kamel, Thuraya AA Ghayath ...
The importance of primary care in medical education is recognized internationally. This medical speciality offers a lot of different and attractive aspects. Beyond the milestones of primary care in medical education is the teaching of medical assessment, skills and practical approach. Thus, primary care will get more interesting and attractive. In medical education, primary care should be thought mainly through clerkships, courses and tutorials. Clerkships should be offered during the whole period of medical school. For medical students, GP surgery should become a «place for apprenticeship». Innovative teaching methods like courses with simulated patients and blended learning, may increase the attractivity. Preceptors must be aware of their function as role models.
Holm, Anne; Aabenhus, Rune
in primary care. The aim of this study was to determine the accuracy of urine culture from different sampling-techniques in symptomatic non-pregnant women in primary care. Methods: A systematic review was conducted by searching Medline and Embase for clinical studies conducted in primary care using...... a randomized or paired design to compare the result of urine culture obtained with two or more collection techniques in adult, female, non-pregnant patients with symptoms of urinary tract infection. We evaluated quality of the studies and compared accuracy based on dichotomized outcomes. Results: We included...... seven studies investigating urine sampling technique in 1062 symptomatic patients in primary care. Mid-stream-clean-catch had a positive predictive value of 0.79 to 0.95 and a negative predictive value close to 1 compared to sterile techniques. Two randomized controlled trials found no difference...
The purpose of this research is to design a patient telephone appointment system for use in the Naval Medical Center San Diego's high volume Primary Care sites, which will reduce variation and ensure...
Budtz-Lilly, Anna; Fink, Per; Ørnbøl, Eva
Mange patienter henvender sig i almen praksis med legemlige symptomer, som ikke passer med traditionelt definerede sygdomme (også kaldet medicinsk uforklarede eller funktionelle symptomer). På baggrund af forskning i almen praksis er der nu udviklet kriterier for en ny diagnose for patienter med ...
Koppula, Sudha; Brown, Judith B; Jordan, John M
To explore the experiences and recommendations for recruitment of family physicians who practise and teach primary care obstetrics. Qualitative study using in-depth interviews. Six primary care obstetrics groups in Edmonton, Alta, that were involved in teaching family medicine residents in the Department of Family Medicine at the University of Alberta. Twelve family physicians who practised obstetrics in groups. All participants were women, which was reasonably representative of primary care obstetrics providers in Edmonton. Each participant underwent an in-depth interview. The interviews were audiotaped and transcribed verbatim. The investigators independently reviewed the transcripts and then analyzed the transcripts together in an iterative and interpretive manner. Themes identified in this study include lack of confidence in teaching, challenges of having learners, benefits of having learners, and recommendations for recruiting learners to primary care obstetrics. While participants described insecurity and challenges related to teaching, they also identified positive aspects, and offered suggestions for recruiting learners to primary care obstetrics. Despite describing poor confidence as teachers and having challenges with learners, the participants identified positive experiences that sustained their interest in teaching. Supporting these teachers and recruiting more such role models is important to encourage family medicine learners to enter careers such as primary care obstetrics.
Full Text Available Abstract Objective – Systematic searching is central to guideline development, yet guidelines in social care present a challenge to systematic searching because they exist within a highly complex policy and service environment. The objective of this study was to highlight challenges and inform practice on identifying social care research literature, drawing on experiences from guideline development in social care. Methods – The researchers reflected on the approaches to searching for research evidence to inform three guidelines. They evaluated the utility of major topic-focused bibliographic database sources through a determining the yield of citations from the search strategies for two guidelines and b identifying which databases contain the citations for three guidelines. The researchers also considered the proportion of different study types and their presence in certain databases. Results – There were variations in the ability of the search terms to capture the studies from individual databases, even with low-precision searches. These were mitigated by searching a combination of databases and other resources that were specific to individual topics. A combination of eight databases was important for finding literature for the included topics. Multiple database searching also mitigates the currency of content, topic and study design focus, and consistency of indexing within individual databases. Conclusion – Systematic searching for research evidence in social care requires considerable thought and development so that the search is fit for the particular purpose of supporting guidelines. This study highlights key challenges and reveals trends when utilising some commonly used databases.
Granero-Moya, Nani; Frías-Osuna, Antonio; Barrio-Cantalejo, Inés M; Ramos-Morcillo, Antonio Jesús
To know the primary care nurses' difficulties to promote advance care planning process with patients in the end of life. Phenomenological qualitative methodology. Health Management Area North of Jaén. Primary care nurses. Purposive sampling. Fourteen in-depth interviews were conducted until the speeches saturation. Content analysis in four steps: transcription, coding, obtaining results and conclusions verification. Supported whit the software Nvivo 8. Triangulation of results between researchers. Professionals' difficulties: Lack of knowledge about the topic, lack of communication skills, lack of experience and presence of negative emotions. In the health institution lack of time and interference with other professionals is a barrier. Also the patient's attitude and the family are identified as an obstacle because few people speak about the end of life. Finally, our society prevents open discussion about issues related to death. Professional learning about advanced care planning, training in communication skills and emotional education are necessary. Health managers should consider the fact that early interventions for planning health decisions require training, time and continued attention. If a cultural change does not happen, an evasive way to face the end of life will persist. Copyright Â© 2016 Elsevier España, S.L.U. All rights reserved.
Kwong, Jonathan L; Ross, Garry; Turner, Linda; Olynyk, Chris; Cheskes, Sheldon; Thurston, Adam; Verbeek, P Richard
Limited evidence supports primary care paramedic (PCP) direct transport of ST-segment elevation myocardial infarction (STEMI) patients for percutaneous coronary intervention (PCI). The goal of this study was to evaluate an urban-based PCP STEMI bypass guideline. We reviewed consecutive Toronto Paramedic Services call reports between April 7, 2015, and May 31, 2016, regarding STEMI patients identified by PCPs. The primary outcome was patient assignment (stable versus unstable) according to guideline criteria. Secondary outcomes were the proportion of PCP-transported patients who had an indication for an advanced care intervention (ACI) or who received an ACI when PCPs rendezvoused with an advanced care paramedic (ACP). Lastly, we reviewed prehospital outcomes of cardiac arrest patients and calculated the difference in transport intervals between direct PCP bypass and a PCI-centre and predicted transport interval to the closest emergency department (ED). Of 361 patients, 232 were PCP transports and 129 were ACP-rendezvous transports. There was a significant difference in the distribution of stable and unstable patients between PCPs and ACPs (p<0.001). For PCP patients, 21/232 (9.1%) had indications for an ACI, whereas 34/129 (26.4%) ACP patients received an ACI. Eleven patients experienced cardiac arrest; 10 were successfully resuscitated (5 of these by PCPs). The median difference between direct PCP bypass and a PCI-centre versus transport to the closest ED was 5.53 minutes (IQR=6.71). We found a significant difference in the distribution of stable and unstable patients and fewer patients with indications for an ACI in PCP patients. This PCP STEMI bypass guideline appears feasible.
Berenguera, Anna; Pons-Vigués, Mariona; Moreno-Peral, Patricia; March, Sebastià; Ripoll, Joana; Rubio-Valera, Maria; Pombo-Ramos, Haizea; Asensio-Martínez, Angela; Bolaños-Gallardo, Eva; Martínez-Carazo, Catalina; Maderuelo-Fernández, José Ángel; Martínez-Andrés, Maria; Pujol-Ribera, Enriqueta
Primary health care (PHC) is the ideal setting to provide integrated services centred on the person and to implement health promotion (HP) activities. To identify proposals to approach HP in the context of primary care according to health-care users aged 45-75 years, key community informants and primary care centre (PCC) workers. Descriptive-interpretive qualitative research with 276 participants from 14 PCC of seven Spanish regions. A theoretical sampling was used for selection. A total of 25 discussion groups, two triangular groups and 30 semi-structured interviews were carried out. A thematic interpretive contents analysis was carried out. Participants consider that HP is not solely a matter for the health sector and they emphasize intersectoral collaboration. They believe that it is important to strengthen community initiatives and to create a healthy social environment that encourages greater responsibility and participation of health-care users in decisions regarding their own health and better management of public services and resources. HP, care in the community and demedicalization should be priorities for PHC. Participants propose organizational changes in the PCC to improve HP. PCC workers are aware that HP falls within the scope of their responsibilities and propose to increase their training, motivation, competences and knowledge of the social environment. Informants emphasize that HP should be person-centred approach and empathic communication. HP activities should be appealing, ludic and of proven effectiveness. According to a socio-ecological and intersectoral model, PHC services must get actively involved in HP together with community and through outreach interventions. © 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.
Primary health care is analyzed as the alternative throughwhich health systems will recover the role they had during thelate twentieth century: working with other sectors to implementhealth promotion actions to improve the users’ quality of lifeand equity. A renewal is presented in recognition of the effortsduring the final century to establish primary care policies andprograms as the core of the health systems, emphasizing thereorientation of health services. This paper discusses the princip...
Holman, G Talley; Beasley, John W; Karsh, Ben-Tzion; Stone, Jamie A; Smith, Paul D; Wetterneck, Tosha B
Primary care efficiency and quality are essential for the nation's health. The demands on primary care physicians (PCPs) are increasing as healthcare becomes more complex. A more complete understanding of PCP workflow variation is needed to guide future healthcare redesigns. This analysis evaluates workflow variation in terms of the sequence of tasks performed during patient visits. Two patient visits from 10 PCPs from 10 different United States Midwestern primary care clinics were analyzed to determine physician workflow. Tasks and the progressive sequence of those tasks were observed, documented, and coded by task category using a PCP task list. Variations in the sequence and prevalence of tasks at each stage of the primary care visit were assessed considering the physician, the patient, the visit's progression, and the presence of an electronic health record (EHR) at the clinic. PCP workflow during patient visits varies significantly, even for an individual physician, with no single or even common workflow pattern being present. The prevalence of specific tasks shifts significantly as primary care visits progress to their conclusion but, notably, PCPs collect patient information throughout the visit. PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a "dance" between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice. Future healthcare redesigns should support a wide variety of task sequences to deliver high-quality primary care. The development of tools such as electronic health records must be based on the realities of primary care visits if they are to successfully support a PCP's mental and physical work, resulting in effective, safe, and efficient primary care. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: email@example.com.
The majority of hypertension detection and management in Canada is provided by family physicians. Although various organizations have called attention to the poor rates of hypertension detection and control on a worldwide basis, the tools and infrastructure that allow for better hypertension management have generally been lacking in primary care. Recent advances in the fields of primary care and chronic disease management have led to the development of frameworks wherein chronic diseases such...
JENKINS, RACHEL; KIIMA, DAVID; NJENGA, FRANK; OKONJI, MARX; KINGORA, JAMES; KATHUKU, DAMMAS; LOCK, SARAH
Integration of mental health into primary care is essential in Kenya, where there are only 75 psychiatrists for 38 million population, of whom 21 are in the universities and 28 in private practice. A partnership between the Ministry of Health, the Kenya Psychiatric Association and the World Health Organization (WHO) Collaborating Centre, Institute of Psychiatry, Kings College London was funded by Nuffield Foundation to train 3,000 of the 5,000 primary health care staff in th...
Crossland, Lisa; Janamian, Tina; Jackson, Claire L
To identify elements that are integral to high-quality practice and determine considerations relating to high-quality practice organisation in primary care. A narrative systematic review of published and grey literature. Electronic databases (PubMed, CINAHL, the Cochrane Library, Embase, Emerald Insight, PsycInfo, the Primary Health Care Research and Information Service website, Google Scholar) were searched in November 2013 and used to identify articles published in English from 2002 to 2013. Reference lists of included articles were searched for relevant unpublished articles and reports. Data were configured at the study level to allow for the inclusion of findings from a broad range of study types. Ten elements were most often included in the existing organisational assessment tools. A further three elements were identified from an inductive thematic analysis of descriptive articles, and were noted as important considerations in effective quality improvement in primary care settings. Although there are some validated tools available to primary care that identify and build quality, most are single-strategy approaches developed outside health care settings. There are currently no validated organisational improvement tools, designed specifically for primary health care, which combine all elements of practice improvement and whose use does not require extensive external facilitation.
González-de Paz, L
The clinical decision making process with ethical implications in the area of primary healthcare differs from other healthcare areas. From the ethical perspective it is important to include these issues in the decision making model. This dissertation explains the need for a process of bioethical deliberation for Primary Healthcare, as well as proposing a method for doing so. The decision process method, adapted to this healthcare area, is flexible and requires a more participative Healthcare System. This proposal involves professionals and the patient population equally, is intended to facilitate the acquisition of responsibility for personal and community health. Copyright © 2012 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España. All rights reserved.
Full Text Available Scott E Conard,1 Maureen Reni Courtney21ACAP Health, Dallas, 2College of Nursing, University of Texas, Arlington, TX, USAAbstract: Primary care medicine in the United States is undergoing a revolutionary shift. Primary care providers and their staff have an extraordinary chance to create and participate in exciting new approaches to care. New strategies will require courage, flexibility, and openness to change by every member of the practice team, especially the lead clinician who is most often the physician, but can also be the nurse practitioner or physician's assistant. Providers must first recognize their need to alter their fundamental identity to incorporate a new kind of leadership role—that of the MDCEO™ (i.e., the individual clinician who leads the practice to ensure that quality, service, and financial systems are developed and effectively managed. This paper provides a practical vision and rationale for the required transition in primary care, pointing the way for how to achieve new practice effectiveness through new leadership roles. It also provides a model to evaluate the status of a primary care practice. The authors have extensive experience in working with primary care providers to radically evolve their clinical practices to become MDCEOs™. The MDCEO™ will articulate the vision and strategy for the practice, define and foster the practice culture, and create and facilitate team development and overall high level functioning. Each member of the team can then begin to lead their part of the practice: a 21st century population-oriented, purpose-based practice resulting in increased quality of care, improved patient outcomes, greater financial success, and enhanced peace of mind.Keywords: primary health care organization and administration, health care reform, leadership, patient-centered care
de Sá, Miriam Ribeiro Calheiros; Thomazinho, Paula de Almeida; Santos, Fabiano Luiz; Cavalcanti, Nicolette Celani; Ribeiro, Carla Trevisan Martins; Negreiros, Maria Fernanda Vieira; Vinhaes, Marcia Regina
To review pediatric physical therapy experiences described in the literature and to analyze the production of knowledge on physical therapy in the context of pediatric primary health care (PPHC). A systematic review was conducted according to the PRISMA criteria. The following databases were searched: MEDLINE, LILACS, SciELO, PubMed, Scopus and Cochrane; Brazilian Ministry of Health's CAPES doctoral dissertations database; and System for Information on Grey Literature in Europe (SIGLE). The following search terms were used: ["primary health care" and ("physical therapy" or "physiotherapy") and ("child" or "infant")] and equivalent terms in Portuguese and Spanish, with no restriction on publication year. Thirteen articles from six countries were analyzed and grouped into three main themes: professional dilemmas (three articles), specific competencies and skills required in a PPHC setting (seven articles), and practice reports (four articles). Professional dilemmas involved expanding the role of physical therapists to encompass community environments and sharing the decision-making process with the family, as well as collaborative work with other health services to identify the needs of children. The competencies and skills mentioned in the literature related to the identification of clinical and sociocultural symptoms that go beyond musculoskeletal conditions, the establishment of early physical therapy diagnoses, prevention of overmedication, and the ability to work as team players. Practice reports addressed stimulation in children with neurological diseases, respiratory treatment, and establishing groups with mothers of children with these conditions. The small number of studies identified in this review suggests that there is little knowledge regarding the roles of physical therapists in PPHC and possibly regarding the professional abilities required in this setting. Therefore, further studies are required to provide data on the field, along with a continuing
Although less focused upon given the current emphasis on the patient-centered medical home innovation, the future for US primary care is arguably one that will be characterized by diversity in service delivery structures and personnel. The drivers of this diversity include increased patient demand requiring a larger number of primary care access points; the need for lower-cost delivery structures that can flourish in a low-margin business model; greater interest in primary care delivery by retailers and hospitals that see their involvement as a means to enhance their core business goals; the increased desire by non-physician providers to gain work independence; and a growing cadre of younger PCPs whose career and job preferences leave them open to working in a variety of different settings and structures. A key issue to ask of a more diversified primary care system is whether or not it will be characterized by competition or cooperation. While a competitive system would not be unexpected given historical and current trends, such a system would likely stunt the prospects for a full revitalization of US primary care. However, there is reason to believe that a cooperative system is possible and would be advantageous, given the mutual dependencies that already exist among primary care stakeholders, and additional steps that could be taken to enhance such dependencies even more into the future.
Anaf, Julia; Baum, Fran; Freeman, Toby; Labonte, Ron; Javanparast, Sara; Jolley, Gwyn; Lawless, Angela; Bentley, Michael
To examine case studies of good practice in intersectoral action for health as one part of evaluating comprehensive primary health care in six sites in South Australia and the Northern Territory. Interviews with primary health care workers, collaborating agency staff and service users (Total N=33); augmented by relevant documents from the services and collaborating partners. The value of intersectoral action for health and the importance of partner relationships to primary health care services were both strongly endorsed. Factors facilitating intersectoral action included sufficient human and financial resources, diverse backgrounds and skills and the personal rewards that sustain commitment. Key constraining factors were financial and time limitations, and a political and policy context which has become less supportive of intersectoral action; including changes to primary health care. While intersectoral action is an effective way for primary health care services to address social determinants of health, commitment to social justice and to adopting a social view of health are constrained by a broader health service now largely reinforcing a biomedical model. Effective organisational practices and policies are needed to address social determinants of health in primary health care and to provide a supportive context for workers engaging in intersectoral action. © 2014 Public Health Association of Australia.
Kortekaas, Marlous F; van de Pol, Alma C; van der Horst, Henriëtte E; Burgers, Jako S; Slort, Willemjan; de Wit, Niek J
PURPOSE. Although in the last decades primary care research has evolved with great success, there is a growing need to prioritize the topics given the limited resources available. Therefore, we constructed a nationwide database of ongoing primary care research projects in the Netherlands, and we assessed if the distribution of research topics matched with primary care practice. We conducted a survey among the main primary care research centres in the Netherlands and gathered details of all ongoing primary care research projects. We classified the projects according to research topic, relation to professional guidelines and knowledge deficits, collaborative partners and funding source. Subsequently, we compared the frequency distribution of clinical topics of research projects to the prevalence of problems in primary care practice. We identified 296 ongoing primary care research projects from 11 research centres. Most projects were designed as randomized controlled trial (35%) or observational cohort (34%), and government funded mostly (60%). Thematically, most research projects addressed chronic diseases, mainly cardiovascular risk management (8%), depressive disorders (8%) and diabetes mellitus (7%). One-fifth of the projects was related to defined knowledge deficits in primary care guidelines. From a clinical primary care perspective, research projects on dermatological problems were significantly underrepresented (P = 0.01). This survey of ongoing projects demonstrates that primary care research has a firm basis in the Netherlands, with a strong focus on chronic disease. The fit with primary care practice can improve, and future research should address knowledge deficits in professional guidelines more.
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
Mundt, Marlon P.; Swedlund, Matthew P.
Background. Research shows that high-functioning teams improve patient outcomes in primary care. However, there is no consensus on a conceptual model of team-based primary care that can be used to guide measurement and performance evaluation of teams. Objective. To qualitatively understand whether the Systems Engineering Initiative for Patient Safety (SEIPS) model could serve as a framework for creating and evaluating team-based primary care. Methods. We evaluated qualitative interview data from 19 clinicians and staff members from 6 primary care clinics associated with a large Midwestern university. All health care clinicians and staff in the study clinics completed a survey of their communication connections to team members. Social network analysis identified key informants for interviews by selecting the respondents with the highest frequency of communication ties as reported by their teammates. Semi-structured interviews focused on communication patterns, team climate and teamwork. Results. Themes derived from the interviews lent support to the SEIPS model components, such as the work system (Team, Tools and Technology, Physical Environment, Tasks and Organization), team processes and team outcomes. Conclusions. Our qualitative data support the SEIPS model as a promising conceptual framework for creating and evaluating primary care teams. Future studies of team-based care may benefit from using the SEIPS model to shift clinical practice to high functioning team-based primary care. PMID:27578837
Objective — To obtain feedback from primary care nurses who attended two study days in child and adolescent mental health. The study days aimed to equip nurses with basic assessment and intervention skills for the most common problems in child and adolescent psychiatric nursing. Method — All 144 and 68 primary ...
Blendon, R J; Szalay, U S; Altman, D E; Chervinsky, G
Voters in the June 2 last-in-the-nation California primary indicated that candidates' character, experience, and leadership ability have become more significant than their stands on such issues as health reform. However, among substantive campaign issues, health care ranked second, behind the economy. That is consistent with previous poll results from New Hampshire, the nation's first primary state.
Drug interactions in primary health care in the George subdistrict, South Africa: a cross-sectional study. PA Kapp, AC Klop, LS Jenkins. Abstract. Objectives: To investigate the prevalence of potential drug-drug interactions in primary healthcare clinics in the George subdistrict, to determine which drugs were involved, and to ...
Objective: The aim of the study was to reveal extent of burnout problem among primary care physicians and the socio-demographic factors affecting its occurrence. Methods: The target population included all physicians working in these two health regions in Kuwait. Two hundred physicians working in the primary health ...
Verbakel, Natasha J.; Langelaan, Maaike; Verheij, Theo J. M.; Wagner, Cordula; Zwart, Dorien L. M.
Background: Patient safety culture, described as shared values, attitudes and behavior of staff in a health-care organization, gained attention as a subject of study as it is believed to be related to the impact of patient safety improvements. However, in primary care, it is yet unknown, which
Abstract. Background: Drug therapy can improve a patient's quality of life and health outcomes if only used properly. However, data on prescription quality at primary health care facilities in Tanzania is scanty. The objective of this study was to assess the quality of drug prescriptions in selected health care facilities in.
Background: The National Health Insurance Scheme (NHIS) was formally launched in Nigeria in 2005 as an option to help bridge the evident gaps in health care financing, with the expectation of it leading to significant improvement in the country's dismal health status indices. Primary Health Care (PHC) is the nation's ...
Holge-Hazelton, B.; Blake-Gumbs, L.; Miedema, B.; Rijswijk, E. van
PURPOSE: Internationally, family physicians (FP) are not routinely involved in young adult cancer (YAC) care. In this short report, we would like to make a compelling argument for primary care involvement. METHODS: Comparative descriptions and literature review. RESULTS: Cancer among YAs is rare and
Introduction: the aim of the study is to estimate the prevalence of suicidal ideation among Moroccan consultants in primary health care system. Methods: we conducted a cross sectional survey in three health care centers in two cities of Morocco to estimate the prevalence of suicidal ideation, plan and suicide attempts among ...
Bender, A D; Geoghegan, S S; Lundquist, S H; Cantone, J M; Krasnick, C J
With increasing competition among hospitals, primary care referral development and management programs offer an opportunity for hospitals to increase their admissions. Such programs require careful development, the commitment of the hospital staff to the strategy, an integration of hospital activities, and an understanding of medical practice management.
The aim of the study was to assess the ability of the primary health care workers to provide basic ophthalmic .... Material resources for eye-care delivery in urban South eastern Nigeria. OJM. 2004; 16: .... However, in a country that is not technologically advanced, coupled with the challenges of scarce resources, it may be ...
Heins, M.; Schellevis, F.; Rijken, M.; Hoek, L. van der; Korevaar, J.
Purpose: The number of cancer survivors is increasing, and patients with cancer often experience long-lasting consequences of cancer and its treatment. Because of the variety of health problems and high prevalence of comorbidity, primary care physicians (PCPs) seem obvious candidates to take care of
Primary health care involves a sustained partnership between patients and providers that addresses the majority of a population's health needs over time. Lengthy waiting time, poor access, lack of information and healthy relationship with healthcare workers in outpatient clinics remain a challenge to quality care.
Pain management in primary care – current perspectives. ... Part of the problem lies with some health-care providers who have failed to keep up with the advances in pain medicine and ... The modern paradigm of pain management has moved from this biomedical to the broader biopsychosocial approach, where pain ...
Background: Drug therapy can improve a patient's quality of life and health outcomes if only used properly. However, data on prescription quality at primary health care facilities in Tanzania is scanty. The objective of this study was to assess the quality of drug prescriptions in selected health care facilities in two districts of ...
Seeking to understand patient perspectives is an important step in the efforts to improve the quality of health care. The purpose of this study was to examine patient satisfaction with primary health care (PHC) services. A purposive sample of 19136 patients aged 18 years and above was interviewed at 266 PHC clinics in ...
A SWOT analysis of the pilot project was completed and recommendations were made on how to integrate it into the district health system. Conclusion. Screening with a fundal camera improved the quality of care for diabetic patients and is feasible in the South African public sector, primary care setting. A single technician ...
treated by properly trained middle cadre eye health worker working with simple diagnostic tools in a primary health care setting or by referring to secondary care in a timely ... Personal and environmental hygiene: (regular hand and face washing, proper disposal of garbage, human and animal waste and maintenance of a.
Christensen, Morten Bondo; Nørøxe, Karen Busk; Moth, Grete
OBJECTIVE: General practitioners are the first point of contact in Danish out-of-hours (OOH) primary care. The large number of contacts implies that prescribing behaviour may have considerable impact on health-care expenditures and quality of care. The aim of this study was to examine the prevail......OBJECTIVE: General practitioners are the first point of contact in Danish out-of-hours (OOH) primary care. The large number of contacts implies that prescribing behaviour may have considerable impact on health-care expenditures and quality of care. The aim of this study was to examine...... data. MAIN OUTCOME MEASURES: Prescriptions were categorised according to Anatomical Therapeutic Chemical Classification (ATC) codes and stratified for patient age, gender and contact type (telephone consultation, clinic consultation or home visit). Prescription rates were calculated as number...
Hails, Katherine; Brill, Charlotte D; Chang, Trina; Yeung, Albert; Fava, Maurizio; Trinh, Nhi-Ha
Major depressive disorder (MDD) is a prevalent illness in minority populations. Minority patients with MDD are often unrecognized and untreated. This review examines promising interventions to address MDD in primary care settings, where minority groups are more likely to seek care. Since 2010, eleven interventions have been developed to address patient-specific and provider-specific barriers, many of which are adaptations of the collaborative care model. Other promising interventions include cultural tailoring of the collaborative care model, as well as the addition of telepsychiatry, motivational interviewing, cultural consultation, and innovations in interpreting. Overall, collaborative care was found feasible and improved satisfaction and treatment engagement of depressed minority patients in primary care. It remains inconclusive whether these newer intervention models improve MDD treatment outcomes. Future research will be needed to establish the effectiveness of these intervention models in improving the treatment outcomes of minority populations with MDD.
Delaney, Brendan C; Peterson, Kevin A; Speedie, Stuart; Taweel, Adel; Arvanitis, Theodoros N; Hobbs, F D Richard
The learning health care system refers to the cycle of turning health care data into knowledge, translating that knowledge into practice, and creating new data by means of advanced information technology. The electronic Primary Care Research Network (ePCRN) was a project, funded by the U.S. National Institutes of Health, with the aim to facilitate clinical research using primary care electronic health records (EHRs). We identified the requirements necessary to deliver clinical studies via a distributed electronic network linked to EHRs. After we explored a variety of informatics solutions, we constructed a functional prototype of the software. We then explored the barriers to adoption of the prototype software within U.S. practice-based research networks. We developed a system to assist in the identification of eligible cohorts from EHR data. To preserve privacy, counts and flagging were performed remotely, and no data were transferred out of the EHR. A lack of batch export facilities from EHR systems and ambiguities in the coding of clinical data, such as blood pressure, have so far prevented a full-scale deployment. We created an international consortium and a model for sharing further ePCRN development across a variety of ongoing projects in the United States and Europe. A means of accessing health care data for research is not sufficient in itself to deliver a learning health care system. EHR systems need to use sophisticated tools to capture and preserve rich clinical context in coded data, and business models need to be developed that incentivize all stakeholders from clinicians to vendors to participate in the system.
Thyrian, Jochen René; Hertel, Johannes; Wucherer, Diana; Eichler, Tilly; Michalowsky, Bernhard; Dreier-Wolfgramm, Adina; Zwingmann, Ina; Kilimann, Ingo; Teipel, Stefan; Hoffmann, Wolfgang
Dementia care management (DCM) can increase the quality of care for people with dementia. Methodologically rigorous clinical trials on DCM are lacking. To test the effectiveness and safety of DCM in the treatment and care of people with dementia living at home and caregiver burden (when available). This pragmatic, general practitioner-based, cluster-randomized intervention trial compared the intervention with care as usual at baseline and at 12-month follow-up. Simple 1:1 randomization of general practices in Germany was used. Analyses were intent to treat and per protocol. In total, 6838 patients were screened for dementia (eligibility: 70 years and older and living at home) from January 1, 2012, to March 31, 2016. Overall, 1167 (17.1%) were diagnosed as having dementia, and 634 (9.3%) provided written informed consent to participate. Dementia care management was provided for 6 months at the homes of patients with dementia. Dementia care management is a model of collaborative care, defined as a complex intervention aiming to provide optimal treatment and care for patients with dementia and support caregivers using a computer-assisted assessment determining a personalized array of intervention modules and subsequent success monitoring. Dementia care management was targeted at the individual patient level and was conducted by 6 study nurses with dementia care-specific qualifications. Quality of life, caregiver burden, behavioral and psychological symptoms of dementia, pharmacotherapy with antidementia drugs, and use of potentially inappropriate medication. The mean age of 634 patients was 80 years. A total of 407 patients received the intended treatment and were available for primary outcome measurement. Of these patients, 248 (60.9%) were women, and 204 (50.1%) lived alone. Dementia care management significantly decreased behavioral and psychological symptoms of dementia (b = -7.45; 95% CI, -11.08 to -3.81; P nurses is an effective collaborative care model
Fragmentation of the postmodern family affects several aspects of primary care. In prevention, the physician-patient relationship is most important in forestalling abuse. In morbidity and diagnosis, single or socially isolated patients are more vulnerable to diseases, such as total allergy syndrome. In acute care, fragmentation increases the number of elderly patients in hospital. And in rehabilitation, the two-career family is no longer able to supplement hospital nursing care as it once did. PMID:21229053
Gill, Preetinder Singh
Engaged employees are an asset to any organization. They are instrumental in ensuring good commercial outcomes through continuous innovation and incremental improvement. A health care facility is similar to a regular work setting in many way