Perry, Danielle; Kolber, Michael R; Korownyk, Christina; Lindblad, Adrienne J; Ramji, Jamil; Ton, Joey; Allan, G Michael
To summarize 10 high-quality studies from 2017 that have strong relevance to primary care practice. Study selection involved routine literature surveillance by a group of primary care health professionals. This included screening abstracts of important journals and Evidence Alerts, as well as searching the American College of Physicians Journal Club. Topics of the 2017 articles include whether treating subclinical hypothyroidism improves outcomes or symptoms; whether evolocumab reduces cardiovascular disease as well as low-density lipoprotein levels; whether lifestyle interventions reduce medication use in patients with diabetes; whether vitamin D prevents cardiovascular disease, cancer, or upper respiratory tract infections; whether canagliflozin reduces clinical events in patients with diabetes; how corticosteroid injections affect knee osteoarthritis; whether drained abscesses benefit from antibiotic treatment; whether patients with diabetes benefit from bariatric surgery; whether exenatide reduces clinical events in patients with diabetes; and whether tympanostomy tubes affect outcomes in recurrent acute otitis media or chronic otitis media. We provide brief summaries, context where needed, and final recommendations for 10 studies with potential effects on primary care. We also briefly review 5 "runner-up" studies. Research from 2017 produced several high-quality studies in diabetes management. These have demonstrated benefit for alternative therapies and offered evidence not previously available. This year's selection of studies also provided information on a variety of conditions and therapies that are, or might become, more common in primary care settings. Copyright© the College of Family Physicians of Canada.
Loeb, Danielle F; Bayliss, Elizabeth A; Candrian, Carey; deGruy, Frank V; Binswanger, Ingrid A
Complex patients are increasingly common in primary care and often have poor clinical outcomes. Healthcare system barriers to effective care for complex patients have been previously described, but less is known about the potential impact and meaning of caring for complex patients on a daily basis for primary care providers (PCPs). Our objective was to describe PCPs' experiences providing care for complex patients, including their experiences of health system barriers and facilitators and their strategies to enhance provision of effective care. Using a general inductive approach, our qualitative research study was guided by an interpretive epistemology, or way of knowing. Our method for understanding included semi-structured in-depth interviews with internal medicine PCPs from two university-based and three community health clinics. We developed an interview guide, which included questions on PCPs' experiences, perceived system barriers and facilitators, and strategies to improve their ability to effectively treat complex patients. To focus interviews on real cases, providers were asked to bring de-identified clinical notes from patients they considered complex to the interview. Interview transcripts were coded and analyzed to develop categories from the raw data, which were then conceptualized into broad themes after team-based discussion. PCPs (N = 15) described complex patients with multidimensional needs, such as socio-economic, medical, and mental health. A vision of optimal care emerged from the data, which included coordinating care, preventing hospitalizations, and developing patient trust. PCPs relied on professional values and individual care strategies to overcome local and system barriers. Team based approaches were endorsed to improve the management of complex patients. Given the barriers to effective care described by PCPs, individual PCP efforts alone are unlikely to meet the needs of complex patients. To fulfill PCP's expressed concepts of
Long, Theodore; Chaiyachati, Krisda; Bosu, Olatunde; Sircar, Sohini; Richards, Bradley; Garg, Megha; McGarry, Kelly; Solomon, Sonja; Berman, Rebecca; Curry, Leslie; Moriarty, John; Huot, Stephen
Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine. We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices. This was a qualitative study based on semi-structured, in-person interviews. Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed. We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis. We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program. Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue
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
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.
Stephanie Anna Lenzen; Trudy van der Weijden; Anna Beurskens; Marloes Amantia van Bokhoven; Ramon Daniëls; Jerôme Jean Jacques van Dongen
Background: The number of people with multiple chronic conditions demanding primary care services is increasing. To deal with the complex health care demands of these people, professionals from different disciplines collaborate. This study aims to explore influential factors regarding
Dongen, J.J. van; Lenzen, S.A.; Bokhoven, M.A. van; Daniels, R.; Weijden, T.T. van der; Beurskens, A.
BACKGROUND: The number of people with multiple chronic conditions demanding primary care services is increasing. To deal with the complex health care demands of these people, professionals from different disciplines collaborate. This study aims to explore influential factors regarding
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
Anna Bryndis Blondal
Full Text Available Even though pharmaceutical care is not a new concept in pharmacy, its introduction and development has proved to be challenging. In Iceland, general practitioners are not familiar with pharmaceutical care and additionally no such service is offered in pharmacies or primary care settings. Introducing pharmaceutical care in primary care in Iceland is making great efforts to follow other countries, which are bringing the pharmacist more into patient care. General practitioners are key stakeholders in this endeavor. The aim of this study was to introduce pharmacist-led pharmaceutical care into primary care clinics in Iceland in collaboration with general practitioners by presenting different setting structures. Action research provided the framework for this research. Data was collected from pharmaceutical care interventions, whereby the pharmaceutical care practitioner ensures that each of a patient’s medications is assessed to determine if it is appropriate, effective, safe, and that the patient can take medicine as expected. Sources of data included pharmaceutical care notes on patients, researcher’s notes, meetings, and interviews with general practitioners over the period of the study. The study ran from September 2013 to October 2015. Three separate semi-structured in-depth interviews were conducted with five general practitioners from one primary health care clinic in Iceland at different time points throughout the study. Pharmaceutical care was provided to elderly patients (n = 125 before and between general practitioners’ interviews. The study setting was a primary care clinic in the Reykjavik area and the patients’ homes. Results showed that the GPs’ knowledge about pharmacist competencies as healthcare providers and their potential in patient care increased. GPs would now like to have access to a pharmacist on a daily basis. Direct contact between the pharmacist and GPs is better when working in the same physical space
Schäfer, W.L.A.; Boerma, W.G.W.; Kringos, D.S.; Maeseneer, J. de; Gress, S.; Heinemann, S.; Rotar-Pavlic, D.; Seghieri, C.; Svab, I.; Berg, M.J. van den; Vainieri, M.; Westert, G.P.; Willems, S.; Groenewegen, P.P.
Background: The QUALICOPC (Quality and Costs of Primary Care in Europe) study aims to evaluate the performance of primary care systems in Europe in terms of quality, equity and costs. The study will provide an answer to the question what strong primary care systems entail and which effects primary
Kringos, Dionne; Boerma, Wienke; Bourgueil, Yann; Cartier, Thomas; Dedeu, Toni; Hasvold, Toralf; Hutchinson, Allen; Lember, Margus; Oleszczyk, Marek; Rotar Pavlic, Danica; Svab, Igor; Tedeschi, Paolo; Wilm, Stefan; Wilson, Andrew; Windak, Adam; Van der Zee, Jouke; Groenewegen, Peter
A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking. Evaluation of strength of primary care in Europe. International comparative cross-sectional study performed in 2009-2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey. Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts' consultations. Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries. Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.
Full Text Available Abstract Background Since 2004, 'stepped-care models' have been adopted in several international evidence-based clinical guidelines to guide clinicians in the organisation of depression care. To enhance the adoption of this new treatment approach, a Quality Improvement Collaborative (QIC was initiated in the Netherlands. Methods Alongside the QIC, an intervention study using a controlled before-and-after design was performed. Part of the study was a process evaluation, utilizing semi-structured group interviews, to provide insight into the perceptions of the participating clinicians on the implementation of stepped care for depression into their daily routines. Participants were primary care clinicians, specialist clinicians, and other healthcare staff from eight regions in the Netherlands. Analysis was supported by the Normalisation Process Theory (NPT. Results The introduction of a stepped-care model for depression to primary care teams within the context of a depression QIC was generally well received by participating clinicians. All three elements of the proposed stepped-care model (patient differentiation, stepped-care treatment, and outcome monitoring, were translated and introduced locally. Clinicians reported changes in terms of learning how to differentiate between patient groups and different levels of care, changing antidepressant prescribing routines as a consequence of having a broader treatment package to offer to their patients, and better working relationships with patients and colleagues. A complex range of factors influenced the implementation process. Facilitating factors were the stepped-care model itself, the structured team meetings (part of the QIC method, and the positive reaction from patients to stepped care. The differing views of depression and depression care within multidisciplinary health teams, lack of resources, and poor information systems hindered the rapid introduction of the stepped-care model. The NPT
Batelaan Neeltje M
Full Text Available Abstract Background Anxiety disorders are highly prevalent in primary care and cause a substantial burden of disease. Screening on risk status, followed by preventive interventions in those at risk may prevent the onset of anxiety disorders, and thereby reduce the disease burden. The willingness to participate in screening and interventions is crucial for the scope of preventive strategies, but unknown. This feasibility study, therefore, investigated participation rates of screening and preventive services for anxiety disorders in primary care, and explored reasons to refrain from screening. Methods In three general practices, screening was offered to individuals visiting their general practitioner (total n = 2454. To assess risk status, a 10-item questionnaire was followed by a telephone interview (including the CIDI when scoring above a predefined threshold. Preventive services were offered to those at risk. Participation rates for screening and preventive services for anxiety disorders were assessed. Those not willing to be screened were asked for their main reason to refrain from screening. Results Of all individuals, 17.3% participated in initial screening, and of those with a possible risk status, 56.0% continued screening. In 30.1% of those assessed, a risk status to develop an anxiety disorder was verified. Of these, 22.6% already received some form of mental health treatment and 38.7% of them agreed to participate in a preventive intervention and were referred. The most frequently mentioned reasons to refrain from screening were the emotional burden associated with elevated risk status, the assumption not to be at risk, and a lack of motivation to act upon an elevated risk status by using preventive services. Conclusions Screening in general practice, followed by offering services to prevent anxiety disorders in those at risk did not appear to be a feasible strategy due to low participation rates. To enable the development of
Twells, Laurie K; Bridger, Tracey; Knight, John C; Alaghehbandan, Reza; Barrett, Brendan
The objective of this study was to explore the relationship between body mass index (BMI), its association with chronic disease, and its impact on health services utilization in the province of Newfoundland and Labrador, Canada, from 1998 to 2002. A data linkage study was conducted involving a provincial health survey linked to 2 health care use administrative databases. The study population comprised 2345 adults between the ages of 20 and 64 years. Self-reported height and weight measures and other covariates, including chronic diseases, were obtained from a provincial survey. BMI categories include: normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), obese class I (BMI 30-34.9), obese class II (BMI ≥ 35), and obese class III (BMI ≥ 40). Survey responses were linked with objective physician and hospital health services utilization over a 5-year period. Weight classifications in the study sample were as follows: 37% normal, 39% overweight, 17% obese, and 6% morbidly obese. The obese and morbidly obese were more likely to report having serious chronic conditions after adjusting for age and sex. Only the morbidly obese group (BMI ≥ 35 kg/m(2)) had a significantly higher number of visits to a general practitioner (GP) over a 5-year period compared to the normal weight group (median 22.0 vs. 17.0, Pchronic conditions and other relevant covariates, being morbidly obese remained a significant predictor of GP visits (Pobesity is placing a burden at the primary health care level. More resources are needed in order to support GPs in their efforts to manage and treat obese adults who have associated comorbidities.
Campbell, A; Manoff, T; Caffery, J
Until recently, there has been a significant gap in the literature exploring the issues of the mental health needs for rural communities in Australia. In this study we investigated the prevalence of diagnosable psychological disorders in both a rural and a non-rural primary care sample in far north Queensland, Australia. In a previous study we had screened some 300 GP attendees, on a number of sociodemographic variables and measures of psychological wellbeing, from four rural GP practices and one regional GP practice. Of these, 130 participants agreed to further follow up. In this study, 118 of the participants were selected and contacted by phone to complete the Composite International Diagnostic Interview-Short Form (CIDI-SF). The CIDI-SF diagnosis was then analysed in relation to the sociodemographic indicators that had previously been collected. The prevalence of diagnosable mental health disorders in the rural sample was found to be higher in comparison with the regional urban sample. The sociodemographic factors of rural residence, gender, and length of residence were associated with having a CIDI-SF diagnosis. Although there were a number of methodological limitations to this study, there did appear to be a significant relationship between rural location and the likelihood of receiving a CIDI-SF diagnosis. Why this might be the case is not clear, and we consider a number of explanations, but our finding suggests that further research in mental health should consider the issue of rurality as a key feature to be explored.
Tierney, E; O'Sullivan, M; Hickey, L; Hannigan, A; May, C; Cullen, W; Kennedy, N; Kineen, L; MacFarlane, A
Primary care is the cornerstone of healthcare reform with policies across jurisdictions promoting interdisciplinary team working. The effective implementation of such health policies requires understanding the perspectives of all actors. However, there is a lack of research about health professionals' views of this process. This study compares Primary Healthcare Professionals' perceptions of the effectiveness of the Primary Care Strategy and Primary Care Team (PCT) implementation in Ireland. Design and Setting: e-survey of (1) General Practitioners (GPs) associated with a Graduate Medical School (N = 100) and (2) Primary Care Professionals in 3 of 4 Health Service Executive (HSE) regions (N = 2309). After piloting, snowball sampling was used to administer the survey. Descriptive analysis was carried out using SPSS. Ratings across groups were compared using non-parametric tests. There were 569 responses. Response rates varied across disciplines (71 % for GPs, 22 % for other Primary Healthcare Professionals (PCPs). Respondents across all disciplines viewed interdisciplinary working as important. Respondents agreed on lack of progress of implementation of formal PCTs (median rating of 2, where 1 is no progress at all and 5 is complete implementation). GPs were more negative about the effectiveness of the Strategy to promote different disciplines to work together (median rating of 2 compared to 3 for clinical therapists and 3.5 for nurses, P = 0.001). Respondents identified resources and GP participation as most important for effective team working. Protected time for meetings and capacity to manage workload for meetings were rated as very important factors for effective team working by GPs, clinical therapists and nurses. A building for co-location of teams was rated as an important factor by nurses and clinical therapists though GPs rated it as less important. Payment to attend meetings and contractual arrangements were considered important factors by
Walter, Alex; Chew-Graham, Carolyn; Harrison, Stephen
How GPs negotiate patient requests is vital to their gatekeeper role but also a source of potential conflict, practitioner stress and patient dissatisfaction. Difficulties may arise when demands of shared decision-making conflict with resource allocation, which may be exacerbated by new commissioning arrangements, with GPs responsible for available services. To explore GPs' accounts of negotiating refusal of patient requests and their negotiation strategies. A qualitative design was employed with two focus groups of GPs and GP registrars followed by 20 semi-structured interviews. Participants were sampled by gender, experience, training/non-training, principal versus salaried or locum. Thematic content analysis proceeded in parallel with interviews and further sampling. The setting was GP practices within an English urban primary care trust. Sickness certification, antibiotics and benzodiazepines were cited most frequently as problematic patient requests. GP trainees reported more conflict within interactions than experienced GPs. Negotiation strategies, such as blaming distant third parties such as the primary care organization, were designed to prevent conflict and preserve the doctor-patient relationship. GPs reported patients' expectations being strongly influenced by previous encounters with other health care professionals. The findings reiterate the prominence of the doctor-patient relationship in GPs' accounts. GPs' relationships with colleagues and the wider National Health Service (NHS) are particular of relevance in light of provisions in the Health and Social Care Bill for clinical commissioning consortia. The ability of GPs to offset blame for rationing decisions to third parties will be undermined if the same GPs commission services.
van Dongen, Jerôme Jean Jacques; Lenzen, Stephanie Anna; van Bokhoven, Marloes Amantia; Daniëls, Ramon; van der Weijden, Trudy; Beurskens, Anna
The number of people with multiple chronic conditions demanding primary care services is increasing. To deal with the complex health care demands of these people, professionals from different disciplines collaborate. This study aims to explore influential factors regarding interprofessional collaboration related to care plan development in primary care. A qualitative study, including four semi-structured focus group interviews (n = 4). In total, a heterogeneous group of experts (n = 16) and health care professionals (n = 15) participated. Participants discussed viewpoints, barriers, and facilitators regarding interprofessional collaboration related to care plan development. The data were analysed by means of inductive content analysis. The findings show a variety of factors influencing the interprofessional collaboration in developing a care plan. Factors can be divided into 5 key categories: (1) patient-related factors: active role, self-management, goals and wishes, membership of the team; (2) professional-related factors: individual competences, domain thinking, motivation; (3) interpersonal factors: language differences, knowing each other, trust and respect, and motivation; (4) organisational factors: structure, composition, time, shared vision, leadership and administrative support; and (5) external factors: education, culture, hierarchy, domain thinking, law and regulations, finance, technology and ICT. Improving interprofessional collaboration regarding care plan development calls for an integral approach including patient- and professional related factors, interpersonal, organisational, and external factors. Further, the leader of the team seems to play a key role in watching the patient perspective, organising and coordinating interprofessional collaborations, and guiding the team through developments. The results of this study can be used as input for developing tools and interventions targeted at executing and improving interprofessional
Alam, Khurshid; Ahmed, Shakil
Abstract Background Little is known about the cost recovery of primary health care facilities in Bangladesh. This study estimated the cost recovery of a primary health care facility run by Building Resources Across Community (BRAC), a large NGO in Bangladesh, for the period of July 2004 - June 2005. This health facility is one of the seven upgraded BRAC facilities providing emergency obstetric care and is typical of the government and private primary health care facilities in Bangladesh. Give...
Annemarije L Kruis
Full Text Available BACKGROUND: Guideline recommendations for chronic obstructive pulmonary disease (COPD are based on the results of large pharmaceutically-sponsored COPD studies (LPCS. There is a paucity of data on disease characteristics at the primary care level, while the majority of COPD patients are treated in primary care. OBJECTIVE: We aimed to evaluate the external validity of six LPCS (ISOLDE, TRISTAN, TORCH, UPLIFT, ECLIPSE, POET-COPD on which current guidelines are based, in relation to primary care COPD patients, in order to inform future clinical practice guidelines and trials. METHODS: Baseline data of seven primary care databases (n=3508 from Europe were compared to baseline data of the LPCS. In addition, we examined the proportion of primary care patients eligible to participate in the LPCS, based on inclusion criteria. RESULTS: Overall, patients included in the LPCS were younger (mean difference (MD-2.4; p=0.03, predominantly male (MD 12.4; p=0.1 with worse lung function (FEV1% MD -16.4; p<0.01 and worse quality of life scores (SGRQ MD 15.8; p=0.01. There were large differences in GOLD stage distribution compared to primary care patients. Mean exacerbation rates were higher in LPCS, with an overrepresentation of patients with ≥ 1 and ≥ 2 exacerbations, although results were not statistically significant. Our findings add to the literature, as we revealed hitherto unknown GOLD I exacerbation characteristics, showing 34% of mild patients had ≥ 1 exacerbations per year and 12% had ≥ 2 exacerbations per year. The proportion of primary care patients eligible for inclusion in LPCS ranged from 17% (TRISTAN to 42% (ECLIPSE, UPLIFT. CONCLUSION: Primary care COPD patients stand out from patients enrolled in LPCS in terms of gender, lung function, quality of life and exacerbations. More research is needed to determine the effect of pharmacological treatment in mild to moderate patients. We encourage future guideline makers to involve primary care
Ruiz Sánchez, Míriam; Borrell-Carrió, Francisco; Ortodó Parra, Cristina; Fernàndez I Danés, Neus; Fité Gallego, Anna
To identify organizational processes, violations of rules, or professional performances that pose clinical levels of insecurity. Descriptive cross-sectional survey with customized externally-behavioral verification and comparison of sources, conducted from June 2008 to February 2010. Thirteen of the 53 primary care teams (PCT) of the Catalonian Health Institute (ICS Costa de Ponent, Barcelona). Employees of 13 PCT classified into: director, nurse director, customer care administrators, and general practitioners. Non-random selection, teaching (TC)/non-teaching, urban (UC)/rural and small/large (LC) health care centers (HCC). A total of 33 indicators were evaluated; 15 of procedures, 9 of attitude, 3 of training, and 6 of communication. Level of uncertainty: <50% positive answers for each indicator. no collaboration. A total of 55 professionals participated (84.6% UC, 46.2% LC and 76.9% TC). Rank distribution: 13 customer care administrators, 13 nurse directors, 13 HCC directors, and 16 general practitioners. Levels of insecurity emerged from the following areas: reception of new medical professionals, injections administration, nursing weekend home calls, urgent consultations to specialists, aggressive patients, critical incidents over the agenda of the doctors, communication barriers with patients about treatment plans, and with immigrants. Clinical safety is on the agenda of the health centers. Identified areas of uncertainty are easily approachable, and are considered in the future system of accreditation of the Catalonian Government. General practitioners are more critical than directors, and teaching health care centers, rural and small HCC had a better sense of security. Copyright © 2012 Elsevier España, S.L. All rights reserved.
Teles, Mariza Alves Barbosa; Barbosa, Mirna Rossi; Vargas, Andréa Maria Duarte; Gomes, Viviane Elizângela; e Ferreira, Efigênia Ferreira; Martins, Andréa Maria Eleutério de Barros Lima; Ferreira, Raquel Conceição
Background Workers in Primary Health Care are often exposed to stressful conditions at work. This study investigated the association between adverse psychosocial work conditions and poor quality of life among Primary Health Care workers. Methods This cross-sectional study included all 797 Primary Health Care workers of a medium-sized city, Brazil: doctors, nurses, nursing technicians and nursing assistants, dentists, oral health technicians, and auxiliary oral hygienists, and community health...
Sada, Yvonne; Street, Richard L.; Singh, Hardeep; Shada, Rachel; Naik, Aanand D.
Objective To explore perceptions of primary care physicians’ (PCPs) and oncologists’ roles, responsibilities, and patterns of communication related to shared cancer care in three integrated health systems that used electronic health records (EHRs). Study design Qualitative study. Methods We conducted semi-structured interviews with ten early stage colorectal cancer patients and fourteen oncologists and PCPs. Sample sizes were determined by thematic saturation. Dominant themes and codes were identified and subsequently applied to all transcripts. Results Physicians reported that EHRs improved communication within integrated systems, but communication with physicians outside their system was still difficult. PCPs expressed uncertainty about their role during cancer care, even though medical oncologists emphasized the importance of co-morbidity control during cancer treatment. Both patients and physicians described additional roles for PCPs, including psychological distress support and behavior modification. Conclusions Integrated systems that use EHRs likely facilitate shared cancer care through improved PCP-oncologist communication. However, strategies to facilitate a more active role for PCPs in managing co-morbidities, psychological distress and behavior modification, as well as to overcome communication challenges between physicians not practicing within the same integrated system, are still needed to improve shared cancer care. PMID:21615196
Spehar, Ivan; Sjøvik, Hege; Karevold, Knut Ivar; Rosvold, Elin Olaug; Frich, Jan C
Objective To explore general practitioners? (GPs) views on leadership roles and leadership challenges in general practice and primary health care. Design We conducted focus groups (FGs) with 17 GPs. Setting Norwegian primary health care. Subjects 17 GPs who attended a 5 d course on leadership in primary health care. Results Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical...
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.
Kendall, Marilyn; Mason, Bruce; Momen, Natalie; Barclay, Stephen; Munday, Dan; Lovick, Roberta; Macpherson, Stella; Paterson, Euan; Baughan, Paul; Cormie, Paul; Kiehlmann, Peter; Free, Amanda; Murray, Scott A
Current models of post-treatment cancer care are based on traditional practices and clinician preference rather than evidence of benefit. To assess the feasibility of using a structured template to provide holistic follow-up of patients in primary care from cancer diagnosis onwards. A two-phase mixed methods action research project. An electronic cancer ongoing review document (CORD) was first developed with patients and general practitioners, and used with patients with a new diagnosis of cancer. This was evaluated through documentary analysis of the CORDs, qualitative interviews with patients, family carers and health professionals and record reviews. The records of 107 patients from 13 primary care teams were examined and 45 interviews conducted. The document was started in 54% of people with newly diagnosed cancer, and prompted clear documentation of multidimension needs and understanding. General practitioners found using the document helped to structure consultations and cover psychosocial areas, but they reported it needed to be better integrated in their medical records with computerized prompts in place. Few clinicians discussed the review openly with patients, and the template was often completed afterwards. Anticipatory cancer care from diagnosis to cure or death, 'in primary care', is feasible in the U.K. and acceptable to patients, although there are barriers. The process promoted continuity of care and holism. A reliable system for proactive cancer care in general practice supported by hospital specialists may allow more survivorship care to be delivered in primary care, as in other long-term conditions.
Martell-Claros, Nieves; Galgo Nafría, Alberto; Abad-Cardiel, María; Álvarez-Álvarez, Beatriz; García Donaire, José Antonio; Márquez-Contreras, Emilio; Molino-González, Ángel
To know the opinion/evaluation of the primary care physicians (PCPH) of the received information about patients that were attended in specialized care (SC). Cross-sectional study. Performed nationwide in primary care centers. Researchers from the primary care network. We used the SEH-LELHA derivation criteria guidelines, plus an ad hoc survey that included demographic and anthropometric data, blood pressure levels, and the main reason for derivation to SC at the baseline and final (post-derivation) visit. In addition, time deployed for the study of every patient, changes in diagnosis and treatment, type of follow-up, issues throughout the derivation process and assessment of the medical referred to the PCPH were evaluated. With participation of 578 researchers from primary, the study included 1715 patients aged 60.7±13.3years, 62.7% male. Patients were taking 2.3±1.2 (range 0-10) antihypertensive drugs pre-referral and 2.5±1.2 (0-9) after derivation. Blood pressure levels changed from 166±21.6 /97.7±12.6mmHg to 143±14.4 /85.5±10.5mmHg. The number of controlled patients (BP<140 and <90mmHg) increased from 5.8% to 32.2%. Time between pre- and post-derivation visit was 72±64days (median 57days, IQ26-99). The PCPH received a medical report in 80.3% of cases, 76.9% with an explanation of the results of the complementary tests, 75.8% with additional information or a reasoning of treatment and in 71% of cases information about the patient future management. 63% of PCPH were fully agreed with the management of the specialist, 29% agree and 2% strongly disagree. The derivation was evaluated as effective or very effective in 86% of patients and no effective in 9%. Communication between AE and SC in HTA is valued satisfactorily by MAP. However there is still room for improvement in the process. Copyright © 2017. Publicado por Elsevier España, S.L.U.
Conclusions At the time of the study the systems that form part of NHS Connecting for Health, apart from the Quality Management and Analysis System (QMAS, were not implemented across the PCT. All the practices in the study acknowledged the benefits new technology would bring to the workplace, but there were also some common concerns, which suggest that staff working in primary care practices are not ready for e-health. Successful implementation of the NHS Connecting for Health programme rests on identifying, acknowledging and overcoming these concerns. A different approach might be required for those practices that have made very little progress in using email or moving towards an electronic patient record. This study suggests that a mistrust of technology and fears as to the heavy initial workload involved in becoming fully computerised have dissuaded some practices from embracing e-health. If NHS Connecting for Health is to be a success, implementation teams might need to focus initially on practices that have been reluctant to use technology to support both clinical care and the day-to-day work of the practice.
Kringos, D.S.; Boerma, W.G.W.; Bourgueil, Y.; Cartier, T.; Dedeu, T.; Hasvold, T.; Groenewegen, P.P.; et al, [No Value
Background A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking. Aim Evaluation of strength of primary care in Europe. Design and setting International comparative cross-sectional study performed in 2009–2010,
Kringos, Dionne; Boerma, Wienke; Bourgueil, Yann; Cartier, Thomas; Dedeu, Toni; Hasvold, Toralf; Hutchinson, Allen; Lember, Margus; Oleszczyk, Marek; Rotar Pavlic, Danica; Svab, Igor; Tedeschi, Paolo; Wilm, Stefan; Wilson, Andrew; Windak, Adam; van der Zee, Jouke; Groenewegen, Peter
A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking. Evaluation of strength of primary care in Europe. International comparative cross-sectional study performed in 2009-2010, involving 27 EU member states, plus
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
Full Text Available Razatul Shima,1,3 Mohd Hairi Farizah,1,2 Hazreen Abdul Majid1,2 1Department of Social and Preventive Medicine; 2Centre for Population Health, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; 3Ministry of Health Malaysia, Putrajaya, Malaysia Purpose: The aim of this study was to explore patients’ experiences with their illnesses and the reasons which influenced them in not following hypertensive care recommendations (antihypertensive medication intake, physical activity, and diet changes in primary health clinic settings. Patients and methods: A qualitative methodology was applied. The data were gathered from in-depth interviews with 25 hypertensive patients attending follow-up in nine government primary health clinics in two districts (Hulu Langat and Klang in the state of Selangor, Malaysia. The transcribed data were analyzed using thematic analysis.Results: There was evidence of lack of patient self-empowerment and community support in Malaysian society. Most of the participants did not take their antihypertensive medication or change their physical activity and diet after diagnosis. There was an agreement between the patients and the health care professionals before starting the treatment recommendation, but there lacked further counseling and monitoring. Most of the reasons given for not taking antihypertensive medication, not doing physical activity and not following diet recommendations were due to side effects or fear of the side effects of antihypertensive medication, patients’ attitudes, lack of information from health care professionals and insufficient social support from their surrounding environment. We also observed the differences on these reasons for nonadherence among the three ethnic groups.Conclusion: Health care professionals should move toward supporting adherence in the management of hypertensive patients by maintaining a dialogue. Patients need to be given time to enable them to overcome their
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
Grimsmo, Anders; Løhre, Audhild; Røsstad, Tove; Gjerde, Ingunn; Heiberg, Ina; Steinsbekk, Aslak
To explore the feasibility of disease-specific clinical pathways when used in primary care. A mixed-method sequential exploratory design was used. First, merging and exploring quality interview data across two cases of collaboration between the specialist care and primary care on the introduction of clinical pathways for four selected chronic diseases. Secondly, using quantitative data covering a population of 214,700 to validate and test hypothesis derived from the qualitative findings. Primary care and specialist care collaborating to manage care coordination. Primary-care representatives expressed that their patients often have complex health and social needs that clinical pathways guidelines seldom consider. The representatives experienced that COPD, heart failure, stroke and hip fracture, frequently seen in hospitals, appear in low numbers in primary care. The quantitative study confirmed the extensive complexity among home healthcare nursing patients and demonstrated that, for each of the four selected diagnoses, a homecare nurse on average is responsible for preparing reception of the patient at home after discharge from hospital, less often than every other year. The feasibility of disease-specific pathways in primary care is limited, both from a clinical and organisational perspective, for patients with complex needs. The low prevalence in primary care of patients with important chronic conditions, needing coordinated care after hospital discharge, constricts transferring tasks from specialist care. Generic clinical pathways are likely to be more feasible and efficient for patients in this setting. Key points Clinical pathways in hospitals apply to single-disease guidelines, while more than 90% of the patients discharged to community health care for follow-up have multimorbidity. Primary care has to manage the health care of the patient holistically, with all his or her complex needs. Patients most frequently admitted to hospitals, i.e. patients with COPD
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.
Full Text Available Abstract Background The epidemiology of chest pain differs strongly between outpatient and emergency settings. In general practice, the most frequent cause is the chest wall pain. However, there is a lack of information about the characteristics of this syndrome. The aims of the study are to describe the clinical aspects of chest wall syndrome (CWS. Methods Prospective, observational, cohort study of patients attending 58 private practices over a five-week period from March to May 2001 with undifferentiated chest pain. During a one-year follow-up, questionnaires including detailed history and physical exam, were filled out at initial consultation, 3 and 12 months. The outcomes were: clinical characteristics associated with the CWS diagnosis and clinical evolution of the syndrome. Results Among 24 620 consultations, we observed 672 cases of chest pain and 300 (44.6% patients had a diagnosis of chest wall syndrome. It affected all ages with a sex ratio of 1:1. History and sensibility to palpation were the keys for diagnosis. Pain was generally moderate, well localised, continuous or intermittent over a number of hours to days or weeks, and amplified by position or movement. The pain however, may be acute. Eighty-eight patients were affected at several painful sites, and 210 patients at a single site, most frequently in the midline or a left-sided site. Pain was a cause of anxiety and cardiac concern, especially when acute. CWS coexisted with coronary disease in 19 and neoplasm in 6. Outcome at one year was favourable even though CWS recurred in half of patients. Conclusion CWS is common and benign, but leads to anxiety and recurred frequently. Because the majority of chest wall pain is left-sided, the possibility of coexistence with coronary disease needs careful consideration.
Verdon, François; Burnand, Bernard; Herzig, Lilli; Junod, Michel; Pécoud, Alain; Favrat, Bernard
The epidemiology of chest pain differs strongly between outpatient and emergency settings. In general practice, the most frequent cause is the chest wall pain. However, there is a lack of information about the characteristics of this syndrome. The aims of the study are to describe the clinical aspects of chest wall syndrome (CWS). Prospective, observational, cohort study of patients attending 58 private practices over a five-week period from March to May 2001 with undifferentiated chest pain. During a one-year follow-up, questionnaires including detailed history and physical exam, were filled out at initial consultation, 3 and 12 months. The outcomes were: clinical characteristics associated with the CWS diagnosis and clinical evolution of the syndrome. Among 24 620 consultations, we observed 672 cases of chest pain and 300 (44.6%) patients had a diagnosis of chest wall syndrome. It affected all ages with a sex ratio of 1:1. History and sensibility to palpation were the keys for diagnosis. Pain was generally moderate, well localised, continuous or intermittent over a number of hours to days or weeks, and amplified by position or movement. The pain however, may be acute. Eighty-eight patients were affected at several painful sites, and 210 patients at a single site, most frequently in the midline or a left-sided site. Pain was a cause of anxiety and cardiac concern, especially when acute. CWS coexisted with coronary disease in 19 and neoplasm in 6. Outcome at one year was favourable even though CWS recurred in half of patients. CWS is common and benign, but leads to anxiety and recurred frequently. Because the majority of chest wall pain is left-sided, the possibility of coexistence with coronary disease needs careful consideration.
Verdon, François; Burnand, Bernard; Herzig, Lilli; Junod, Michel; Pécoud, Alain; Favrat, Bernard
Background The epidemiology of chest pain differs strongly between outpatient and emergency settings. In general practice, the most frequent cause is the chest wall pain. However, there is a lack of information about the characteristics of this syndrome. The aims of the study are to describe the clinical aspects of chest wall syndrome (CWS). Methods Prospective, observational, cohort study of patients attending 58 private practices over a five-week period from March to May 2001 with undifferentiated chest pain. During a one-year follow-up, questionnaires including detailed history and physical exam, were filled out at initial consultation, 3 and 12 months. The outcomes were: clinical characteristics associated with the CWS diagnosis and clinical evolution of the syndrome. Results Among 24 620 consultations, we observed 672 cases of chest pain and 300 (44.6%) patients had a diagnosis of chest wall syndrome. It affected all ages with a sex ratio of 1:1. History and sensibility to palpation were the keys for diagnosis. Pain was generally moderate, well localised, continuous or intermittent over a number of hours to days or weeks, and amplified by position or movement. The pain however, may be acute. Eighty-eight patients were affected at several painful sites, and 210 patients at a single site, most frequently in the midline or a left-sided site. Pain was a cause of anxiety and cardiac concern, especially when acute. CWS coexisted with coronary disease in 19 and neoplasm in 6. Outcome at one year was favourable even though CWS recurred in half of patients. Conclusion CWS is common and benign, but leads to anxiety and recurred frequently. Because the majority of chest wall pain is left-sided, the possibility of coexistence with coronary disease needs careful consideration. PMID:17850647
Lieshout, J. van; Frigola Capell, E.; Ludt, S.; Grol, R.P.T.M.; Wensing, M.J.P.
OBJECTIVES: Cardiovascular risk management (CVRM) received by patients shows large variation across countries. In this study we explored the aspects of primary care organisation associated with key components of CVRM in coronary heart disease (CHD) patients. DESIGN: Observational study. SETTING: 273 primary care practices in Austria, Belgium, England, Finland, France, Germany, The Netherlands, Slovenia, Switzerland and Spain. PARTICIPANTS: A random sample of 4563 CHD patients identified by co...
Miedema, Baukje; Easley, Julie; Thompson, Ashley E; Boivin, Antoine; Aubrey-Bassler, Kris; Katz, Alan; Hogg, William E; Breton, Mylaine; Francoeur, Danièle; Wong, Sabrina T; Wodchis, Walter P
To examine access to primary care in new and traditional models using 2 dimensions of the concept of patient-centred access. An international survey examining the quality and costs of primary health care (the QUALICOPC study) was conducted in 2013 in Canada. This study adopted a descriptive cross-sectional survey method using data from practices across Canada. Each participating practice filled out the Family Physician Survey and the Practice Survey, and patients in each participating practice were asked to complete the Patient Experiences Survey. All 10 Canadian provinces. A total of 759 practices and 7172 patients. Independent t tests were conducted to examine differences between new and traditional models of care in terms of availability and accommodation, and affordability of care. Of the 759 practices, 407 were identified as having new models of care and 352 were identified as traditional. New models of care were distinct with respect to payment structure, opening hours, and having an interdisciplinary work force. Most participating practices were from large cities or suburban areas. There were few differences between new and traditional models of care regarding accessibility and accommodation in primary care. Patients under new models of care reported easier access to other physicians in the same practice, while patients from traditional models reported seeing their regular family physicians more frequently. There was no difference between the new and traditional models of care with regard to affordability of primary care. Patients attending clinics with new models of care reported that their physicians were more involved with them as a whole person than patients attending clinics based on traditional models did. Primary care access issues do not differ strongly between traditional and new models of care; however, patients in the new models of care believed that their physicians were more involved with them as people.
Van den Berg Michael J
Full Text Available Abstract Background The QUALICOPC (Quality and Costs of Primary Care in Europe study aims to evaluate the performance of primary care systems in Europe in terms of quality, equity and costs. The study will provide an answer to the question what strong primary care systems entail and which effects primary care systems have on the performance of health care systems. QUALICOPC is funded by the European Commission under the "Seventh Framework Programme". In this article the background and design of the QUALICOPC study is described. Methods/design QUALICOPC started in 2010 and will run until 2013. Data will be collected in 31 European countries (27 EU countries, Iceland, Norway, Switzerland and Turkey and in Australia, Israel and New Zealand. This study uses a three level approach of data collection: the system, practice and patient. Surveys will be held among general practitioners (GPs and their patients, providing evidence at the process and outcome level of primary care. These surveys aim to gain insight in the professional behaviour of GPs and the expectations and actions of their patients. An important aspect of this study is that each patient's questionnaire can be linked to their own GP's questionnaire. To gather data at the structure or national level, the study will use existing data sources such as the System of Health Accounts and the Primary Health Care Activity Monitor Europe (PHAMEU database. Analyses of the data will be performed using multilevel models. Discussion By its design, in which different data sources are combined for comprehensive analyses, QUALICOPC will advance the state of the art in primary care research and contribute to the discussion on the merit of strengthening primary care systems and to evidence based health policy development.
Wen, Tong; Zhang, Yan; Wang, Xue; Tang, Guo
The intention to leave a job, known as turnover intention, among primary care doctors has a significant impact on primary health care service delivery. We investigated primary care doctors' turnover intention and analysed associated factors involved in primary health facilities in Chongqing, China. A total of 440 doctors were interviewed, they were selected using a multi-stage stratified random sampling method. The survey instrument was a self-administered questionnaire which assessed socio-demographic and work-related characteristics, job satisfaction and turnover intention. The data were analysed using χ 2 test, one-way analysis of variance, exploratory factor analysis and linear regression analysis. Our study found that 42.3% of the primary care doctors we sampled in Chongqing, China, intended to resign. Location, age, job title, doctor's position level, work pressure and job satisfaction were associated with turnover intention. Job satisfaction included both employment-related job satisfaction (including "your chance of promotion", "your rate of pay" and two other items) and satisfaction with the job itself (including "the freedom to choose your own method of working", "your job safety" and two other items). Improving job satisfaction, in terms of salary, promotion and job safety, is crucial for reducing turnover intention among primary care doctors. Therefore, we suggest that the government increase its financial investment in primary care facilities, especially in less-developed areas, and reform incentive mechanisms to improve the job satisfaction of primary care doctors. The government should consider policies such as establishing a social pension programme for village-level doctors and providing more opportunities for job promotion among primary care doctors, especially township-level doctors. Attention should also be paid to the impact of rapid urbanization, which could lead to increased workload or increased opportunities for career development, thus
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
Conclusions In the group of practices studied, levels of recording were generally assessed to be of sufficient quality to enable a database of quality-evaluated, anonymised primary care records to be created.
Adcock, G B
Corporate-based nurse managed centers are not the national norm. More prevalent is the use of an occupational health or physician-directed medical model of care. The author describes how a 14-year-old primary care center at a North Carolina computer software company is just "business as usual" when viewed in the context of the company's philosophy, goals, and culture. Included are considerations for nurse practitioners interested in the successful transplantation of this primary care model to other settings.
Micó-Pérez, R M; Payares-Herrera, C; Palomo-Jiménez, P I; Sánchez-Fierro, J; Avendaño-Solá, C; Llisterri-Caro, J L
The objective of this study was to evaluate the awareness and training needs on biosimilar drugs in Primary Care (PC) physicians. Descriptive cross-sectional study based on an on-line questionnaire with a total of 34 multiple choice questions, published on the SEMERGEN website. The main Knowledge areas were: biosimilar definition; regulatory and legal framework; prescription, traceability, interchangeability and pharmacovigilance; availability of biosimilars in the PC setting, and the biosimilars contribution to sustainability. The software used for the analysis and data processing was the Barbwin 7.5. An analysis was performed on the responses from 701 questionnaires completed. There was a slight majority (57%) of women participants. The majority of participant worked in urban centres (60.91%). The definition of biosimilar was not known by 58% of those that responded, and 73% were unaware that the management of biosimilars and generics was not comparable. Most (84%) of those that responded were not aware that the studies required for the approval of biosimilars is different from reference biological medicines. Around two-thirds (66%) those that responded did not know of any biosimilars available in PC setting, and the 94% were also unaware of the Spanish legal framework for the management of biosimilar medicines. The current knowledge about biosimilars among PC physicians is low. The critical areas in need of further training include specific information on biosimilars currently available in PC setting, as well as key aspects regarding prescription, interchangeability and pharmacovigilance requirements. Six out of ten doctors do not know of any biosimilar used in PC in Spain. Copyright © 2018 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
Reid, Steve; Mash, Bob
This article is part of a series on African Primary Care Research and focuses on the topic of qualitative interviewing in primary care. In particular it looks at issues of study design, sample size, sampling and interviewing in relation to individual and focus group interviews.There is a particular focus on helping postgraduate students at a Masters level to write their research proposals.
Adaji, Akuh; Newcomb, Richard D; Wang, Zhen; Williams, Mark
The impact of "real world" collaborative care on depression and absenteeism for depressed employees seen in primary care practices using objective employer absence data. A retrospective cohort study comparing depressed employees seen in primary care practices who enrolled for a "real world" collaborative care program to practice as usual (PAU) on objective absence days and depression response and remission at 6, and 12-month time periods. Absence days were more in the collaborative care group compared with the PAU group at 3 and 6 months but at 12 months the difference was no longer statistically significant. Collaborative care led to better response and remission depression scores compared with PAU at 12 months. Collaborative care led to faster improvement in depression symptoms but did not translate to less time away from work.
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
Saitz, Richard; Horton, Nicholas J; Larson, Mary Jo; Winter, Michael; Samet, Jeffrey H
To assess whether receipt of primary medical care can lead to improved outcomes for adults with addictions. We studied a prospective cohort of adults enrolled in a randomized trial to improve linkage with primary medical care. Subjects at a residential detoxification unit with alcohol, heroin or cocaine as a substance of choice, and no primary medical care were enrolled. Receipt of primary medical care was assessed over 2 years. Outcomes included (1) alcohol severity, (2) drug severity and (3) any substance use. For the 391 subjects, receipt of primary care (> or = 2 visits) was associated with a lower odds of drug use or alcohol intoxication (adjusted odds ratio (AOR) 0.45, 95% confidence interval (CI) 0.29-0.69, 2 d.f. chi(2)P = 0.002). For 248 subjects with alcohol as a substance of choice, alcohol severity was lower in those who received primary care [predicted mean Addiction Severity Index (ASI) alcohol scores for those reporting > or = 2, 1 and 0 visits, respectively, 0.30, 0.26 and 0.34, P = 0.04]. For 300 subjects with heroin or cocaine as a substance of choice, drug severity was lower in those who received primary care (predicted mean ASI drug scores for those reporting > or = 2, 1 and 0 visits, respectively, 0.13, 0.15 and 0.16, P = 0.01). Receipt of primary medical care is associated with improved addiction severity. These results support efforts to link patients with addictions to primary medical care services.
Song, Hummy; Ryan, Molly; Tendulkar, Shalini; Fisher, Josephine; Martin, Julia; Peters, Antoinette S; Frolkis, Joseph P; Rosenthal, Meredith B; Chien, Alyna T; Singer, Sara J
Team-based care is essential for delivering high-quality, comprehensive, and coordinated care. Despite considerable research about the effects of team-based care on patient outcomes, few studies have examined how team dynamics relate to provider outcomes. The aim of this study was to examine relationships among team dynamics, primary care provider (PCP) clinical work satisfaction, and patient care coordination between PCPs in 18 Harvard-affiliated primary care practices participating in Harvard's Academic Innovations Collaborative. First, we administered a cross-sectional survey to all 548 PCPs (267 attending clinicians, 281 resident physicians) working at participating practices; 65% responded. We assessed the relationship of team dynamics with PCPs' clinical work satisfaction and perception of patient care coordination between PCPs, respectively, and the potential mediating effect of patient care coordination on the relationship between team dynamics and work satisfaction. In addition, we embedded a qualitative evaluation within the quantitative evaluation to achieve a convergent mixed methods design to help us better understand our findings and illuminate relationships among key variables. Better team dynamics were positively associated with clinical work satisfaction and quality of patient care coordination between PCPs. Coordination partially mediated the relationship between team dynamics and satisfaction for attending clinicians, suggesting that higher satisfaction depends, in part, on better teamwork, yielding more coordinated patient care. We found no mediating effects for resident physicians. Qualitative results suggest that sources of satisfaction from positive team dynamics for PCPs may be most relevant to attending clinicians. Improving primary care team dynamics could improve clinical work satisfaction among PCPs and patient care coordination between PCPs. In addition to improving outcomes that directly concern health care providers, efforts to
van de Pol, Marjolein Helena Johanna; Fluit, Cornelia Rita Maria Gertruda; Lagro, Joep; Niessen, Danielle; Rikkert, Marcellinus Gerardus Maria Olde; Lagro-Janssen, Antoinette Leonarda Maria
Background In recent years, primary health care for the ageing population has become increasingly complex. Aim This study sought to explore the views and needs of healthcare professionals and older patients relating to primary care in order to identify focal areas for improving primary health care for older people. Design and setting This research was structured as a mixed interview study with focus groups and individual interviews. Participants were made up of primary healthcare professionals and older patients. Patients were recruited from five elderly care homes in a small city in the southern part of the Netherlands. Method All interviews were transcribed verbatim and analysed by two individual researchers applying constant comparative analysis. Data collection proceeded until saturation was reached. Results Participants in the study agreed about the need for primary care for older patients, and showed sympathy with one another’s perspectives. They did note, however, a number of obstacles hindering good healthcare provision. The major themes that arose were: ‘autonomy and independence’, ‘organisational barriers’, and ‘professional expertise’. Participants generally noted that it is important to clarify differences in perspectives about good care between patients and healthcare professionals. Conclusion Effective primary care intervention for older patients requires mutual understanding of the expectations and goals of all parties involved. There are a number of important requirements, especially accessible patient information in the form of care plans; specialist training for nurses and GPs on complex care and multimorbidity; and training on discussing autonomy, goal setting, and shared care. Further improvement in health care for older people and its evaluation research should focus on these requirements. PMID:26212845
Spanish doctors are still leaving the country to look for quality work. Ireland is not a country with many Spanish professionals but it is interesting to know its particular Health care system. Ireland is one of the countries with a national health care system, although it has a mixture of private health care insurance schemes. People have a right to health care if they have been living in Ireland at least for a year. Access to the primary care health system depends on age and income: free of charge for Category 1 and co-payments for the rest. This division generates great inequalities among the population. Primary Care doctors are self-employed, and they work independently. However, since 2001 they have tended to work in multidisciplinary teams in order to strengthen the Primary Care practice. Salary is gained from a combination of public and private incomes which are not differentiated. The role of the General Practitioner consists in the treatment of acute and chronic diseases, minor surgery, child care, etc. There is no coordination between Primary and Secondary care. Access to specialised medicine is regulated by the price of consultation. Primary Care doctors are not gatekeepers. To be able to work here, doctors must have three years of training after medical school. After that, Continuing Medical Education is compulsory, and the college of general practitioners monitors it annually. The Irish health care system does not fit into the European model. Lack of a clear separation between public and private health care generates great inequalities. The non-existence of coordination between primary and specialised care leads to inefficiencies, which Ireland cannot allow itself after a decade of economic crisis. Copyright © 2017 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
Yousef A Al-Turki
Conclusions: Complete (severe and partial erectile dysfunction was quite common among adult diabetic patients in a hospital-based primary care setting in Saudi Arabia. It is important for primary care physicians to diagnose erectile dysfunction in diabetic patients, and to counsel them early, as most patients are hesitant to discuss their concern during a consultation. Further studies are recommended to evaluate the effect of other risk factors on erectile dysfunction in diabetic patients.
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.
Full Text Available Background Although collaborative team models (CTM improve care processes and health outcomes, their diffusion poses challenges related to difficulties in securing their adoption by primary care clinicians (PCPs. The objectives of this study are to understand: (1 how the perceived characteristics of a CTM influenced clinicians' decision to adopt -or not- the model; and (2 the model's diffusion process. Methods We conducted a longitudinal case study based on the Diffusion of Innovations Theory. First, diffusion curves were developed for all 175 PCPs and 59 nurses practicing in one borough of Paris. Second, semi-structured interviews were conducted with a representative sample of 40 PCPs and 15 nurses to better understand the implementation dynamics. Results Diffusion curves showed that 3.5 years after the start of the implementation, 100% of nurses and over 80% of PCPs had adopted the CTM. The dynamics of the CTM's diffusion were different between the PCPs and the nurses. The slopes of the two curves are also distinctly different. Among the nurses, the critical mass of adopters was attained faster, since they adopted the CTM earlier and more quickly than the PCPs. Results of the semi-structured interviews showed that these differences in diffusion dynamics were mostly founded in differences between the PCPs' and the nurses' perceptions of the CTM's compatibility with norms, values and practices and its relative advantage (impact on patient management and work practices. Opinion leaders played a key role in the diffusion of the CTM among PCPs. Conclusion CTM diffusion is a social phenomenon that requires a major commitment by clinicians and a willingness to take risks; the role of opinion leaders is key. Paying attention to the notion of a critical mass of adopters is essential to developing implementation strategies that will accelerate the adoption process by clinicians.
Alexopoulos, George S.; Katz, Ira R.; Bruce, Martha L.; Heo, Moonseong; Have, Thomas Ten; Raue, Patrick; Bogner, Hillary R.; Schulberg, Herbert C.; Mulsant, Benoit H.; Reynolds, Charles F.
Objective This study compared time to first remission for elderly depressed patients in primary care for practices that implemented a care management model versus those providing usual care. In addition, it sought to identify risk factors for nonremission that could guide treatment planning and referral to care managers or specialists. Method Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) data were analyzed. Participants were older patients (≥60 years) selected following screening of 9,072 randomly identified primary care patients. The present analysis examined patients with major depression and a 24-item Hamilton Depression Rating Scale score of 18 or greater who were followed for at least 4 months (N=215). Primary care practices were randomly assigned to offer the PROSPECT intervention or usual care. The intervention consisted of services of trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 18 months. Results First remission occurred earlier and was more common among patients receiving the intervention than among those receiving usual care. For all patients, limitations in physical and emotional functions predicted poor remission rate. Patients experiencing hopelessness were more likely to achieve remission if treated in intervention practices. Similarly, the intervention was more effective in patients with low baseline anxiety. Conclusions Longitudinal assessment of depression, hopelessness, anxiety, and physical and emotional functional limitations in depressed older primary care patients is critical. Patients with prominent symptoms or impairment in these areas may be candidates for care management or mental health care, since they are at risk for remaining depressed and disabled. PMID:15800144
Basu, Sanjay; Phillips, Russell S; Bitton, Asaf; Song, Zirui; Landon, Bruce E
Physicians have traditionally been reimbursed for face-to-face visits. A new non-visit-based payment for chronic care management (CCM) of Medicare patients took effect in January 2015. To estimate financial implications of CCM payment for primary care practices. Microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements. National Ambulatory Medical Care Survey and other published sources. Medicare patients. 10 years. Practice-level. Comparison of CCM delivery approaches by staff and physicians. Net revenue per full-time equivalent (FTE) physician; time spent delivering CCM services. If nonphysician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. Practices could expect approximately $332 per enrolled patient per year (95% CI, $234 to $429) if CCM services were delivered by registered nurses (RNs), approximately $372 (CI, $276 to $468) if services were delivered by licensed practical nurses, and approximately $385 (CI, $286 to $485) if services were delivered by medical assistants. For a typical practice, this equates to more than $75 ,00 of net annual revenue per FTE physician and 12 hours of nursing service time per week if 50% of eligible patients enroll. At a minimum, 131 Medicare patients (CI, 115 to 140 patients) must enroll for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services. If physicians were to deliver all CCM services, approximately 25% of practices nationwide could expect net revenue losses due to opportunity costs of face-to-face visit time. The CCM program may alter long-term primary care use, which is difficult to predict. Practices that rely on nonphysician team members to deliver CCM services will probably experience substantial net revenue gains but must enroll a sufficient number of eligible patients to recoup costs. None.
Ranstad, Karin; Midlöv, Patrik; Halling, Anders
Socioeconomic status and geographical factors are associated with health and use of healthcare. Well-performing primary care contributes to better health and more adequate healthcare. In a primary care system based on patient's choice of practice, this choice (listing) is a key to understand the system. To explore the relationship between population and practices in a primary care system based on listing. Cross-sectional population-based study. Logistic regressions of the associations between active listing in primary care, income, education, distances to healthcare and geographical location, adjusting for multimorbidity, age, sex and type of primary care practice. Population over 15 years (n=123 168) in a Swedish county, Blekinge (151 731 inhabitants), in year 2007, actively or passively listed in primary care. The proportion of actively listed was 68%. Actively listed in primary care on 31 December 2007. Highest ORs for active listing in the model including all factors according to income had quartile two and three with OR 0.70 (95% CI 0.69 to 0.70), and those according to education less than 9 years of education had OR 0.70 (95% CI 0.68 to 0.70). Best odds for geographical factors in the same model had municipality C with OR 0.85 (95% CI 0.85 to 0.86) for active listing. Akaike's Information Criterion (AIC) was 124 801 for a model including municipality, multimorbidity, age, sex and type of practice and including all factors gave AIC 123 934. Higher income, shorter education, shorter distance to primary care or longer distance to hospital is associated with active listing in primary care.Multimorbidity, age, geographical location and type of primary care practice are more important to active listing in primary care than socioeconomic status and distance to healthcare. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Spehar, Ivan; Sjøvik, Hege; Karevold, Knut Ivar; Rosvold, Elin Olaug; Frich, Jan C.
Objective To explore general practitioners’ (GPs) views on leadership roles and leadership challenges in general practice and primary health care. Design We conducted focus groups (FGs) with 17 GPs. Setting Norwegian primary health care. Subjects 17 GPs who attended a 5 d course on leadership in primary health care. Results Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement. Conclusions GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance. Key points Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that: There is a lack of preparation and formal training for the leadership role. GPs experience tensions between the clinical and leadership role. GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care. PMID:28277051
Spehar, Ivan; Sjøvik, Hege; Karevold, Knut Ivar; Rosvold, Elin Olaug; Frich, Jan C
To explore general practitioners' (GPs) views on leadership roles and leadership challenges in general practice and primary health care. We conducted focus groups (FGs) with 17 GPs. Norwegian primary health care. 17 GPs who attended a 5 d course on leadership in primary health care. Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement. GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance. KEY POINTS Little is known about doctors' experiences and views about leadership in general practice and primary health care. Our study suggests that: There is a lack of preparation and formal training for the leadership role. GPs experience tensions between the clinical and leadership role. GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.
Bower, Peter; Macdonald, Wendy; Harkness, Elaine; Gask, Linda; Kendrick, Tony; Valderas, Jose M; Dickens, Chris; Blakeman, Tom; Sibbald, Bonnie
Primary care professionals often manage patients with multiple long-term health conditions, but managing multimorbidity is challenging given time and resource constraints and interactions between conditions. To explore GP and nurse perceptions of multimorbidity and the influence on service organization and clinical decision making. A qualitative interview study with primary care professionals in practices in Greater Manchester, U.K. Interviews were conducted with 15 GPs and 10 practice nurses. Primary care professionals identified tensions between delivering care to meet quality targets and fulfilling the patient's agenda, tensions which are exacerbated in multimorbidity. They were aware of the inconvenience suffered by patients through attendance at multiple clinic appointments when care was structured around individual conditions. They reported difficulties managing patients with multimorbidity in limited consultation time, which led to adoption of an 'additive-sequential' decision-making model which dealt with problems in priority order until consultation resources were exhausted, when further management was deferred. Other challenges included the need for patients to co-ordinate their care, the difficulties of self-management support in multimorbidity and problems of making sense of the relationships between physical and mental health. Doctor and nurse accounts included limited consideration of multimorbidity in terms of the interactions between conditions or synergies between management of different conditions. Primary care professionals identify a number of challenges in care for multimorbidity and adopt a particular model of decision making to deliver care for multiple individual conditions. However, they did not describe specific decision making around managing multimorbidity per se.
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.
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.
McIlrath, Carole; Keeney, Sinead; McKenna, Hugh; McLaughlin, Derek
This paper is a report of a study conducted to identify and gain consensus on appropriate benchmarks for effective primary care-based nursing services for adults with depression. Worldwide evidence suggests that between 5% and 16% of the population have a diagnosis of depression. Most of their care and treatment takes place in primary care. In recent years, primary care nurses, including community mental health nurses, have become more involved in the identification and management of patients with depression; however, there are no appropriate benchmarks to guide, develop and support their practice. In 2006, a three-round electronic Delphi survey was completed by a United Kingdom multi-professional expert panel (n = 67). Round 1 generated 1216 statements relating to structures (such as training and protocols), processes (such as access and screening) and outcomes (such as patient satisfaction and treatments). Content analysis was used to collapse statements into 140 benchmarks. Seventy-three benchmarks achieved consensus during subsequent rounds. Of these, 45 (61%) were related to structures, 18 (25%) to processes and 10 (14%) to outcomes. Multi-professional primary care staff have similar views about the appropriate benchmarks for care of adults with depression. These benchmarks could serve as a foundation for depression improvement initiatives in primary care and ongoing research into depression management by nurses.
Full Text Available Katja Goetz,1 Jessica Bungartz,2 Joachim Szecsenyi,1 Jost Steinhaeuser3 1Department of General Practice and Health Services Research, University of Heidelberg, Heidelberg, Germany; 2Praxis Medizin im Zentrum, München, Germany; 3Institute of Family Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany Background: Patients’ evaluation of medical care is an essential dimension of quality of care and an important aspect of the feedback cycle for health care providers. The aim of this study was to document how patients with a Turkish background evaluate primary care in Germany and determine which aspects of care are associated with language abilities.Methods: The study was based on an observational design. Patients with a Turkish background from German primary care practices completed the EUROPEP (European Project on Patient Evaluation of General Practice Care questionnaire consisting of 23 items. Seventeen primary care practices were involved with either German (n=8 or Turkish (n=9 general practitioners (GPs.Results: A convenience sample of 472 patients with a Turkish background from 17 practices participated in the study (response rate 39.9%. Practices with a German GP had a lower response rate (19.6% than those with a Turkish GP (57.5%. Items evaluated the highest were “keeping data confidential” (73.4% and “quick services for urgent health problems” (69.9%. Subgroup analysis showed lower evaluation scores from patients with good or excellent German language abilities. Patients who consulted a Turkish GP had higher evaluation scores.Conclusion: The evaluation from patients with a Turkish background living in Germany with either Turkish or German GPs showed lower scores than patients in other studies in Europe using EUROPEP. However, our results had higher evaluation scores than those of Turkish patients evaluating GPs in Turkey. Therefore, different explanation models for these findings should be explored in future studies
Oneib, Bouchra; Sabir, Maria; Otheman, Yassine; Abda, Naima; Ouanass, Abderrazzak
The aim of the study is to estimate the prevalence of suicidal ideation among Moroccan consultants in primary health care system. We conducted a cross sectional survey in three health care centers in two cities of Morocco to estimate the prevalence of suicidal ideation, plan and suicide attempts among 396 consultants in the primary health care system, using the Mini International neuropsychiatric interview. Patients were 18 years and older, without known psychiatric or chronic somatic disease. Statistical analysis was performed by the SPSS 13.0 software. The prevalence of suicidal ideation was 5.3%, and 2.7% of the patients planned their suicide and 1.2% tried to commit suicide. The multivariate analysis did not demonstrate significant association. Suicidal ideation, plan and suicide attempts are prevalent in primary health care patients, but they are still under diagnosed. An adequate training of physicians and the establishment of education programs is essential to reduce the rate of suicide.
instrument for prediction of the deterioration of the illness process and point at possibilities of prevention. The practical consequences of the study results for primary care will be analysed in expert focus groups in order to develop strategies for the inclusion of the aspects of multimorbidity in primary care guidelines.
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.
Rhodes, Penny; McDonald, Ruth; Campbell, Stephen; Daker-White, Gavin; Sanders, Caroline
This study explores the ways in which patients make sense of 'safety' in the context of primary medical care. Drawing on qualitative interviews with primary care patients, we reveal patients' conceptualisation of safety as fluid, contingent, multi-dimensional, and negotiated. Participant accounts drew attention to a largely invisible and inaccessible (but taken for granted) architecture of safety, the importance of psycho-social as well as physical dimensions and the interactions between them, informal strategies for negotiating safety, and the moral dimension of safety. Participants reported being proactive in taking action to protect themselves from potential harm. The somewhat routinised and predictable nature of the primary medical care consultation, which is very different from 'one off' inpatient spells, meant that patients were not passive recipients of care. Instead they had a stock of accumulated knowledge and experience to inform their actions. In addition to highlighting the differences and similarities between hospital and primary care settings, the study suggests that a broad conceptualisation of patient safety is required, which encompasses the safety concerns of patients in primary care settings. © 2015 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL.
Italy is not a country where Spanish doctors emigrate, as there is an over-supply of health care professionals. The Italian Servizio Sanitario Nazionale has some differences compared to the Spanish National Health System. The Servizio Sanitario Nazionale is financed by national and regional taxes and co-payments. There are taxes earmarked for health, and Primary Care receives 50% of the total funds. Italian citizens and residents in Italy have the right to free health cover. However, there are co-payments for laboratory and imaging tests, pharmaceuticals, specialist ambulatory services, and emergencies. Co-payments vary in the different regions. The provision of services is regional, and thus fragmentation and major inequities are the norm. Doctors in Primary Care are self-employed and from 2000 onwards, there are incentives to work in multidisciplinary teams. Salary is regulated by a national contract and it is the sum of per-capita payments and extra resources for specific activities. Responsibilities are similar to those of Spanish professionals. However, medical care is more personal. Relationships between Primary Care and specialised care depend on the doctors' relationships. Primary Care doctors are gatekeepers for specialised care, except for gynaecology, obstetrics and paediatrics. Specialised training is compulsory in order to work as general practitioner. The Italian Health Care System is a national health system like the Spanish one. However, health care professionals are self-employed, and there are co-payments. In spite of co-payments, Italians have one of the highest average life expectancy, and they support a universal and publicly funded health-care system. Copyright © 2017 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
van Lieshout, Jan; Frigola Capell, Eva; Ludt, Sabine; Grol, Richard; Wensing, Michel
Cardiovascular risk management (CVRM) received by patients shows large variation across countries. In this study we explored the aspects of primary care organisation associated with key components of CVRM in coronary heart disease (CHD) patients. Observational study. 273 primary care practices in Austria, Belgium, England, Finland, France, Germany, The Netherlands, Slovenia, Switzerland and Spain. A random sample of 4563 CHD patients identified by coded diagnoses in eight countries, based on prescription lists and while visiting the practice in one country each. We performed an audit in primary care practices in 10 European countries. We used six indicators to measure key components of CVRM: risk factor recording, antiplatelet therapy, influenza vaccination, blood pressure levels (systolic organisation based on 39 items. Using multilevel regression analyses we explored the effects of practice organisation on CVRM, controlling for patient characteristics. Better overall organisation of a primary care practice was associated with higher scores on three indicators: risk factor registration (B=0.0307, porganisation was not found to be related with recorded blood pressure or cholesterol levels. Only the organisational domains 'self-management support' and 'use of clinical information systems' were linked to three CVRM indicators. A better organisation of a primary care practice was associated with better scores on process indicators of CVRM in CHD patients, but not on intermediate patient outcome measures. Direct support for patients and clinicians seemed most influential.
Full Text Available Adina Abdullah,1 Su May Liew,1 Nik Sherina Hanafi,1 Chirk Jenn Ng,1 Pauline Siew Mei Lai,1 Yook Chin Chia,1 Chu Kiong Loo2 1Department of Primary Care Medicine, Faculty of Medicine, University Malaya Primary Care Research Group, University of Malaya, Kuala Lumpur, Malaysia; 2Department of Artificial Intelligence, Faculty of Computer Science and Information Technology, University of Malaya, Kuala Lumpur, Malaysia Background: Telemonitoring of home blood pressure (BP is found to have a positive effect on BP control. Delivering a BP telemonitoring service in primary care offers primary care physicians an innovative approach toward management of their patients with hypertension. However, little is known about patients’ acceptance of such service in routine clinical care.Objective: This study aimed to explore patients’ acceptance of a BP telemonitoring service delivered in primary care based on the technology acceptance model (TAM.Methods: A qualitative study design was used. Primary care patients with uncontrolled office BP who fulfilled the inclusion criteria were enrolled into a BP telemonitoring service offered between the period August 2012 and September 2012. This service was delivered at an urban primary care clinic in Kuala Lumpur, Malaysia. Twenty patients used the BP telemonitoring service. Of these, 17 patients consented to share their views and experiences through five in-depth interviews and two focus group discussions. An interview guide was developed based on the TAM. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was used for analysis.Results: Patients found the BP telemonitoring service easy to use but struggled with the perceived usefulness of doing so. They expressed confusion in making sense of the monitored home BP readings. They often thought about the implications of these readings to their hypertension management and overall health. Patients wanted more feedback from their doctors and
Background For over two decades occupational therapists have been encouraged to enhance their roles within primary care and focus on health promotion and prevention activities. While there is a clear fit between occupational therapy and primary care, there have been few practice examples, despite a growing body of evidence to support the role. In 2010, the province of Ontario, Canada provided funding to include occupational therapists as members of Family Health Teams, an interprofessional model of primary care. The integration of occupational therapists into this model of primary care is one of the first large scale initiatives of its kind in North America. The objective of the study was to examine how occupational therapy services are being integrated into primary care teams and understand the structures supporting the integration. Methods A multiple case study design was used to provide an in-depth description of the integration of occupational therapy. Four Family Health Teams with occupational therapists as part of the team were identified. Data collection included in-depth interviews, document analyses, and questionnaires. Results Each Family Health Team had a unique organizational structure that contributed to the integration of occupational therapy. Communication, trust and understanding of occupational therapy were key elements in the integration of occupational therapy into Family Health Teams, and were supported by a number of strategies including co-location, electronic medical records and team meetings. An understanding of occupational therapy was critical for integration into the team and physicians were less likely to understand the occupational therapy role than other health providers. Conclusion With an increased emphasis on interprofessional primary care, new professions will be integrated into primary healthcare teams. The study found that explicit strategies and structures are required to facilitate the integration of a new professional group
This research study combines qualitative and quantitative methodology in reflectively exploring positive case studies to ascertain strategies that...enabled patients to engage in self-management. Moreover, this study seeks to better understand how applying the ADA Standards of Care in a military
Sundborg Eva M
Full Text Available Abstract Background Intimate partner violence (IPV has a deep impact on women's health. Nurses working in primary health care need to be prepared to identify victims and offer appropriate interventions, since IPV is often seen in primary health care. The aim of the study was to assess nurses' preparedness to identify and provide nursing care to women exposed to IPV who attend primary health care. Method Data was collected using a questionnaire to nurses at the primary health care centres. The response rate was 69.3%. Logistic regression analysis was used to test relationships among variables. Results Shortcomings were found regarding preparedness among nurses. They lacked organisational support e.g. guidelines, collaboration with others and knowledge regarding the extensiveness of IPV. Only half of them always asked women about violence and mostly when a woman was physically injured. They felt difficulties to know how to ask and if they identified violence they mostly offered the women a doctor's appointment. Feeling prepared was connected to obtaining knowledge by themselves and also to identifying women exposed to IPV. Conclusion The majority of the nurses were found to be quiet unprepared to provide nursing care to women exposed to IPV. Consequences might be treatment of symptoms but unidentified abuse and more and unnecessary suffering for these women. Improvements are needed on both at the level of the organisation and individual.
Lieshout, J. van; Frigola Capell, E.; Ludt, S.; Grol, R.P.T.M.; Wensing, M.J.P.
OBJECTIVES: Cardiovascular risk management (CVRM) received by patients shows large variation across countries. In this study we explored the aspects of primary care organisation associated with key components of CVRM in coronary heart disease (CHD) patients. DESIGN: Observational study. SETTING: 273
Warmelink, J Catja; Hoijtink, Kirsten; Noppers, Marloes; Wiegers, Therese A; de Cock, T Paul; Klomp, Trudy; Hutton, Eileen K
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. a qualitative analysis was used, based on the constructivist/interpretative paradigm. Three open-ended questions in written or online questionnaire, analysed to identify factors that are linked with job satisfaction, were as follows: 'What are you very satisfied with, in your work as a midwife?', 'What would you most like to change about your work as a midwife?' and 'What could be improved in your work?'. 20 of the 519 primary care practices in the Netherlands in May 2010 were included. at these participating practices 99 of 108 midwives returned a written or online questionnaire. in general, most of the participating primary care midwives were satisfied with their job. The factors positively associated with their job satisfaction were their direct contact with clients, the supportive co-operation and teamwork with immediate colleagues, the organisation of and innovation within their practice group and the independence, autonomy, freedom, variety and opportunities that they experienced in their work. Regarding improvements, the midwives desired a reduction in non-client-related activities, such as paperwork and meetings. They wanted a lower level of work pressure, and a reduced case-load in order to have more time to devote to individual clients׳ needs. Participants identified that co-operation with other partners in the health care system could also be improved. our knowledge, our study is the first explorative study on factors associated with job satisfaction of primary care midwives. While there are several studies on job satisfaction in health care; little is known about the working conditions of midwives in primary care settings. Although the participating primary care midwives in the Netherlands were satisfied with their
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.
Conclusions Progress toward a problem-oriented EPR system based on episodes of care that includes decision support is necessary to satisfy the needs expressed by GPs. Further research could solve the problem of integration of functionality for consultation with specialists and integration with patient held records. Results from this study could contribute to further development of the next generation of EPRs in primary care, as well as inspire the application of EPRs in other parts of the health sector.
Coupe, Nia; Anderson, Emma; Gask, Linda; Sykes, Paul; Richards, David A; Chew-Graham, Carolyn
Collaborative care (CC) is an organisational framework which facilitates the delivery of a mental health intervention to patients by case managers in collaboration with more senior health professionals (supervisors and GPs), and is effective for the management of depression in primary care. However, there remains limited evidence on how to successfully implement this collaborative approach in UK primary care. This study aimed to explore to what extent CC impacts on professional working relationships, and if CC for depression could be implemented as routine in the primary care setting. This qualitative study explored perspectives of the 6 case managers (CMs), 5 supervisors (trial research team members) and 15 general practitioners (GPs) from practices participating in a randomised controlled trial of CC for depression. Interviews were transcribed verbatim and data was analysed using a two-step approach using an initial thematic analysis, and a secondary analysis using the Normalisation Process Theory concepts of coherence, cognitive participation, collective action and reflexive monitoring with respect to the implementation of CC in primary care. Supervisors and CMs demonstrated coherence in their understanding of CC, and consequently reported good levels of cognitive participation and collective action regarding delivering and supervising the intervention. GPs interviewed showed limited understanding of the CC framework, and reported limited collaboration with CMs: barriers to collaboration were identified. All participants identified the potential or experienced benefits of a collaborative approach to depression management and were able to discuss ways in which collaboration can be facilitated. Primary care professionals in this study valued the potential for collaboration, but GPs' understanding of CC and organisational barriers hindered opportunities for communication. Further work is needed to address these organisational barriers in order to facilitate
Taylor, Anna; Stapley, Sally; Hamilton, William
Jaundice is a rare but important symptom of malignant and benign conditions. When patients present in primary care, understanding the relative likelihood of different disease processes can help GPs to investigate and refer patients appropriately. To identify and quantify the various causes of jaundice in adults presenting in primary care. Historical cohort study using electronic primary care records. UK General Practice Research Database. Participants (186 814 men and women) aged >45 years with clinical events recorded in primary care records between 1 January 2005 and 31 December 2007. Data were searched for episodes of jaundice and explanatory diagnoses identified within the subsequent 12 months. If no diagnosis was found, the patient's preceding medical record was searched for relevant chronic diseases. From the full cohort, 277 patients had at least one record of jaundice between 1 January 2005 and 31 December 2006. Ninety-two (33%) were found to have bile duct stones; 74 (27%) had an explanatory cancer [pancreatic cancer 34 (12%), cholangiocarcinoma 13 (5%) and other diagnosed primary malignancy 27 (10%)]. Liver disease attributed to excess alcohol explained 26 (9%) and other diagnoses were identified in 24 (9%). Sixty-one (22%) had no diagnosis related to jaundice recorded. Although the most common cause of jaundice is bile duct stones, cancers are present in over a quarter of patients with jaundice in this study, demonstrating the importance of urgent investigation into the underlying cause.
Van Gelder, Vincent A; Scherpbier-De Haan, Nynke D; De Grauw, Wim J C; Vervoort, Gerald M M; Van Weel, Chris; Biermans, Marion C J; Braspenning, Jozé C C; Wetzels, Jack F M
Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality. To assess the quality of care (QoC) of CKD in primary healthcare in relation to patient and practice characteristics in order to tailor improvement strategies. Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults). CKD management of patients under the care of their general practitioner (GP) was qualified using indicators derived from the Dutch interdisciplinary CKD guideline for primary care and nephrology and included (1) monitoring of renal function, albuminuria, blood pressure, and glucose, (2) monitoring of metabolic parameters, and alongside the guideline: (3) recognition of CKD. The outcome indicator was (4) achieving blood pressure targets. Multilevel logistic regression analysis was applied to identify associated patient and practice characteristics. Kidney function or albuminuria data were available for 59 728 adult patients; 9288 patients had CKD, of whom 8794 were under GP care. Monitoring of disease progression was complete in 42% of CKD patients, monitoring of metabolic parameters in 2%, and blood pressure target was reached in 43.1%. GPs documented CKD in 31.4% of CKD patients. High QoC was strongly associated with diabetes, and to a lesser extent with hypertension and male sex. Room for improvement was found in all aspects of CKD management. As QoC was higher in patients who received structured diabetes care, future CKD care may profit from more structured primary care management, e.g. according to the chronic care model. Quality of care for chronic kidney disease patients in primary care can be improved. In comparison with guideline advice, adequate monitoring of disease progression was observed in 42%, of metabolic parameters in 2%, correct recognition of impaired renal function in 31%, and reaching blood pressure targets in 43% of chronic
Claire van Deventer
Keywords: child HIV, doctor involvement, primary health care, quality improvement ... expertise increased, PHC facilities are now expected to be able to .... organised patient documentation were revisited. .... Review: what can we learn from quality ... South Pacific: Review of evidence and lessons from an innovative.
Full Text Available Abstract Background Treatment of depression, the most prevalent and costly mental disorder, needs to be improved. Non-concordance with clinical guidelines and non-adherence can limit the efficacy of pharmacological treatment of depression. Through pharmaceutical care, pharmacists can improve patients' compliance and wellbeing. The aim of this study is to evaluate the effectiveness and cost-effectiveness of a community pharmacist intervention developed to improve adherence and outcomes of primary care patients with depression. Methods/design A randomized controlled trial, with 6-month follow-up, comparing patients receiving a pharmaceutical care support programme in primary care with patients receiving usual care. The total sample comprises 194 patients (aged between 18 and 75 diagnosed with depressive disorder in a primary care health centre in the province of Barcelona (Spain. Subjects will be asked for written informed consent in order to participate in the study. Diagnosis will be confirmed using the SCID-I. The intervention consists of an educational programme focused on improving knowledge about medication, making patients aware of the importance of compliance, reducing stigma, reassuring patients about side-effects and stressing the importance of carrying out general practitioners' advice. Measurements will take place at baseline, and after 3 and 6 months. Main outcome measure is compliance with antidepressants. Secondary outcomes include; clinical severity of depression (PHQ-9, anxiety (STAI-S, health-related quality of life (EuroQol-5D, satisfaction with the treatment received, side-effects, chronic physical conditions and socio-demographics. The use of healthcare and social care services will be assessed with an adapted version of the Client Service Receipt Inventory (CSRI. Discussion This trial will provide valuable information for health professionals and policy makers on the effectiveness and cost-effectiveness of a pharmaceutical
Full Text Available Abstract Background Strengthening primary health care is critical to reducing health inequity between Indigenous and non-Indigenous Australians. The Audit and Best practice for Chronic Disease Extension (ABCDE project has facilitated the implementation of modern Continuous Quality Improvement (CQI approaches in Indigenous community health care centres across Australia. The project demonstrated improvements in health centre systems, delivery of primary care services and in patient intermediate outcomes. It has also highlighted substantial variation in quality of care. Through a partnership between academic researchers, service providers and policy makers, we are now implementing a study which aims to 1 explore the factors associated with variation in clinical performance; 2 examine specific strategies that have been effective in improving primary care clinical performance; and 3 work with health service staff, management and policy makers to enhance the effective implementation of successful strategies. Methods/Design The study will be conducted in Indigenous community health centres from at least six States/Territories (Northern Territory, Western Australia, New South Wales, South Australia, Queensland and Victoria over a five year period. A research hub will be established in each region to support collection and reporting of quantitative and qualitative clinical and health centre system performance data, to investigate factors affecting variation in quality of care and to facilitate effective translation of research evidence into policy and practice. The project is supported by a web-based information system, providing automated analysis and reporting of clinical care performance to health centre staff and management. Discussion By linking researchers directly to users of research (service providers, managers and policy makers, the partnership is well placed to generate new knowledge on effective strategies for improving the quality of primary
Son, G.E. van; Hoeken, D. van; Bartelds, A.I.; Furth, E.F. van; Hoek, H.W.
OBJECTIVE: This Dutch epidemiological study used primary care-based data to examine changes in the incidence of eating disorders in the 1990s compared to the 1980s. METHOD: A nationwide network of general practitioners, serving a representative sample of the total Dutch population, recorded newly
Ruijs, C.D.M.; Kerkhof, A.J.F.M.; van der Wal, G.; Onwuteaka-Philipsen, B.D.
Background: Unbearable suffering most frequently is reported in end-of-life cancer patients in primary care. However, research seldom addresses unbearable suffering. The aim of this study was to comprehensively investigate the various aspects of unbearable suffering in end-of-life cancer patients
Valk, Mark J.; Mosterd, Arend; Broekhuizen, Berna D L; Zuithoff, Nicolaas P A; Landman, Marcel A J; Hoes, Arno W.; Rutten, Frans H.
Background Access to echocardiography in primary care is limited, but is necessary to accurately diagnose heart failure (HF). Aim To determine the proportion of patients with a GP's diagnosis of HF who really have HF. Design and setting A cross-sectional study of patients in 30 general practices
Hugenholtz, M.; Bröer, C.; van Daalen, R.
Background: Children are more frequent users of out-of-hours primary care than other age groups, although their medical problems are less urgent. Aim: To gain insight into the health-seeking behaviour of parents who ask for immediate medical attention for their children. Design of study: Qualitative
VonKorff, M; Ustun, TB; Ormel, J; Kaplan, [No Value; Simon, GE
We assessed the replicability of reliability and validity of a brief self-report disability scale, adapted from the Medical Outcomes Survey (short form), in a 15-center, cross-national, multilingual study of psychological illness among primary care patients (n = 5438). Across all 15 centers in the
Capurso, Gabriele; Archibugi, Livia; Pasquali, Piera; Aceti, Alessandro; Balducci, Paolo; Bianchi, Patrizia; Buono, Francesco; Camerucci, Stefano; Cantarini, Rosanna; Centofanti, Sergio; Colantonio, Patrizia; Cremaschi, Riccarda; Crescenzi, Sergio; Di Mauro, Caterina; Di Renzi, Davide; Filabozzi, Andrea; Fiorillo, Alfonso; Giancaspro, Giuseppe; Giovannetti, Paola; Lanna, Giuseppe; Medori, Claudio; Merletti, Emilio; Nunnari, Enzo; Paris, Francesca; Pavone, Marco; Piacenti, Angela; Rossi, Almerindo; Scamuffa, Maria Cristina; Spinelli, Giovanni; Taborchi, Marco; Valente, Biagio; Villanova, Antonella; Chiriatti, Alberto; Delle Fave, Gianfranco
Data on chronic pancreatitis prevalence are scanty and usually limited to hospital-based studies. Investigating chronic pancreatitis prevalence in primary care. Participating primary care physicians reported the prevalence of chronic pancreatitis among their registered patients, environmental factors and disease characteristics. The data were centrally reviewed and chronic pancreatitis cases defined according to M-ANNHEIM criteria for diagnosis and severity and TIGAR-O classification for etiology. Twenty-three primary care physicians participated in the study. According to their judgment, 51 of 36.401 patients had chronic pancreatitis. After reviewing each patient data, 11 turned out to have definite, 5 probable, 19 borderline and 16 uncertain disease. Prevalence was 30.2/100.000 for definite cases and 44.0/100.000 for definite plus probable cases. Of the 16 patients with definite/probable diagnosis, 8 were male, with mean age of 55.6 (±16.7). Four patients had alcoholic etiology, 5 post-acute/recurrent pancreatitis, 6 were deemed to be idiopathic. Four had pancreatic exocrine insufficiency, 10 were receiving pancreatic enzymes, and six had pain. Most patients had initial stage and non-severe disease. This is the first study investigating the prevalence of chronic pancreatitis in primary care. Results suggest that the prevalence in this context is higher than in hospital-based studies, with specific features, possibly representing an earlier disease stage. Copyright © 2016 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.
van Son, Gabrielle E.; van Hoeken, Daphne; Bartelds, Aad I. M.; van Furth, Eric F.; Hoek, Hans W.
Objective: This Dutch epidemiological study used primary care-based data to examine changes in the incidence of eating disorders in the 1990s compared to the 1980s. Method: A nationwide network of general practitioners, serving a representative sample of the total Dutch population, recorded newly
Hatlebakk, Jan G; Hyggen, Arild; Madsen, Per H; Walle, Per O; Schulz, Tom; Mowinckel, Petter; Bernklev, Tomm; Berstad, Arnold
Objective To compare the effects and tolerability of omeprazole and cisapride with that of placebo for control of heartburn in primary care patients. Design Randomised, double blind, placebo controlled study. Setting 65 primary care practices in Norway. Participants 483 untreated patients with complaints of heartburn ⩾3 days a week, with at most grade 1 reflux oesophagitis. Interventions Omeprazole 20 mg once daily, cisapride 20 mg twice daily, or placebo for 8 weeks. Main outcome measures Adequate control of heartburn, defined as ⩽1 day of the past 7 days with no more than mild heartburn, after 4 weeks of treatment. Results In the all patients treated analysis, adequate control of heartburn was achieved in 71% of patients taking omeprazole, 22% taking cisapride, and 18% taking placebo after 4 weeks of treatment (omeprazole v cisapride and placebo, Pheartburn whereas cisapride 20 mg twice daily was not significantly more effective than placebo. Key messagesIn primary care patients, heartburn is commonly treated empiricallyMost randomised clinical trials of treatment for heartburn have been conducted in specialist care, and documentation for empirical treatment is limitedOmeprazole was significantly more effective than cisapride or placebo in controlling heartburn and other symptoms of gastro-oesophageal reflux after 2, 4, and 8 weeks, whereas cisapride did not differ significantly from placeboOmeprazole should be considered as a first choice for empirical treatment of heartburn in primary care PMID:10463897
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
Background: The well-being of women and children is one of the major determinants ... The Sample for the study were women recruited from 11 primary health care ... respondents educational level and knowledge of preconception care (X =24.76, ... single adult or married couple) are in an optimal state .... The major site for.
Northridge, Mary E.; Birenz, Shirley; Gomes, Danni; Golembeski, Cynthia A.; Greenblatt, Ariel Port; Shelley, Donna; Russell, Stefanie L.
Purpose There is a need for research to facilitate the widespread implementation, dissemination, and sustained utilization of evidence-based primary care screening, monitoring, and care coordination guidelines, thereby increasing the impact of dental hygienists’ actions on patients’ oral and general health. The aims of this formative study are to: (1) explore dental hygienists’ and dentists’ perspectives regarding the integration of primary care activities into routine dental care; and (2) assess the needs of dental hygienists and dentists regarding primary care coordination activities and use of information technology to obtain clinical information at chairside. Methods This qualitative study recruited ten hygienists and six dentists from ten New York City area dental offices with diverse patient mixes and volumes. A New York University faculty hygienist conducted semi-structured, in-depth interviews, which were digitally recorded and transcribed verbatim. Data analysis consisted of multilevel coding based on the Consolidated Framework for Implementation Research, resulting in emergent themes with accompanying categories. Results The dental hygienists and dentists interviewed as part of this study fail to use evidence-based guidelines to screen their patients for primary care sensitive conditions. Overwhelmingly, dental providers believe that tobacco use and poor diet contribute to oral disease, and report using electronic devices at chairside to obtain web-based health information. Conclusion Dental hygienists are well positioned to help facilitate greater integration of oral and general health care. Challenges include lack of evidence-based knowledge, coordination between dental hygienists and dentists, and systems-level support, with opportunities for improvement based upon a theory-driven framework. PMID:27340183
Östlund, Ann-Sofi; Kristofferzon, Marja-Leena; Häggström, Elisabeth; Wadensten, Barbro
Motivational interviewing is a collaborative conversational style intended to strengthen motivation to change. It has been shown to be effective in addressing many different lifestyle problems as well as in chronic disease management, and many disease prevention guidelines promote use of motivational interviewing. The aim of the present study was twofold: to assess to what extent the primary care nurses in the study perform motivational interviewing according to the Motivational Interviewing Treatment Integrity Code and to investigate how the participating primary care nurses rated their own performance in motivational interviewing. The study was based on twelve primary care nurses' audio-recorded motivational interviewing sessions with patients (total 32 sessions). After each session, the nurses completed a questionnaire regarding their experience of their own performance in motivational interviewing. The audio-recorded sessions were analyzed using Motivational Interviewing Integrity Code 3.1.1. None of the nurses achieved beginning proficiency in all parts of any motivational interviewing sessions and two nurses did not achieve beginning proficiency in any parts or sessions. Making more complex than simple reflections was the specific verbal behavior/summary score that most nurses achieved. Beginning proficiency/competency in "percent open questions" was the summary score that fewest achieved. Primary care nurses did not achieve beginning proficiency/competency in all aspects of motivational interviewing in their recorded sessions with patients, where lifestyle change was discussed. This indicates a need for improvement and thus additional training, feedback and supervision in clinical practice with motivational interviewing.
Draper, Claire A; Draper, Catherine E; Bresick, Graham F
Chronic disease is by far the leading cause of death worldwide and of increasing concern in low- and middle-income countries, including South Africa, where chronic diseases disproportionately affect the poor living in urban settings. The Provincial Government of the Western Cape (PGWC) has prioritized the management of chronic diseases and has developed a policy and framework (Adult Chronic Disease Management Policy 2009) to guide and improve the prevention and management of chronic diseases at a primary care level. The aim of this study is to assess the alignment of current primary care practices with the PGWC Adult Chronic Disease Management policy. One comprehensive primary care facility in a Cape Town health district was used as a case study. Data was collected via semi-structured interviews (n = 10), focus groups (n = 8) and document review. Participants in this study included clinical staff involved in chronic disease management at the facility and at a provincial level. Data previously collected using the Integrated Audit Tool for Chronic Disease Management (part of the PGWC Adult Chronic Disease Management policy) formed the basis of the guide questions used in focus groups and interviews. The results of this research indicate a significant gap between policy and its implementation to improve and support chronic disease management at this primary care facility. A major factor seems to be poor policy knowledge by clinicians, which contributes to an individual rather than a team approach in the management of chronic disease patients. Poor interaction between facility- and community-based services also emerged. A number of factors were identified that seemed to contribute to poor policy implementation, the majority of which were staff related and ultimately resulted in a decrease in the quality of patient care. Chronic disease policy implementation needs to be improved in order to support chronic disease management at this facility. It is possible that similar
Aalto, Anna-Mari; Elovainio, Marko; Tynkkynen, Liina-Kaisa; Reissell, Eeva; Vehko, Tuulikki; Chydenius, Miisa; Sinervo, Timo
The ongoing Finnish health and social service reform will expand choice by opening the market for competition between public and private service providers. This study examined the attitudes of primary care patients towards choice and which patient-related factors are associated with these attitudes. A sample of attenders during one week in health centres of 12 big cities and municipal consortiums (including seven outsourced local units) and in primary care units of one private company providing outsourced services for municipalities (aged 18-95, n=8128) was used. The questionnaire included questions on choice-related attitudes, sociodemographic factors, health status, use of health services and patient satisfaction. Of the responders, 77% regarded choice to be important, 49% perceived genuine opportunities to make choices and 35% were satisfied with the choice-relevant information. Higher age, low education, having a chronic illness, frequent use of services, having a personal physician and being satisfied with the physician and with waiting times were related to assigning more importance on choice. Younger patients, those with higher education as well as those with chronic illness regarded their opportunities of choosing the service provider and availability of choice-relevant information poorer. The Finnish primary care patients value choice, but they are critical of the availability of choice-relevant information. Choices of patients with complex health care needs should be supported by developing integrated care alternatives and by increasing the availability of information on existing care alternatives to meet their needs.
Mamdouh M. Shubair
Full Text Available Background: Men in rural and northern areas of Canada experience considerable challenges in health care access for chronic conditions such as obesity, type 2 diabetes (T2D, and cancer. Obese men (body mass index/BMI ≥ 30 kg/m2 in rural/remote northern British Columbia (BC experience poorer health outcomes due to cancer risk compared to other men elsewhere in urban Canada. Context: Challenges faced by men who develop cancer as a complication of being obese are paramount in terms of primary care treatment of their cancers. Oftentimes cancer treatment is multi-modal and complex. Models of shared care have been proposed to provide coordinated survivorship care to the growing population of rural male cancer patients suffering from obesity and the Metabolic Syndrome (MetS. Methods: Objectives: The main objective of the study was to examine the type of cancer care programs that may have focused on men with cancer in northern British Columbia (BC. A secondary objective is to identify challenges in care experienced by men with cancer during their transition from in-hospital care back to their home communities. Population: We conducted a comprehensive literature review and a qualitative focus group interview with primary care physicians (PCPs, oncologists (n=8, and a convenience sample of male cancer patients (n=6 who have underlying obesity and Metabolic Syndrome (MetS. We examined the types of cancer care programs that may have targeted such men. We further identified challenges experienced by male cancer patients while transitioning back to their home communities. Results: The focus group results outlined themes speaking to a comprehensive shared care model that goes beyond surveillance of cancer recurrence in men with obesity. Conclusion: A shared survivorship care plan or model integrates collaboration among specialists in clinical decision making and best practice for treatment of cancer in obese men.
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.
Soto Moreno, A; Venegas Moreno, E; Santos Rubio, M; Sanz, León; García Luna, P P
The worsening of the nutritional status of certain segments of the population has led to frequent situations of chronic undernourishment even in the healthy population. There are very few data available on the prevalence and causes of malnutrition in Primary Health Care. The present study attempts to provide measurable information, obtained at random from the doctors involved in the country's Primary Health Care, on the characteristics of the undernourished patients, the cause of the undernourishment, the diagnostic means used, the treatment applied and the progress of the patients regularly treated in Primary Health Care facilities. A sample of 1,819 doctors in Primary Health Care were surveyed to know their opinions on the nutritional status of their patients. They were asked to complete a "Patient Record" for the first patient to enter their office suffering from undernourishment. A total of 505 Patient Records were received from the different Primary Health Care doctors taking part in the study throughout Spain. Of the patients included, 10% were aged less than 10, while 46.7% were between 16 and 65 years of age and 44.2% were over 65. The main diagnosis in these patients was varied, with cancer patients (22.6%) and anorexics, including anorexia nerviosa and other non-oncological causes, (16.4%) the most common. As for the tests used for diagnosing undernourishment, those most frequently applied were physical examination (61%) and biochemical tests (56.4%). The risk factor most commonly found in these patients was old age/senility (21%). Nutritional support (55.8%) and dietary recommendations (45.3%) were the therapies most often applied. Only 47% of patients correctly implemented their treatment according to the doctors in Primary Health Care and the prognosis was as follows: 31% were expected to improve, 20% to worsen and 44% of cases would remain stable. From this study, it is concluded that most undernourished patients in Primary Health Care are there due
Aleluia, Italo Ricardo Santos; Medina, Maria Guadalupe; Almeida, Patty Fidelis de; Vilasbôas, Ana Luiza Queiroz
International and Brazilian studies have highlighted the importance of the coordination of care for the organization of local health systems. This study aimed to analyze the coordination of care by Primary Health Care (PHC) in a municipal health system in the State of Bahia. This study was conducted in the lead municipality of the macro-region and involved two levels of analysis: PHC team and municipal management. Outlining conditions for the study were defined (hypertension and diabetes mellitus) and an objective image corresponding to the coordination of care was developed based on current national and international literature review. Semi-structured interviews with professionals, managers of PHC services were conducted and current documentary sources were also used. It was demonstrated that the coordination of care has not been met by municipal systems, where only 14 of the 22 proposed criteria have been met. The main difficulties and reasons were: a lack of health care protocols and the non-implementation of computer systems and telecommunication technologies. The results and the conceptual framework to assess the coordination of care are relevant contributions to this study, which can be applied to other contexts with similar characteristics.
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.
Leavey, Gerard; Mallon, Sharon; Rondon-Sulbaran, Janeet; Galway, Karen; Rosato, Michael; Hughes, Lynette
Although Primary care is crucial for suicide prevention, clinicians tend to report completed suicides in their care as non-preventable. We aimed to examine systemic inadequacies in suicide prevention from the perspectives of bereaved family members and GPs. Qualitative study of 72 relatives or close friends bereaved by suicide and 19 General Practitioners who have experienced the suicide of patients. Relatives highlight failures in detecting symptoms and behavioral changes and the inability of GPs to understand the needs of patients and their social contexts. A perceived overreliance on anti-depressant treatment is a major source of criticism by family members. GPs tend to lack confidence in the recognition and management of suicidal patients, and report structural inadequacies in service provision. Mental health and primary care services must find innovative and ethical ways to involve families in the decision-making process for patients at risk of suicide.
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
Pawa, Jasmine; Robson, John; Hull, Sally
Primary care practices are increasingly working in larger groups. In 2009, all 36 primary care practices in the London borough of Tower Hamlets were grouped geographically into eight managed practice networks to improve the quality of care they delivered. Quantitative evaluation has shown improved clinical outcomes. To provide insight into the process of network implementation, including the aims, facilitating factors, and barriers, from both the clinical and managerial perspectives. A qualitative study of network implementation in the London borough of Tower Hamlets, which serves a socially disadvantaged and ethnically diverse population. Nineteen semi-structured interviews were carried out with doctors, nurses, and managers, and were informed by existing literature on integrated care and GP networks. Interviews were recorded and transcribed, and thematic analysis used to analyse emerging themes. Interviewees agreed that networks improved clinical care and reduced variation in practice performance. Network implementation was facilitated by the balance struck between 'a given structure' and network autonomy to adopt local solutions. Improved use of data, including patient recall and peer performance indicators, were viewed as critical key factors. Targeted investment provided the necessary resources to achieve this. Barriers to implementing networks included differences in practice culture, a reluctance to share data, and increased workload. Commissioners and providers were positive about the implementation of GP networks as a way to improve the quality of clinical care in Tower Hamlets. The issues that arose may be of relevance to other areas implementing similar quality improvement programmes at scale. © British Journal of General Practice 2017.
Sánchez-Reales, S; Tornero-Gómez, M J; Martín-Oviedo, P; Redondo-Jiménez, M; del-Arco-Jódar, R
Our aim is to present the first year of operation of a Clinical Psychology service in a Primary Care setting. A descriptive study was performed by analysing the requests and the care intervention of the Psychology Service, in collaboration with 36 general practitioners (33% of the staff), belonging to 6 health centres. Within the one year period, 171 outpatients from 15 years and older were referred with mild psychological disorders (> 61 in the global assessment functioning scale, APA, 2002). A total of 111 outpatients received psychological care. The main diagnoses were adaptation disorder, affective disorder, and anxiety. More than half (54.82%) of them achieved a full recovery. After a year follow up, a drop of 25.19% was observed in medicines use. The Primary Care Psychology team is a halfway unit between Primary Care practitioners and specialised units in order to deal with mild mental symptomatology which otherwise could be undertreated. It represents an important support for practitioners. Secondly, the early intervention can prevent mental problems becoming chronic, as shown by the drop in medication use. In spite of the not very high agreement between the practitioner's diagnoses and those made by the Psychology unit, it has set up an important means of communication and with direct and immediate interdisciplinary action. This should eventually lead to savings in economic resources and human suffering. Copyright © 2014. Publicado por Elsevier España, S.L.U.
Mishuris, Rebecca G; Stewart, Max; Fix, Gemmae M; Marcello, Thomas; McInnes, D Keith; Hogan, Timothy P; Boardman, Judith B; Simon, Steven R
Electronic, or web-based, patient portals can improve patient satisfaction, engagement and health outcomes and are becoming more prevalent with the advent of meaningful use incentives. However, adoption rates are low, particularly among vulnerable patient populations, such as those patients who are home-bound with multiple comorbidities. Little is known about how these patients view patient portals or their barriers to using them. To identify barriers to and facilitators of using My HealtheVet (MHV), the United States Department of Veterans Affairs (VA) patient portal, among Veterans using home-based primary care services. Qualitative study using in-depth semi-structured interviews. We conducted a content analysis informed by grounded theory. Fourteen Veterans receiving home-based primary care, surrogates of two of these Veterans, and three home-based primary care (HBPC) staff members. We identified five themes related to the use of MHV: limited knowledge; satisfaction with current HBPC care; limited computer and Internet access; desire to learn more about MHV and its potential use; and value of surrogates acting as intermediaries between Veterans and MHV. Despite their limited knowledge of MHV and computer access, home-bound Veterans are interested in accessing MHV and using it as an additional point of care. Surrogates are also potential users of MHV on behalf of these Veterans and may have different barriers to and benefits from use. © 2014 John Wiley & Sons Ltd.
Bello, Aminu K; Ronksley, Paul E; Tangri, Navdeep; Singer, Alexander; Grill, Allan; Nitsch, Dorothea; Queenan, John A; Lindeman, Cliff; Soos, Boglarka; Freiheit, Elizabeth; Tuot, Delphine; Mangin, Dee; Drummond, Neil
Effective chronic disease care is dependent on well-organised quality improvement (QI) strategies that monitor processes of care and outcomes for optimal care delivery. Although healthcare is provincially/territorially structured in Canada, there are national networks such as the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) as important facilitators for national QI-based studies to improve chronic disease care. The goal of our study is to improve the understanding of how patients with chronic kidney disease (CKD) are managed in primary care and the variation across practices and provinces and territories to drive improvements in care delivery. The CPCSSN database contains anonymised health information from the electronic medical records for patients of participating primary care practices (PCPs) across Canada (n=1200). The dataset includes information on patient sociodemographics, medications, laboratory results and comorbidities. Leveraging validated algorithms, case definitions and guidelines will help define CKD and the related processes of care, and these enable us to: (1) determine prevalent CKD burden; (2) ascertain the current practice pattern on risk identification and management of CKD and (3) study variation in care indicators (eg, achievement of blood pressure and proteinuria targets) and referral pattern for specialist kidney care. The process of care outcomes will be stratified across patients' demographics as well as provider and regional (provincial/territorial) characteristics. The prevalence of CKD stages 3-5 will be presented as age-sex standardised prevalence estimates stratified by province and as weighted averages for population rates with 95% CIs using census data. For each PCP, age-sex standardised prevalence will be calculated and compared with expected standardised prevalence estimates. The process-based outcomes will be defined using established methods. The CPCSSN is committed to high ethical standards when dealing with
Kallio, Jouko; Kauppila, Timo; Suominen, Lasse; Heikkinen, Anna Maria
A playful competition was launched in a primary dental health care system to improve the recording of diagnoses into an electronic patient chart system and to study what diagnoses were used in primary dental care. This was a longitudinal follow-up study with public sector primary dental care practices in a Finnish city. A one-year-lasting playful competition between the dental care teams was launched and the monthly percentage of dentists' visits with recorded diagnosis before, during, and after the intervention was recorded. The assessed diagnoses were recorded with the International Classification of Diseases (ICD-10). Before the competition, the level of diagnosis recordings was practically zero. At the end of this intervention, about 25% of the visits had a recorded diagnosis. Two years after the competition, this percentage was 35% without any additional measures. The most frequent diagnoses were dental caries (K02, 38.6%), other diseases of hard tissues of teeth (K03, 14.8%), and diseases of pulp and periapical tissues (K04, 11.4%). Commitment to the idea that recording of diagnoses was beneficial improved the recording of dental diagnoses. However, the diagnoses obtained did not accurately reflect the reputed prevalence of oral diseases in the Finnish population.
Full Text Available Introduction. A playful competition was launched in a primary dental health care system to improve the recording of diagnoses into an electronic patient chart system and to study what diagnoses were used in primary dental care. Methods. This was a longitudinal follow-up study with public sector primary dental care practices in a Finnish city. A one-year-lasting playful competition between the dental care teams was launched and the monthly percentage of dentists’ visits with recorded diagnosis before, during, and after the intervention was recorded. The assessed diagnoses were recorded with the International Classification of Diseases (ICD-10. Results. Before the competition, the level of diagnosis recordings was practically zero. At the end of this intervention, about 25% of the visits had a recorded diagnosis. Two years after the competition, this percentage was 35% without any additional measures. The most frequent diagnoses were dental caries (K02, 38.6%, other diseases of hard tissues of teeth (K03, 14.8%, and diseases of pulp and periapical tissues (K04, 11.4%. Conclusions. Commitment to the idea that recording of diagnoses was beneficial improved the recording of dental diagnoses. However, the diagnoses obtained did not accurately reflect the reputed prevalence of oral diseases in the Finnish population.
Vest, Bonnie M; York, Trevor R M; Sand, Jessica; Fox, Chester H; Kahn, Linda S
Primary care physicians (PCPs) are optimally situated to identify and manage early stage chronic kidney disease (CKD). Nonetheless, studies have documented suboptimal PCP understanding, awareness, and management of early CKD. The TRANSLATE CKD study is an ongoing national, mixed-methods, cluster randomized control trial that examines the implementation of evidence-based guidelines for CKD into primary care practice. As part of the mixed-methods process evaluation, semistructured interviews were conducted by phone with 27 providers participating in the study. Interviews were audio-taped and transcribed. Thematic content analysis was used to identify themes. Themes were categorized according to the 4 domains of Normalization Process Theory (NPT). Identified themes illuminated the complex work undertaken to manage CKD in primary care practices. Barriers to guideline implementation were identified in each of the 4 NPT domains, including (1) lack of knowledge and understanding around CKD (coherence), (2) difficulties engaging providers and patients in CKD management (cognitive participation), (3) limited time and competing demands (collective action), and (4) challenges obtaining and using data to monitor progress (reflexive monitoring). Addressing the barriers to implementation with concrete interventions at the levels at which they occur, informed by NPT, will ultimately improve the quality of CKD patient care. © Copyright 2015 by the American Board of Family Medicine.
Full Text Available Background The symptom of fatigue is one of the top five most frequently presented health complaints in primary care, yet it remains underexplored in the Canadian primary care context.Objective The objective of this study was to examine the prevalence and impact of patients presenting with fatigue in primary care, using the only known electronic database in Canada to capture patient-reported symptoms.Methods Data were extracted from the Deliver Primary Healthcare Information (DELPHI database, an electronic medical record database located in Ontario, Canada. Patients were identified using the International Classification of Primary Care, Revised Second Edition coding system. Two groups of patients (fatigue or non-fatigue symptom were followed for one year and compared. Both descriptive and multivariable analyses were conducted.Results A total of 103 fatigue symptom patients, and 103 non-fatigue symptom patients, were identified in the DELPHI database. The period prevalence of fatigue presentation was 8.2%, with the majority of patients being female and over 60 years of age. These patients experienced numerous co-occurring morbidities, in addition to the fatigue itself. During the one year follow-up period, fatigue symptom patients had significantly higher rates of subsequent visits (IRR = 1.19, p = 0.038 and investigations (IRR = 1.68, p < 0.001, and markedly high levels of referrals following their index visit.Conclusions This research used an electronic database to examine the symptom, fatigue. Using these data, fatigue symptom patients were found to have higher rates of health care utilisation, compared to non-fatigue symptom patients.
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.
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
The Vantaa Primary Care Depression Study (PC-VDS) is a naturalistic and prospective cohort study concerning primary care patients with depressive disorders. It forms a collaborative research project between the Department of Mental and Alcohol Research of the National Public Health Institute, and the Primary Health Care Organization of the City of Vantaa. The aim is to obtain a comprehensive view on clinically significant depression in primary care, and to compare depressive patients in prima...
Blakeman, Tom; Protheroe, Joanne; Chew-Graham, Carolyn; Rogers, Anne; Kennedy, Anne
Background Primary care is recognised to have an important role in the delivery of care for people with chronic kidney disease (CKD). However, there is evidence that CKD management is currently suboptimal, with a range of practitioner concerns about its management. Aim To explore processes underpinning the implementation of CKD management in primary care. Design and setting Qualitative study in general practices participating in a chronic kidney disease collaborative undertaken as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester. Method Semi-structured interviews were conducted with GPs and practice nurses (n = 21). Normalisation Process Theory provided a framework for generation and analysis of the data. Results A predominant theme was anxiety about the disclosure of early-stage CKD with patients. The tensions experienced related to identifying and discussing CKD in older people and patients with stage 3A, embedding early-stage CKD within vascular care, and the distribution of work within the practice team. Participants provided accounts of work undertaken to resolve the difficulties encountered, with efforts having tended to focus on reassuring patients. Analysis also highlighted how anxiety surrounding disclosure influenced, and was shaped by, the organisation of care for people with CKD and associated long-term conditions. Conclusion Offering reassurance alone may be of limited benefit, and current management of early-stage CKD in primary care may miss opportunities to address susceptibility to kidney injury, improve self-management of vascular conditions, and improve the management of multimorbidity. PMID:22520910
and/or home-based treatment did not cure a patient, other alternatives are looked for such as ... multiple health-care resources, successful rural primary health care strategy would give due attention to such local ...... Nurse practitioners and.
Goetz, Katja; Jossen, Marianne; Szecsenyi, Joachim; Rosemann, Thomas; Hahn, Karolin; Hess, Sigrid
Job satisfaction of physicians is an important issue for performance of a health care system. The aim of the study was to evaluate the job satisfaction of primary care physicians in Switzerland and to explore associations between overall job satisfaction, individual characteristics and satisfaction with aspects of work within the practice separated by gender. This cross-sectional study was based on a job satisfaction survey. Data were collected from 176 primary care physicians working in 91 primary care practices. Job satisfaction was measured with the 10-item Warr-Cook-Wall job satisfaction scale. Stepwise linear regression analysis was performed for physicians separated by gender. The response rate was 92.6%. Primary care physicians reported the highest level of satisfaction with 'freedom of working method' (mean = 6.45) and the lowest satisfaction for 'hours of work' (mean = 5.38) and 'income' (mean = 5.49). Moreover, some aspects of job satisfaction were rated higher by female physicians than male physicians. Within the stepwise regression analysis, the aspect 'opportunity to use abilities' (β = 0.644) showed the highest association to overall job satisfaction for male physicians while for female physicians it was income (β = 0.733). The presented results contribute to an understanding of factors that influence levels of satisfaction of female and male physicians. Therefore, research and intervention about job satisfaction should consider gender as well as the stereotypes that come along with these social roles. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: email@example.com.
Glynn, Liam G; Glynn, Fergus; Casey, Monica; Wilkinson, Louise Gaffney; Hayes, Patrick S; Heaney, David; Murphy, Andrew W M
Problematic translational gaps continue to exist between demonstrating the positive impact of healthcare interventions in research settings and their implementation into routine daily practice. The aim of this qualitative evaluation of the SMART MOVE trial was to conduct a theoretically informed analysis, using normalisation process theory, of the potential barriers and levers to the implementation of a mhealth intervention to promote physical activity in primary care. The study took place in the West of Ireland with recruitment in the community from the Clare Primary Care Network. SMART MOVE trial participants and the staff from four primary care centres were invited to take part and all agreed to do so. A qualitative methodology with a combination of focus groups (general practitioners, practice nurses and non-clinical staff from four separate primary care centres, n = 14) and individual semi-structured interviews (intervention and control SMART MOVE trial participants, n = 4) with purposeful sampling utilising the principles of Framework Analysis was utilised. The Normalisation Process Theory was used to develop the topic guide for the interviews and also informed the data analysis process. Four themes emerged from the analysis: personal and professional exercise strategies; roles and responsibilities to support active engagement; utilisation challenges; and evaluation, adoption and adherence. It was evident that introducing a new healthcare intervention demands a comprehensive evaluation of the intervention itself and also the environment in which it is to operate. Despite certain obstacles, the opportunity exists for the successful implementation of a novel healthcare intervention that addresses a hitherto unresolved healthcare need, provided that the intervention has strong usability attributes for both disseminators and target users and coheres strongly with the core objectives and culture of the health care environment in which it is to operate. We
Full Text Available Abstract Background The biggest barrier to treatment of common mental disorders in primary care settings is low recognition among health care providers. This study attempts to explore the explanatory models of common mental disorders (CMD with the goal of identifying how they could help in improving the recognition, leading to effective treatment in primary care. Results The paper describes findings of a cross sectional qualitative study nested within a large randomized controlled trial (the Manas trial. Semi structured interviews were conducted with 117 primary health care attendees (30 males and 87 females suffering from CMD. Main findings of the study are that somatic phenomena were by far the most frequent presenting problems; however, psychological phenomena were relatively easily elicited on probing. Somatic phenomena were located within a biopsychosocial framework, and a substantial proportion of informants used the psychological construct of ‘tension’ or ‘worry’ to label their illness, but did not consider themselves as suffering from a ‘mental disorder’. Very few gender differences were observed in the descriptions of symptoms but at the same time the pattern of adverse life events and social difficulties varied across gender. Conclusion Our study demonstrates how people present their illness through somatic complaints but clearly link their illness to their psychosocial world. However they do not associate their illness to a ‘mental disorder’ and this is an important phenomenon that needs to be recognized in management of CMD in primary settings. Our study also elicits important gender differences in the experience of CMD.
Full Text Available PURPOSE: It is largely unknown how the medical treatment of patients diagnosed with dementia is followed up in primary care. Therefore, we studied patient medical records from two dementia clinics and from the referring primary care centres. METHODS: A retrospective study of 241 patients was conducted from April to October 2011 in north west Stockholm, Sweden. Over half (51.5% of the patients had Alzheimer's disease (AD, the remainder had mixed AD/vascular dementia (VaD. Eighty-four medical reports from primary care (35% of the study group were analysed at follow-up 18 months after diagnosis. RESULTS: All four dementia drugs available on the Swedish market (three cholinesterase inhibitors [donepezil, rivastigmine and galantamine] and memantine were prescribed at the two dementia clinics. The most commonly used dementia drug was galantamine. There were differences between the two dementia clinics in preference and combination of drugs and of treatment given to male and female patients. At follow-up, 84% were still on dementia medication. Drug use was followed up by the general practitioners (GPs in two-thirds of the cases. Eighteen per cent of the GPs' medical records made no reference to the patient's dementia or treatment even though dementia drugs were included in the list of medications prescribed. CONCLUSIONS: The results indicate that the Swedish guidelines for treatment of cognitive symptoms in AD are being followed in primary care. However, documentation of follow-up of drug treatment was sometimes insufficient, which calls for development of guidelines for complete medical records and medication lists.
Sharma, Maneesh; Lee, Chee; Kantorovich, Svetlana; Tedtaotao, Maria; Smith, Gregory A.
Background: Opioid abuse in chronic pain patients is a major public health issue. Primary care providers are frequently the first to prescribe opioids to patients suffering from pain, yet do not always have the time or resources to adequately evaluate the risk of opioid use disorder (OUD). Purpose: This study seeks to determine the predictability of aberrant behavior to opioids using a comprehensive scoring algorithm (“profile”) incorporating phenotypic and, more uniquely, genotypic risk factors. Methods and Results: In a validation study with 452 participants diagnosed with OUD and 1237 controls, the algorithm successfully categorized patients at high and moderate risk of OUD with 91.8% sensitivity. Regardless of changes in the prevalence of OUD, sensitivity of the algorithm remained >90%. Conclusion: The algorithm correctly stratifies primary care patients into low-, moderate-, and high-risk categories to appropriately identify patients in need for additional guidance, monitoring, or treatment changes. PMID:28890908
Lim, Yvonne Mei Fong; Yusof, Maryati; Sivasampu, Sheamini
Purpose The purpose of this paper is to assess National Medical Care Survey data quality. Design/methodology/approach Data completeness and representativeness were computed for all observations while other data quality measures were assessed using a 10 per cent sample from the National Medical Care Survey database; i.e., 12,569 primary care records from 189 public and private practices were included in the analysis. Findings Data field completion ranged from 69 to 100 per cent. Error rates for data transfer from paper to web-based application varied between 0.5 and 6.1 per cent. Error rates arising from diagnosis and clinical process coding were higher than medication coding. Data fields that involved free text entry were more prone to errors than those involving selection from menus. The authors found that completeness, accuracy, coding reliability and representativeness were generally good, while data timeliness needs to be improved. Research limitations/implications Only data entered into a web-based application were examined. Data omissions and errors in the original questionnaires were not covered. Practical implications Results from this study provided informative and practicable approaches to improve primary health care data completeness and accuracy especially in developing nations where resources are limited. Originality/value Primary care data quality studies in developing nations are limited. Understanding errors and missing data enables researchers and health service administrators to prevent quality-related problems in primary care data.
Skånér, Ylva; Arrelöv, Britt; Backlund, Lars G; Fresk, Magdalena; Aström, Amanda Waleh; Nilsson, Gunnar H
In the period 2004-2009, national and regional initiatives were developed in Sweden to improve the quality of sickness certificates. Parameters for assessing the quality of sickness certificates in primary health care have been proposed. The aim of this study was to measure the quality of sickness certification in primary health care by means of assessing sickness certificates issued between 2004 and 2009 in Stockholm. This was a retrospective study using data retrieved from sickness certificates contained in the electronic patient records of 21 primary health care centres in Stockholm County covering six consecutive years. A total number of 236 441 certificates were used in the current study. Seven quality parameters were chosen as outcome measures. Descriptive statistics and regression models with time, sex and age group as explanatory variables were used. During the study period, the quality of the sickness certification practice improved as the number of days on first certification decreased and the proportion of duly completely and acceptable certificates increased. Assessment of need for vocational rehabilitation and giving a prognosis for return to work were not significantly improved during the same period. Time was the most influential variable. The quality of sickness certification practice improved for most of the parameters, although additional efforts to improve the quality of sickness certificates are needed. Measures, such as reminders, compulsory certificate fields and structured guidance, could be useful tools to achieve this objective.
Fortney, Luke; Luchterhand, Charlene; Zakletskaia, Larissa; Zgierska, Aleksandra; Rakel, David
Focus Area: Integrative Algorithms of Care Purpose: Burnout, attrition, and low work satisfaction of primary care physicians are growing concerns and can have a negative influencee on health care. Interventions for clinicians that improve work-life balance are few and poorly understood. We undertook this study as a first step in investigating whether an abbreviated mindfulness intervention could increase job satisfaction, quality of life, and compassion among primary care clinicians. Methods:...
Clark, Christopher E; Taylor, Rod S; Shore, Angela C; Campbell, John L
Objective To determine whether a difference in systolic blood pressure readings between arms can predict a reduced event free survival after 10 years. Design Cohort study. Setting Rural general practice in Devon, United Kingdom. Participants 230 people receiving treatment for hypertension in primary care. Intervention Bilateral blood pressure measurements recorded at three successive surgery attendances. Main outcome measures Cardiovascular events and deaths from all causes during a median fo...
Full Text Available This pilot study was undertaken to identify characteristics and approaches (e.g., social, behavioral, and/or systems factors which differentiate primary care medical offices achieving higher rates of HPV vaccination.Eligible primary care practice sites providing care to adolescent patients were recruited within an eight county region of western New York State between June 2016 and July 2016. Practice sites were categorized as higher (n = 3 or lower performing (n = 2 based on three dose series completion rates for HPV vaccinations among females aged 13–17 years. Interviewer administered surveys were completed with office staff (n = 37 and focused on understanding approaches to adolescent vaccination. Results were summarized using basic descriptive statistics.Higher performing offices reported more full-time clinical staff (median = 25 vs. 9.5 in lower performing clinics, larger panels of patients ages 11–17 years (median = 3541 vs. 925 and completion of NYSIIS data entry within two weeks of vaccination. (less than a month vs. two. Staff in higher performing offices reviewed medical charts prior to scheduled visits (100% vs. 50 and identified their office vaccine champion as a physician and/or a nurse manager (75% vs. 22%. Also, staffs from higher performing offices were more likely to report the combination of having an office vaccine champion, previewing charts and using standing orders. These preliminary findings support future research examining implementation of organizational processes including identifying a vaccine champion, using standing orders and previewing medical charts prior to office visits as strategies to increase rates of HPV vaccination in primary care offices. Keywords: HPV vaccination, Adolescents, Primary care, Standing orders, Implementation, Vaccine champion
Simonian, Susan J.
This article reviews issues related to behavioral screening in pediatric primary care settings. Structural-organizational issues affecting the use of pediatric primary care screening are discussed. This study also reviewed selected screening instruments that have utility for use in the primary care setting. Clinical and research issues related to…
Jaarsveld, C.H.M. van; Gulliford, M.C.
OBJECTIVE: This study aimed to use primary care electronic health records to evaluate the prevalence of overweight and obesity in 2-15-year-old children in England and compare trends over the last two decades. DESIGN: Cohort study of primary care electronic health records. SETTING: 375 general
Sá, Luísa; Teixeira, Andreia Sofia Costa; Tavares, Fernando; Costa-Santos, Cristina; Couto, Luciana; Costa-Pereira, Altamiro; Hespanhol, Alberto Pinto; Santos, Paulo
Objectives To characterise the test ordering pattern in Northern Portugal and to investigate the influence of context-related factors, analysing the test ordered at the level of geographical groups of family physicians and at the level of different healthcare organisations. Design Cross-sectional study. Setting Northern Primary Health Care, Portugal. Participants Records about diagnostic and laboratory tests ordered from 2035 family physicians working at the Northern Regional Health Administration, who served approximately 3.5 million Portuguese patients, in 2014. Outcomes To determine the 20 most ordered diagnostic and laboratory tests in the Northern Regional Health Administration; to identify the presence and extent of variations in the 20 most ordered diagnostic and laboratory tests between the Groups of Primary Care Centres and between health units; and to study factors that may explain these variations. Results The 20 most ordered diagnostic and laboratory tests almost entirely comprise laboratory tests and account for 70.9% of the total tests requested. We can trace a major pattern of test ordering for haemogram, glucose, lipid profile, creatinine and urinalysis. There was a significant difference (P<0.001) in test orders for all tests between Groups of Primary Care Centres and for all tests, except glycated haemoglobin (P=0.06), between health units. Generally, the Personalised Healthcare Units ordered more than Family Health Units. Conclusions The results from this study show that the most commonly ordered tests in Portugal are laboratory tests, that there is a tendency for overtesting and that there is a large variability in diagnostic and laboratory test ordering in different geographical and organisational Portuguese primary care practices, suggesting that there may be considerable potential for the rationalisation of test ordering. The existence of Family Health Units seems to be a strong determinant in decreasing test ordering by Portuguese family
Mackey, Sandra; Kwok, Cannas; Anderson, Judith; Hatcher, Deborah; Laver, Sharon; Dickson, Cathy; Stewart, Lyn
Nurses have a pivotal role in changing the focus of the health system toward a primary health care approach, yet little is known about the effectiveness of nursing students' educational preparation for this role. The aim of the study was to investigate undergraduate Australian nursing students' knowledge of and attitudes toward the primary health care approach. A cross-sectional, descriptive research design was applied. Two Australian universities, one with a rural base and one in the metropolitan area of Sydney, were involved. Both universities offer undergraduate and postgraduate nursing courses on multiple campuses. A convenience sample of 286 undergraduate nursing students, each of whom had completed a unit of study on PHC. All provided consent to participate in the study. Data was collected using the Primary Health Care Questionnaire via online survey platform SurveyMonkey for a period of three weeks in June 2015. Total knowledge scores ranged from 19.68 to 95.78 with the mean knowledge score being 69.19. Total attitude scores ranged from 33.12 to 93.88 with a mean score of 70.45. Comparison of knowledge scores showed mean scores of students born in Australia were significantly higher than those of students who were born overseas (p=0.01), and mean scores of students enrolled in the metropolitan university were also significantly higher than mean scores of students' enrolled in the rural university (p=0.002). In terms of attitudes scores, mean scores of Australian-born students were significantly higher than those of students born overseas (p=0.001), and older students' mean attitude scores were shown to be significantly higher than younger students' (pattitudes toward primary health care. Copyright © 2017 Elsevier Ltd. All rights reserved.
The economic crisis and deterioration of the Portuguese National Health service has forced professionals to leave the country. The Portuguese National Health System was introduced in 1976, but it has been unable to provide citizens with the social and health advantages of an equality of access and free national health system. The Portuguese National Health System is financed by taxes. However, a 35% of its incomes are from private sources. The health minister decides the budget, and it is based on an historical financing plus a per capita system. Portuguese citizens and immigrants are entitled to free health care, but there is a co-payment for care, diagnostic, pharmacy, and emergency care. Health care provision is a mixture of public and private health care at a regional level. It leads to fragmentation of services and greater inequalities. Doctors are civil servants. Salary is regulated and it depends on seniority and on-call shifts. Primary care activities are similar to those of their Spanish counterparts. General practitioners have gatekeeper function, but the system is imperfect, and patients with private insurance get direct access to the specialist. Specialist training is similar to the training system in Spain. Continuing education is not regulated. The Portuguese Health System has been trying to become a national health system since 1979. Political instability, fragmentation of services, lack of clarity between public and private and co-payments are important constraints. Inequalities are an important problem to reconsider while discussing a national health system. Copyright © 2017 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
Goh, Teik T; Eccles, Martin P
Abstract Background Attributes of teams could affect the quality of care delivered in primary care. The aim of this study was to systematically review studies conducted within the UK NHS primary care that have measured team climate using the Team Climate Inventory (TCI), and to describe, if reported, the relationship between the TCI and measures of quality of care. Findings The databases MEDLINE, EMBASE, and CINAHL were searched. The reference lists of included article were checked and one re...
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
Alber, Kathrin; Kuehlein, Thomas; Schedlbauer, Angela; Schaffer, Susann
Medical overuse is a topic of growing interest in health care systems and especially in primary care. It comprises both over investigation and overtreatment. Quaternary prevention strategies aim at protecting patients from unnecessary or harmful medicine. The objective of this study was to gain a deeper understanding of relevant aspects of medical overuse in primary care from the perspective of German general practitioners (GPs). We focused on the scope, consequences and drivers of medical overuse and strategies to reduce it (=quaternary prevention). We used the qualitative Grounded Theory approach. Theoretical sampling was carried out to recruit GPs in Bavaria, Germany. We accessed the field of research through GPs with academic affiliation, recommendations by interview partners and personal contacts. They differed in terms of primary care experience, gender, region, work experience abroad, academic affiliation, type of specialist training, practice organisation and position. Qualitative in-depth face-to-face interviews with a semi-structured interview guide were conducted (n = 13). The interviews were audiotaped and transcribed verbatim. Data analysis was carried out using open and axial coding. GPs defined medical overuse as unnecessary investigations and treatment that lack patient benefit or bear the potential to cause harm. They observed that medical overuse takes place in all three German reimbursement categories: statutory health insurance, private insurance and individual health services (direct payment). GPs criticised the poor acceptance of gate-keeping in German primary care. They referred to a low-threshold referral policy and direct patient access to outpatient secondary care, leading to specialist treatment without clear medical indication. The GPs described various direct drivers of medical overuse within their direct area of influence. They also emphasised indirect drivers related to system or societal processes. The proposed strategies for
Lacroix-Hugues, V; Darmon, D; Pradier, C; Staccini, P
The objective of our study was to assess the feasibility of gathering data stored in primary care Electronic Health records (EHRs) in order to create a research database (PRIMEGE PACA project). The software for EHR models of two office and patient data management systems were analyzed; anonymized data was extracted and imported into a MySQL database. An ETL procedure to code text in ICPC2 codes was implemented. Eleven general practitioners (GPs) were enrolled as "data producers" and data were extracted from 2012 to 2015. In this paper, we explain the ways to make this process feasible as well as illustrate its utility for estimating epidemiological indicators and professional practice assessments. Other software is currently being analyzed for integration and expansion of this panel of GPs. This experimentation is recognized as a robust framework and is considered to be the technical foundation of the first regional observatory of primary care data.
Full Text Available Abstract Background Little is known about the cost recovery of primary health care facilities in Bangladesh. This study estimated the cost recovery of a primary health care facility run by Building Resources Across Community (BRAC, a large NGO in Bangladesh, for the period of July 2004 - June 2005. This health facility is one of the seven upgraded BRAC facilities providing emergency obstetric care and is typical of the government and private primary health care facilities in Bangladesh. Given the current maternal and child mortality in Bangladesh and the challenges to addressing health-related Millennium Development Goal (MDG targets the financial sustainability of such facilities is crucial. Methods The study was designed as a case study covering a single facility. The methodology was based on the 'ingredient approach' using the allocation techniques by inpatient and outpatient services. Cost recovery of the facility was estimated from the provider's perspective. The value of capital items was annualized using 5% discount rate and its market price of 2004 (replacement value. Sensitivity analysis was done using 3% discount rate. Results The cost recovery ratio of the BRAC primary care facility was 59%, and if excluding all capital costs, it increased to 72%. Of the total costs, 32% was for personnel while drugs absorbed 18%. Capital items were17% of total costs while operational cost absorbed 12%. Three-quarters of the total cost was variable costs. Inpatient services contributed 74% of total revenue in exchange of 10% of total utilization. An average cost per patient was US$ 10 while it was US$ 67 for inpatient and US$ 4 for outpatient. Conclusion The cost recovery of this NGO primary care facility is important for increasing its financial sustainability and decreasing donor dependency, and achieving universal health coverage in a developing country setting. However, for improving the cost recovery of the health facility, it needs to increase
Kontopantelis, Evangelos; Stevens, Richard John; Helms, Peter J; Edwards, Duncan; Doran, Tim; Ashcroft, Darren M
UK primary care databases (PCDs) are used by researchers worldwide to inform clinical practice. These databases have been primarily tied to single clinical computer systems, but little is known about the adoption of these systems by primary care practices or their geographical representativeness. We explore the spatial distribution of clinical computing systems and discuss the implications for the longevity and regional representativeness of these resources. Cross-sectional study. English primary care clinical computer systems. 7526 general practices in August 2016. Spatial mapping of family practices in England in 2016 by clinical computer system at two geographical levels, the lower Clinical Commissioning Group (CCG, 209 units) and the higher National Health Service regions (14 units). Data for practices included numbers of doctors, nurses and patients, and area deprivation. Of 7526 practices, Egton Medical Information Systems (EMIS) was used in 4199 (56%), SystmOne in 2552 (34%) and Vision in 636 (9%). Great regional variability was observed for all systems, with EMIS having a stronger presence in the West of England, London and the South; SystmOne in the East and some regions in the South; and Vision in London, the South, Greater Manchester and Birmingham. PCDs based on single clinical computer systems are geographically clustered in England. For example, Clinical Practice Research Datalink and The Health Improvement Network, the most popular primary care databases in terms of research outputs, are based on the Vision clinical computer system, used by <10% of practices and heavily concentrated in three major conurbations and the South. Researchers need to be aware of the analytical challenges posed by clustering, and barriers to accessing alternative PCDs need to be removed. © 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.
Barrios, V; Escobar, C; Lobos, J M; Polo, J; Vargas, D
Approximately 40% of patients with non-valvular auricular fibrillation (NVAF) who receive vitamin K antagonists (VKA) in Primary Care in Spain have poor anticoagulation control. The objective of the study Actuación en antiCoagulación, Tratamiento y Uso de anticoagulantes orales de acción directa (ACOD) en Atención primaria (ACTUA) (Action in Coagulation, Treatment and Use of direct oral anticoagulants [DOACs]) in Primary Care) was to analyse the current situation regarding the use of VKA and non-vitamin K antagonist oral anticoagulants (NOACs) in patients with NVAF in Primary Care in Spain and the possible issues arising from it. An online survey was created covering various aspects of the use of oral anticoagulants in NAFV. A two-round modified Delphi approach was used. Results were compiled as a set of practical guidelines. Forty-four experts responded to the survey. Consensus was reached in 62% (37/60) of the items. Experts concluded that a considerable number of patients with NVAF who receive VKA do not have a well-controlled INR and that a substantial group of patients who could benefit from being treated with NOACs do not receive them. The use of NOACs increases the probability of having good anticoagulation control and decreases the risk of severe and intracranial haemorrhage. Current limitations to the use of NOACs include administrative barriers, insufficient knowledge about the benefits and risks of NOACs, limited experience of doctors in using them, and their price. Renal insufficiency influences the choice of a particular anticoagulant. The ACTUA study highlights the existing controversies about the use of oral anticoagulants for the treatment of NVAF in Primary Care in Spain, and provides consensus recommendations that may help to improve the use of these medications. Copyright © 2016 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
Catalao, Raquel; Eshetu, Tigist; Tsigebrhan, Ruth; Medhin, Girmay; Fekadu, Abebaw; Hanlon, Charlotte
In order to tackle the considerable treatment gap for epilepsy in many low- and middle-income countries (LMICs), a task sharing model is recommended whereby care is integrated into primary health services. However, there are limited data on implementation and impact of such services in LMICs. Our study aimed to explore the perspectives of service users and caregivers on the accessibility, experience and perceived impact of epilepsy treatment received in a task-shared model in a rural district of Ethiopia. A qualitative study was carried out using interviews with purposively sampled service users (n = 13) and caregivers (n = 3) from a community-ascertained cohort of people with epilepsy receiving integrated services in primary care in rural Ethiopia. Interviews followed a topic guide with questions regarding acceptability, satisfaction, barriers to access care, pathways through care and impact of services. Framework analysis was employed to analyse the data. Proximity of the new service in local primary health centers decreased the cost of transportation for the majority of service users thus improving access to services. First-hand experience of services was in some cases associated with a willingness to promote the services and inform others of the existence of effective biomedical treatment for epilepsy. However, most service users and their caregivers continued to seek help from traditional healers alongside biomedical care. Most of the care received was focused on medication provision with limited information provided on how to manage their illness and its effects. Caregivers and service users spoke about the high emotional and financial burden of the disease and lack of ongoing practical and emotional support. The majority of participants reported clinical improvement on medication, which in over half of the participants was associated with ability to return to money generating activities. Task-sharing improved the accessibility of epilepsy care for
Dillen, S.M. van; Noordman, J.; Dulmen, S. van; Hiddink, G.J.
BACKGROUND/OBJECTIVE: To assess the quality of weight-loss counseling provided by Dutch primary care practice nurses (PNs) to overweight and obese patients including both PNs' compliance with the Five A's Model for behavioral counseling in primary care, and the use of different communication styles.
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
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
Full Text Available Abstract Background In Sweden three key criteria are used for priority setting: severity of the health condition; patient benefit; and cost-effectiveness. They are derived from the ethical principles established by the Swedish parliament 1997 but have been used only to a limited extent in primary care. The aim of this study was to describe and analyse: 1 GPs', nurses', and patients' prioritising in routine primary care 2 The association between the three key priority setting criteria and the overall priority assigned by the GPs and nurses to individual patients. Methods Paired questionnaires were distributed to all patients and the GPs or nurses they had contact with during a 2-week period at four health centres in Sweden. The staff registered the health conditions or health problem, and the planned intervention. Then they estimated the severity of the health condition, the expected patient benefit, and the cost-effectiveness of the planned intervention. Both the staff and the patients reported their overall prioritisation of the patient. In total, 1851 paired questionnaires were collected. Results Compared to the medical staff, the patients assigned relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions. Severity of the health condition was the priority setting criterion that had the strongest association with the overall priority for the staff as a whole, but for the GPs it was cost-effectiveness. Conclusions The challenge for primary care providers is to balance the patients' demands with medical needs and cost-effectiveness. Transparent priority setting in primary care might contribute to a greater consensus between GPs and nurses on how to use the key priority setting criteria.
Arvidsson, Eva; André, Malin; Borgquist, Lars; Andersson, David; Carlsson, Per
In Sweden three key criteria are used for priority setting: severity of the health condition; patient benefit; and cost-effectiveness. They are derived from the ethical principles established by the Swedish parliament 1997 but have been used only to a limited extent in primary care. The aim of this study was to describe and analyse: 1) GPs', nurses', and patients' prioritising in routine primary care 2) The association between the three key priority setting criteria and the overall priority assigned by the GPs and nurses to individual patients. Paired questionnaires were distributed to all patients and the GPs or nurses they had contact with during a 2-week period at four health centres in Sweden. The staff registered the health conditions or health problem, and the planned intervention. Then they estimated the severity of the health condition, the expected patient benefit, and the cost-effectiveness of the planned intervention. Both the staff and the patients reported their overall prioritisation of the patient. In total, 1851 paired questionnaires were collected. Compared to the medical staff, the patients assigned relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions. Severity of the health condition was the priority setting criterion that had the strongest association with the overall priority for the staff as a whole, but for the GPs it was cost-effectiveness. The challenge for primary care providers is to balance the patients' demands with medical needs and cost-effectiveness. Transparent priority setting in primary care might contribute to a greater consensus between GPs and nurses on how to use the key priority setting criteria.
Full Text Available Abstract Background The objectives of this study were: a to examine physician attitudes to and experience of the practice of evidence-based medicine (EBM in primary care; b to investigate the influence of patient preferences on clinical decision-making; and c to explore the role of intuition in family practice. Method Qualitative analysis of semi-structured interviews of 15 family physicians purposively selected from respondents to a national survey on EBM mailed to a random sample of Canadian family physicians. Results Participants mainly welcomed the promotion of EBM in the primary care setting. A significant number of barriers and limitations to the implementation of EBM were identified. EBM is perceived by some physicians as a devaluation of the 'art of medicine' and a threat to their professional/clinical autonomy. Issues regarding the trustworthiness and credibility of evidence were of great concern, especially with respect to the influence of the pharmaceutical industry. Attempts to become more evidence-based often result in the experience of conflicts. Patient factors exert a powerful influence on clinical decision-making and can serve as trumps to research evidence. A widespread belief that intuition plays a vital role in primary care reinforced views that research evidence must be considered alongside other factors such as patient preferences and the clinical judgement and experience of the physician. Discussion Primary care physicians are increasingly keen to consider research evidence in clinical decision-making, but there are significant concerns about the current model of EBM. Our findings support the proposed revisions to EBM wherein greater emphasis is placed on clinical expertise and patient preferences, both of which remain powerful influences on physician behaviour.
Tracy, C Shawn; Dantas, Guilherme Coelho; Upshur, Ross E G
The objectives of this study were: a) to examine physician attitudes to and experience of the practice of evidence-based medicine (EBM) in primary care; b) to investigate the influence of patient preferences on clinical decision-making; and c) to explore the role of intuition in family practice. Qualitative analysis of semi-structured interviews of 15 family physicians purposively selected from respondents to a national survey on EBM mailed to a random sample of Canadian family physicians. Participants mainly welcomed the promotion of EBM in the primary care setting. A significant number of barriers and limitations to the implementation of EBM were identified. EBM is perceived by some physicians as a devaluation of the 'art of medicine' and a threat to their professional/clinical autonomy. Issues regarding the trustworthiness and credibility of evidence were of great concern, especially with respect to the influence of the pharmaceutical industry. Attempts to become more evidence-based often result in the experience of conflicts. Patient factors exert a powerful influence on clinical decision-making and can serve as trumps to research evidence. A widespread belief that intuition plays a vital role in primary care reinforced views that research evidence must be considered alongside other factors such as patient preferences and the clinical judgement and experience of the physician. Primary care physicians are increasingly keen to consider research evidence in clinical decision-making, but there are significant concerns about the current model of EBM. Our findings support the proposed revisions to EBM wherein greater emphasis is placed on clinical expertise and patient preferences, both of which remain powerful influences on physician behaviour.
Greiver, Michelle; Wintemute, Kimberly; Aliarzadeh, Babak; Martin, Ken; Khan, Shahriar; Jackson, Dave; Leggett, Jannet; Lambert-Lanning, Anita; Siu, Maggie
Consistent and standardized coding for chronic conditions is associated with better care; however, coding may currently be limited in electronic medical records (EMRs) used in Canadian primary care.Objectives To implement data management activities in a community-based primary care organisation and to evaluate the effects on coding for chronic conditions. Fifty-nine family physicians in Toronto, Ontario, belonging to a single primary care organisation, participated in the study. The organisation implemented a central analytical data repository containing their EMR data extracted, cleaned, standardized and returned by the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), a large validated primary care EMR-based database. They used reporting software provided by CPCSSN to identify selected chronic conditions and standardized codes were then added back to the EMR. We studied four chronic conditions (diabetes, hypertension, chronic obstructive pulmonary disease and dementia). We compared changes in coding over six months for physicians in the organisation with changes for 315 primary care physicians participating in CPCSSN across Canada. Chronic disease coding within the organisation increased significantly more than in other primary care sites. The adjusted difference in the increase of coding was 7.7% (95% confidence interval 7.1%-8.2%, p Data management activities were associated with an increase in standardized coding for chronic conditions. Exploring requirements to scale and spread this approach in Canadian primary care organisations may be worthwhile.
Upham, Susan J; Janamian, Tina; Crossland, Lisa; Jackson, Claire L
To determine the relevance and utility of online tools and resources to support organisational performance development in primary care and to complement the Primary Care Practice Improvement Tool (PC-PIT). A purposively recruited Expert Advisory Panel of 12 end users used a modified Delphi technique to evaluate 53 tools and resources identified through a previously conducted systematic review. The panel comprised six practice managers and six general practitioners who had participated in the PC-PIT pilot study in 2013-2014. Tools and resources were reviewed in three rounds using a standard pre-tested assessment form. Recommendations, scores and reasons for recommending or rejecting each tool or resource were analysed to determine the final suite of tools and resources. The evaluation was conducted from November 2014 to August 2015. Recommended tools and resources scored highly (mean score, 16/20) in Rounds 1 and 2 of review (n = 25). These tools and resources were perceived to be easily used, useful to the practice and supportive of the PC-PIT. Rejected resources scored considerably lower (mean score, 5/20) and were noted to have limitations such as having no value to the practice and poor utility (n = 6). A final review (Round 3) of 28 resources resulted in a suite of 21 to support the elements of the PC-PIT. This suite of tools and resources offers one approach to supporting the quality improvement initiatives currently in development in primary care reform.
Asselin, J; Osunlana, A M; Ogunleye, A A; Sharma, A M; Campbell-Scherer, D
Increasingly, research is directed at advancing methods to address obesity management in primary care. In this paper we describe the role of interdisciplinary collaboration, or lack thereof, in patient weight management within 12 teams in a large primary care network in Alberta, Canada. Qualitative data for the present analysis were derived from the 5As Team (5AsT) trial, a mixed-method randomized control trial of a 6-month participatory, team-based educational intervention aimed at improving the quality and quantity of obesity management encounters in primary care practice. Participants (n = 29) included in this analysis are healthcare providers supporting chronic disease management in 12 family practice clinics randomized to the intervention arm of the 5AsT trial including mental healthcare workers (n = 7), registered dietitians (n = 7), registered nurses or nurse practitioners (n = 15). Participants were part of a 6-month intervention consisting of 12 biweekly learning sessions aimed at increasing provider knowledge and confidence in addressing patient weight management. Qualitative methods included interviews, structured field notes and logs. Four common themes of importance in the ability of healthcare providers to address weight with patients within an interdisciplinary care team emerged, (i) Availability; (ii) Referrals; (iii) Role perception and (iv) Messaging. However, we find that what was key to our participants was not that these issues be uniformly agreed upon by all team members, but rather that communication and clinic relationships support their continued negotiation. Our study shows that firm clinic relationships and deliberate communication strategies are the foundation of interdisciplinary care in weight management. Furthermore, there is a clear need for shared messaging concerning obesity and its treatment between members of interdisciplinary teams. © 2016 World Obesity.
Basto-Pereira, Miguel; Furtado, Sara Isabel Félix; Silva, Ricardo Jorge Pereira; Fachado González, Francisco; Vara Fernandes, Tito Manuel; Correia de Sousa, Jaime; Yaphe, John
Performance indicators assessing the quality of medical care and linked to pay for performance may cause disagreement. Portuguese indicators included in recent health care reform are controversial. To obtain consensus from opinion leaders in family medicine regarding the performance indicators for practice management used in the evaluation of Family Health Units in Portugal. Eighty-nine specialists in primary care were invited to answer the following question in an online Delphi study: 'Which performance indicators should be assessed regarding the organization and management of clinical practice in primary care in Portugal?' A Likert scale was used to evaluate validity, reliability, feasibility and sensitivity to change. Twenty-seven experts participated in the second round and achieved a high degree of consensus. Eight categories were created for analysis. The experts suggested the use of existing indicators as well as new indicators. Thirty-nine indicators suggested by the experts are currently in use in Portugal. The assessment of the number of clinical acts performed, the number of administrative acts, and evaluation of the clinical demographic profile achieved a high degree of consensus. The expert panel suggested fifty new indicators. Five categories of these new indicators had a high degree of consensus, and three categories had a low degree of consensus. The expert panel recommended that performance indicators of practice management should first assess the quantity of clinical and administrative activities undertaken. These indicators must take into account the human and financial resources available to the clinic and its demographic context.
Neenan, M. Elaine; And Others
A study describes the characteristics of the current primary dental care workforce (dentists, hygienists, assistants), its distribution, and its delivery system in private and public sectors. Graduate dental school enrollments, trends in patient visits, employment patterns, state dental activities, and workforce issues related to health care…
... Experience in a primary health care facility in Rivers State, South-South Nigeria. ... health center increased by 3.09% (p-value > 0.05); the patients that had their babies in the facility were ... 100, 000 live births, based on historical studies and.
Full Text Available Abstract Background Early diagnosis of anaemia represents an important task within primary care settings. This study reports on the frequency of new cases of anaemia among patients attending rural primary care settings in Crete (Greece and to offer an estimate of iron deficiency anaemia (IDA frequency in this study group. Methods All patients attending the rural primary health care units of twelve general practitioners (GPs on the island of Crete for ten consecutive working days were eligible to participate in this study. Hemoglobin (Hb levels were measured by portable analyzers. Laboratory tests to confirm new cases of anaemia were performed at the University General Hospital of Heraklion. Results One hundred and thirteen out of 541 recruited patients had a low value of Hb according to the initial measurement obtained by the use of the portable analyzer. Forty five (45.5% of the 99 subjects who underwent laboratory testing had confirmed anaemia. The mean value of the Hb levels in the group with confirmed anaemia, as detected by the portable analyzer was 11.1 g/dl (95% Confidence Interval (CI from 10.9 to 11.4 and the respective mean value of the Hb levels obtained from the full blood count was 11.4 g/dl (95% CI from 11.2 to 11.7 (P = 0.01. Sixteen out of those 45 patients with anaemia (35.6% had IDA, with ferritin levels lower than 30 ng/ml. Conclusion Keeping in mind that this paper does not deal with specificity or sensitivity figures, it is suggested that in rural and remote settings anaemia is still invisible and point of care testing may have a place to identify it.
Watson, Jessica; de Salis, Isabel; Hamilton, Willie; Salisbury, Chris
Background Inflammatory markers can be helpful as part of the diagnostic workup for specific diseases or for monitoring disease activity. A third use is as a screening and/or triage tool to differentiate between the presence or absence of disease. Most research into inflammatory markers looks at diagnosis of specific diseases and comes from secondary care. Qualitative studies to explore when and why clinicians use these tests in primary care are lacking. Aim To identify clinicians’ approaches to inflammatory marker testing in primary care. Design and setting Qualitative study with 26 GPs and nurse practitioners. Method Interviews were conducted using a semi-structured topic guide. Clinicians reviewed recent cases of inflammatory marker testing in their pathology inbox. Interviews were audiorecorded and transcribed. Qualitative analysis was conducted by two of the authors. Results Clinicians are uncertain about the appropriate use of inflammatory markers and differ in their approach to testing patients with undifferentiated symptoms. Normal or significantly elevated inflammatory markers are seen as helpful, but mildly raised inflammatory markers in the context of non-specific symptoms are difficult to interpret. Clinicians describe a tension between not wanting to ‘miss anything’ and, on the other hand, being wary of picking up borderline abnormalities that can lead to cascades of further tests. Diagnostic uncertainty is a common reason for inflammatory marker testing, with the aim to reassure; however, paradoxically, inconclusive results can generate a cycle of uncertainty and anxiety. Conclusion Further research is needed to define when inflammatory marker testing is useful in primary care and how to interpret results. PMID:26852797
Sherwood, Nancy E; JaKa, Meghan M; Crain, A Lauren; Martinson, Brian C; Hayes, Marcia G; Anderson, Julie D
The Healthy Homes/Healthy Kids Preschool (HHHK-Preschool) pilot program is an obesity prevention intervention integrating pediatric care provider counseling and a phone-based program to prevent unhealthy weight gain among 2- to 4-year-old children at risk for obesity (BMI percentile between the 50th and 85th percentile and at least one overweight parent) or currently overweight (85th percentile ≤ BMI pediatric primary care clinics were randomized to: (1) the Busy Bodies/Better Bites Obesity Prevention Arm or the (2) Healthy Tots/Safe Spots safety/injury prevention Contact Control Arm. Baseline and 6-month data were collected, including measured height and weight, accelerometry, previous day dietary recalls, and parent surveys. Intervention process data (e.g., call completion) were also collected. High intervention completion and satisfaction rates were observed. Although a statistically significant time by treatment interaction was not observed for BMI percentile or BMI z-score, post-hoc examination of baseline weight status as a moderator of treatment outcome showed that the Busy Bodies/Better Bites obesity prevention intervention appeared to be effective among children who were in the overweight category at baseline relative to those who were categorized as at risk for obesity (p = 0.04). HHHK-Preschool pilot study results support the feasibility, acceptability, and potential efficacy in already overweight children of a pediatric primary care-based obesity prevention intervention integrating brief provider counseling and parent-targeted phone coaching. What's New: Implementing pediatric primary care-based obesity interventions is challenging. Previous interventions have primarily involved in-person sessions, a barrier to sustained parent involvement. HHHK-preschool pilot study results suggest that integrating brief provider counseling and parent-targeted phone coaching is a promising approach.
McDonald, Ruth; Harrison, Stephen; Checkland, Kath; Campbell, Stephen M; Roland, Martin
To explore the impact of financial incentives for quality of care on practice organisation, clinical autonomy, and internal motivation of doctors and nurses working in primary care. Ethnographic case study. Two English general practices. 12 general practitioners, nine nurses, four healthcare assistants, and four administrative staff. Observation of practices over a five month period after the introduction of financial incentives for quality of care introduced in the 2004 general practitioner contract. After the introduction of the quality and outcomes framework there was an increase in the use of templates to collect data on quality of care. New regimens of surveillance were adopted, with clinicians seen as "chasers" or the "chased," depending on their individual responsibility for delivering quality targets. Attitudes towards the contract were largely positive, although discontent was higher in the practice with a more intensive surveillance regimen. Nurses expressed more concern than doctors about changes to their clinical practice but also appreciated being given responsibility for delivering on targets in particular disease areas. Most doctors did not question the quality targets that existed at the time or the implications of the targets for their own clinical autonomy. Implementation of financial incentives for quality of care did not seem to have damaged the internal motivation of the general practitioners studied, although more concern was expressed by nurses.
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
Full Text Available Abstract Background This study is part of a nationwide evaluation of complementary medicine in Switzerland (Programme Evaluation of Complementary Medicine PEK and was funded by the Swiss Federal Office of Public Health. The main objective of this study is to investigate patient satisfaction and perception of side effects in homeopathy compared with conventional care in a primary care setting. Methods We examined data from two cross-sectional studies conducted in 2002–2003. The first study was a physician questionnaire assessing structural characteristics of practices. The second study was conducted on four given days during a 12-month period in 2002/2003 using a physician and patient questionnaire at consultation and a patient questionnaire mailed to the patient one month later (including Europep questionnaire. The participating physicians were all trained and licensed in conventional medicine. An additional qualification was required for medical doctors providing homeopathy (membership in the Swiss association of homeopathic physicians SVHA. Results A total of 6778 adult patients received the questionnaire and 3126 responded (46.1%. Statistically significant differences were found with respect to health status (higher percentage of chronic and severe conditions in the homeopathic group, perception of side effects (higher percentage of reported side effects in the conventional group and patient satisfaction (higher percentage of satisfied patients in the homeopathic group. Conclusion Overall patient satisfaction was significantly higher in homeopathic than in conventional care. Homeopathic treatments were perceived as a low-risk therapy with two to three times fewer side effects than conventional care
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...... Guideline. RESULTS: Data were available from 143 health centres in Finland (49%). The views of head physicians and senior nursing officers on the adoption of the Hypertension Guideline were not consistent. Head physicians more often than senior nursing officers (44% vs. 29%, p ...: Hypertension Guideline recommendations that require joint agreements between professionals are less often adopted than simple, precise recommendations. More emphasis on effective multidisciplinary collaboration is needed....
Wranik, W Dominika; Hayden, Jill A; Price, Sheri; Parker, Robin M N; Haydt, Susan M; Edwards, Jeanette M; Suter, Esther; Katz, Alan; Gambold, Liesl L; Levy, Adrian R
Western publicly funded health care systems increasingly rely on interdisciplinary teams to support primary care delivery and management of chronic conditions. This knowledge synthesis focuses on what is known in the academic and grey literature about optimal structural characteristics of teams. Its goal is to assess which factors contribute to the effective functioning of interdisciplinary primary care teams and improved health system outcomes, with specific focus on (i) team structure contribution to team process, (ii) team process contribution to primary care goals, and (iii) team structure contribution to primary care goals. The systematic search of academic literature focuses on four chronic conditions and co-morbidities. Within this scope, qualitative and quantitative studies that assess the effects of team characteristics (funding, governance, organization) on care process and patient outcomes will be searched. Electronic databases (Ovid MEDLINE, Embase, CINAHL, PAIS, Web of Science) will be searched systematically. Online web-based searches will be supported by the Grey Matters Tool. Studies will be included, if they report on interdisciplinary primary care in publicly funded Western health systems, and address the relationships between team structure, process, and/or patient outcomes. Studies will be selected in a three-stage screening process (title/abstract/full text) by two independent reviewers in each stage. Study quality will be assessed using the Mixed Methods Assessment Tool. An a priori framework will be applied to data extraction, and a narrative framework approach is used for the synthesis. Using an integrated knowledge translation approach, an electronic decision support tool will be developed for decision makers. It will be searchable along two axes of inquiry: (i) what primary care goals are supported by specific team characteristics and (ii) how should teams be structured to support specific primary care goals? The results of this evidence
Sibbald, Shannon L.; Wathen, C. Nadine; Kothari, Anita; Day, Adam M. B.
Objective: Improving the process of evidence-based practice in primary health care requires an understanding of information exchange among colleagues. This study explored how clinically oriented research knowledge flows through multidisciplinary primary health care teams (PHCTs) and influences clinical decisions. Methods: This was an exploratory mixed-methods study with members of six PHCTs in Ontario, Canada. Quantitative data were collected using a questionnaire and analyzed with social network analysis (SNA) using UCINet. Qualitative data were collected using semi-structured interviews and analyzed with content analysis procedures using NVivo8. Results: It was found that obtaining research knowledge was perceived to be a shared responsibility among team members, whereas its application in patient care was seen as the responsibility of the team leader, usually the senior physician. PHCT members acknowledged the need for resources for information access, synthesis, interpretation, or management. Conclusion: Information sharing in interdisciplinary teams is a complex and multifaceted process. Specific interventions need to be improved such as formalizing modes of communication, better organizing knowledge-sharing activities, and improving the active use of allied health professionals. Despite movement toward team-based models, senior physicians are often gatekeepers of uptake of new evidence and changes in practice. PMID:23646028
Lollier, Allison; Rodriguez, Elisa M; Saad-Harfouche, Frances G; Widman, Christy A; Mahoney, Martin C
This pilot study was undertaken to identify characteristics and approaches (e.g., social, behavioral, and/or systems factors) which differentiate primary care medical offices achieving higher rates of HPV vaccination. Eligible primary care practice sites providing care to adolescent patients were recruited within an eight county region of western New York State between June 2016 and July 2016. Practice sites were categorized as higher (n = 3) or lower performing (n = 2) based on three dose series completion rates for HPV vaccinations among females aged 13-17 years. Interviewer administered surveys were completed with office staff (n = 37) and focused on understanding approaches to adolescent vaccination. Results were summarized using basic descriptive statistics. Higher performing offices reported more full-time clinical staff (median = 25 vs. 9.5 in lower performing clinics), larger panels of patients ages 11-17 years (median = 3541 vs. 925) and completion of NYSIIS data entry within two weeks of vaccination. (less than a month vs. two). Staff in higher performing offices reviewed medical charts prior to scheduled visits (100% vs. 50) and identified their office vaccine champion as a physician and/or a nurse manager (75% vs. 22%). Also, staffs from higher performing offices were more likely to report the combination of having an office vaccine champion, previewing charts and using standing orders. These preliminary findings support future research examining implementation of organizational processes including identifying a vaccine champion, using standing orders and previewing medical charts prior to office visits as strategies to increase rates of HPV vaccination in primary care offices.
Shepherd, Victoria; Thomas-Jones, Emma; Ridd, Matthew J; Hood, Kerenza; Addison, Katy; Francis, Nick A
Recruitment of participants is particularly challenging in primary care, with less than a third of randomised controlled trials (RCT) achieving their target within the original time frame. Participant identification, consent, randomisation and data collection can all be time-consuming. Trials recruiting an incident, as opposed to a prevalent, population may be particularly affected. This paper describes the impact of a deferred recruitment model in a RCT of antibiotics for children with infected eczema in primary care, which required the recruitment of cases presenting acutely. Eligible children were identified by participating general practitioners (GPs) and referred to a study research nurse, who then visited them at home. This allowed the consent and recruitment processes to take place outside the general practice setting. Information was recorded about patients who were referred and recruited, or if not, the reasons for non-recruitment. Data on recruitment challenges were collected through semi-structured interviews and questionnaires with a sample of participating GPs. Data were thematically analysed to identify key themes. Of the children referred to the study 34% (58/171) were not recruited - 48% (28/58) because of difficulties arranging a baseline visit within the defined time frame, 31% (18/58) did not meet the study inclusion criteria at the time of nurse assessment, and 21% (12/58) declined participation. GPs had positive views about the recruitment process, reporting that parents valued and benefitted from additional contact with a nurse. GPs felt that the deferred recruitment model did not negatively impact on the study. GPs and parents recognised the benefits of deferred recruitment, but these did not translate into enhanced recruitment of participants. The model resulted in the loss of a third of children who were identified by the GP as eligible, but not subsequently recruited to the study. If the potential for improving outcomes in primary care
Gnädinger, Markus; Conen, Dieter; Herzig, Lilli; Puhan, Milo A; Staehelin, Alfred; Zoller, Marco; Ceschi, Alessandro
To describe the type, frequency, seasonal and regional distribution of medication incidents in primary care in Switzerland and to elucidate possible risk factors for medication incidents. Prospective surveillance study. Swiss primary healthcare, Swiss Sentinel Surveillance Network. Patients with drug treatment who experienced any erroneous event related to the medication process and interfering with normal treatment course, as judged by their physician. The 180 physicians in the study were general practitioners or paediatricians participating in the Swiss Federal Sentinel reporting system in 2015. Primary: medication incidents; secondary: potential risk factors like age, gender, polymedication, morbidity, care-dependency, previous hospitalisation. The mean rates of detected medication incidents were 2.07 per general practitioner per year (46.5 per 1 00 000 contacts) and 0.15 per paediatrician per year (2.8 per 1 00 000 contacts), respectively. The following factors were associated with medication incidents (OR, 95% CI): higher age 1.004 per year (1.001; 1.006), care by community nurse 1.458 (1.025; 2.073) and care by an institution 1.802 (1.399; 2.323), chronic conditions 1.052 (1.029; 1.075) per condition, medications 1.052 (1.030; 1.074) per medication, as well as Thurgau Morbidity Index for stage 4: 1.292 (1.004; 1.662), stage 5: 1.420 (1.078; 1.868) and stage 6: 1.680 (1.178; 2.396), respectively. Most cases were linked to an incorrect dosage for a given patient, while prescription of an erroneous medication was the second most common error. Medication incidents are common in adult primary care, whereas they rarely occur in paediatrics. Older and multimorbid patients are at a particularly high risk for medication incidents. Reasons for medication incidents are diverse but often seem to be linked to communication problems. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No
Rojas Loría, Kattia; Gutiérrez Rosado, Teresa; Alvarado, Ricardo; Fernández Sánchez, Anna
Describe the relationship between the attitude towards violence against women (VAW) of professionals of the health of primary care with variables such professional satisfaction, workload, orientation of professional practice, knowledge, training and use of network in Catalonia and Costa Rica. Cross-exploratory and comparative study. Primary care in Barcelona and nearby counties and the Greater Metropolitan Area (GAM) of Costa Rica. 235 primary health professionals of Medicine, Nursing, Psychology and Social Work. Questionnaire with eight sections about attitudes, professional satisfaction, and orientation of professional practice, workload, knowledge, training and use of network. Three types of analysis were carried out: a descriptive one by country; a bivariate analysis; and a multivariable linear regression model. Primary Health Professionals attitudes towards VAW health were similar in both contexts (Catalonia: 3.90 IC 95% 3.84-3.96; Costa Rica: 4.03 IC 95% 3.94-4.13). The variables associated with attitudes towards VAW were: Use of network resources (B=0.20, 95% CI -0.14-0.25, P=<.001), Training (B=0.10, 95% CI 0.04 to 0.17, P=<0.001), and country, Costa Rica (B=0.16, 95% CI 0.06 to 0.25, P=<0.001). There was no interaction between the country and the other variables, suggesting that the association between the variables and the attitude is similar in both countries. The results suggest that increased use of network resources and training are related to a positive attitude towards VWA in primary health professionals, both in Catalonia and Costa Rica. Copyright © 2014 Elsevier España, S.L.U. All rights reserved.
Assendelft Willem JJ
Full Text Available Abstract Background Better management of affective and somatoform disorders may reduce consultation rates in primary care. Somatoform disorders are highly prevalent in primary care and co-morbidity with affective disorders is substantial, but it is as yet unclear which portion of the health care use may be ascribed to each disorder. Our objective was to investigate the use of primary care for undifferentiated somatoform disorders, other somatoform disorders, anxiety and depressive disorders prospectively. Methods In eight family practices 1046 consulting patients (25–79 yrs were screened and a stratified sample of 473 was interviewed. Somatoform disorders, anxiety and depressive disorders were diagnosed (DSM IV using SCAN 2.1. The electronic records of 400 participants regarding somatic diseases, medication and healthcare use were available through their family physicians (FP. Results In the follow-up year patients with psychiatric disorders had more face-to-face contacts with the FP than patients who had no psychiatric disorder: average 7–10 versus 5. The impact on the use of primary care by patients with somatoform disorders was comparable to patients with depressive or anxiety disorders. Undifferentiated somatoform disorders had an independent impact on the use of primary care after adjustment for anxiety and depressive disorders, resulting in 30% more consultations (IRR 1.3 (95% CI: 1.1–1.7. Anxiety disorders had no independent effect. Conclusion Health care planning should focus on the recognition and treatment of somatoform as well as affective disorders.
Tørring, Marie Louise; Frydenberg, Morten; Hansen, Rikke Pilegaard
with CRC were included in a prospective, population-based study in a Danish county. The diagnostic interval was defined as the time from first presentation of symptoms until diagnosis. We analysed patients separately according to the general practitioner’s interpretation of symptoms. Logistic regression...... years decreased with diagnostic intervals up to 5 weeks and then increased (P=0.002). In patients presenting with vague symptoms, the association was reverse, although not statistically significant. CONCLUSION: Detecting cancer in primary care is two sided: aimed at expediting ill patients while...
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.
Bower, P.; Macdonald, W.; Harkness, E.; Gask, L.; Kendrick, T.; Valderas, J.M.; Dickens, C.; Blakeman, T.; Sibbald, B.S.
BACKGROUND: Primary care professionals often manage patients with multiple long-term health conditions, but managing multimorbidity is challenging given time and resource constraints and interactions between conditions. OBJECTIVE: To explore GP and nurse perceptions of multimorbidity and the
Kvalevog, Kristen J
.... Over 90,679 beneficiaries currently live in -the-Fort Campbell-catchment area and receive primary care at Blanchfield Army Community Hospital through the Red, White, Blue, Gold, and Young Eagle Clinics...
Full Text Available Background The use of medication is at the heart of primary care, but is also the cause for major health concerns. It is therefore important to examine the prescription of medication process.Objective This study identifies the barriers and facilitators perceived by community pharmacists and primary care physicians concerning the adoption of a nationwide electronic prescribing (e-prescribing network in the province of Quebec, Canada.Methods We used purposive sampling to identify the most intensive users of the e-prescribing network. We conducted phone and in-person interviews. Interviews were transcribed, and we analysed their content with NVivo, using the clinical adoption framework (CAF for the codification of the data.Results We interviewed 33 pharmacists, 2 pharmacy technicians, 11 physicians and 3 clinic managers. Adoption of the e-prescribing network was fairly low. The respondents underlined adaptation of their work environment, openness to change and perception of benefits as facilitators to the adoption of the network. However, important barriers were perceived, including system quality issues and paper prescriptions being the only legal document in the prescribing process. Even if respondents recognised that the e-prescribing network can offer substantial benefits to the prescribing process, issues still persisted and raised barriers to the full use of such a network, especially in a context where different local information systems are connected within a nationwide e-prescribing network.Conclusion This study, based on the CAF, provides a better understanding of the factors related to the adoption of a nationwide e-prescribing network connecting primary care clinics and community pharmacies.
Tudor Car, Lorainne; Papachristou, Nikolaos; Gallagher, Joseph; Samra, Rajvinder; Wazny, Kerri; El-Khatib, Mona; Bull, Adrian; Majeed, Azeem; Aylin, Paul; Atun, Rifat; Rudan, Igor; Car, Josip; Bell, Helen; Vincent, Charles; Franklin, Bryony Dean
Medication error is a frequent, harmful and costly patient safety incident. Research to date has mostly focused on medication errors in hospitals. In this study, we aimed to identify the main causes of, and solutions to, medication error in primary care. We used a novel priority-setting method for identifying and ranking patient safety problems and solutions called PRIORITIZE. We invited 500 North West London primary care clinicians to complete an open-ended questionnaire to identify three main problems and solutions relating to medication error in primary care. 113 clinicians submitted responses, which we thematically synthesized into a composite list of 48 distinct problems and 45 solutions. A group of 57 clinicians randomly selected from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians' scores was presented using the average expert agreement (AEA). The study was conducted between September 2013 and November 2014. The top three problems were incomplete reconciliation of medication during patient 'hand-overs', inadequate patient education about their medication use and poor discharge summaries. The highest ranked solutions included development of a standardized discharge summary template, reduction of unnecessary prescribing, and minimisation of polypharmacy. Overall, better communication between the healthcare provider and patient, quality assurance approaches during medication prescribing and monitoring, and patient education on how to use their medication were considered the top priorities. The highest ranked suggestions received the strongest agreement among the clinicians, i.e. the highest AEA score. Clinicians identified a range of suggestions for better medication management, quality assurance procedures and patient education. According to clinicians, medication errors can be largely prevented with feasible and affordable interventions. PRIORITIZE is a new, convenient, systematic, and replicable method
Birt, Linda; Emery, Jon D; Prevost, A Toby; Sutton, Stephen; Walter, Fiona M
Routine family history risk assessment for chronic diseases could enable primary care practitioners to efficiently identify at-risk patients and promote preventive management strategies. To investigate patients' understanding and responses to family history risk assessment in primary care. A mixed methods study set in 10 Eastern England general practices. Participants in a family history questionnaire validation study were triaged into population or increased risk for four chronic diseases (type 2 diabetes, cardiovascular disease, breast cancer, colorectal cancer). Questionnaires completed immediately prior to the family history consultation (baseline) and 4 weeks later (follow-up) assessed the psychological impact, including State-Trait Anxiety Inventory scores. Semi-structured interviews explored the meaning participants gave to their personal familial disease risk. Four hundred and fifty-three participants completed both baseline and follow-up questionnaires and 30 were interviewed. At follow-up, there was no increase in anxiety among either group, or differences between the groups [difference in mean change 0.02, 95% confidence interval -2.04, 2.08, P = 0.98]. There were no significant changes over time in self-rated health in either group. At follow-up, participants at increased risk (n = 153) were more likely to have recent changes to behaviour and they had stronger intentions to make changes to diet (P = 0.001), physical activity (P = 0.006) and to seek further information in the future than those at population risk (n = 300; P assessment for familial risk of chronic diseases may be undertaken in primary care without causing anxiety or reducing self-rated health. Patient responses to family history risk assessment may inform promotion of preventive management strategies. © The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
Full Text Available Abstract Background Dizziness is a common complaint of older patients in primary care, yet not much is known about the course of incident dizziness. The aim of the study was to follow-up symptoms, subjective impairments and needs of older patients (≥65 with incident dizziness and to determine predictors of chronic dizziness. Furthermore, we analysed general practitioners' (GPs' initial diagnoses, referrals and revised diagnoses after six months. Methods An observational study was performed in 21 primary care practices in Germany, including a four-week and six-month follow-up. A questionnaire comprising characteristic matters of dizziness and a series of validated instruments was completed by 66 participants during enrolment and follow-up (after 1 month and 6 months. After six months, chart reviews and face-to-face interviews were also performed with the GPs. Results Mean scores of dizziness handicap, depression and quality of life were not or only slightly affected, and did not deteriorate during follow-up; however, 24 patients (34.8% showed a moderate or severe dizziness handicap, and 43 (62.3% showed a certain disability in terms of quality of life at the time of enrolment. In multivariate analysis, n = 44 patients suffering from chronic dizziness (dependent variable, i.e. relapsing or persistent at six months initially had a greater dizziness handicap (OR 1.42, 95%CI 1.05-1.47 than patients with transient dizziness. GPs referred 47.8% of the patients to specialists who detected two additional cases of benign paroxysmal positional vertigo (BPPV. Conclusions New-onset dizziness relapsed or persisted in a considerable number of patients within six months. This was difficult to predict due to the patients' heterogeneous complaints and characteristics. Symptom persistence does not seem to be associated with deterioration of the psychological status in older primary care patients. Management strategies should routinely consider BPPV as
Olsen, Douglas P; Dixon, Jane Karpe; Grey, Margaret; Deshefy-Longhi, Terry; Demarest, Jo Cecille
This study explores and compares the privacy concerns of primary care nurse practitioners (NPs) and their patients. Privacy concerns were identified in separate focus groups of NPs and patients, and then parallel survey instruments were designed and administered to 27 NPs and 185 of their patients. All subjects were recruited through APRNet, a regional practice-based research network of NPs in southern New England encompassing 58 practices. Both groups demonstrated high levels of concern regarding privacy. While NPs and patients had similar levels of concern about most issues, there were some notable differences regarding breeches because of carelessness, disclosures for research, and which disorders require the most care in maintaining privacy. These results allow NPs to anticipate patient privacy concerns and to enhance trust in the clinical relationship. These results also indicate the need to educate patients regarding privacy rights and expectations.
Weiss, T W; Siris, E S; Barrett-Connor, E; Miller, P D; McHorney, C A
This study investigated osteoporosis management trends from 1998 to 2006 among 808 primary care physicians involved in the US-based NORA (National Osteoporosis Risk Assessment) study. These results suggest some significant improvements in osteoporosis management over the past eight years. The purpose of this study was to investigate osteoporosis management trends among a large cohort of primary care physicians (PCPs) involved in the US-based NORA (National Osteoporosis Risk Assessment) study. In 2006, we undertook a resurvey of the 2,836 NORA PCPs who completed a baseline survey in 1998. Of the 2,199 PCPs for whom we had current contact information and who were still practicing, we collected usable surveys from 808 (37% response rate). From 1998 to 2006, more than double the percentage of NORA PCPs reported using BMDs "often" (35% vs. 87%). There was a doubling of the percentage of NORA PCPs who reported that a T-score of NORA PCPs who reported using bone turnover markers to screen, diagnosis, or monitor osteoporosis almost tripled (19% vs. 55%). The percentage of patients prescribed or recommended hormone therapy dropped sixfold (67% to 11%), and the percentage of patients prescribed bisphosphonates increased fourfold from 15% to 59%. These results suggest some significant improvements in osteoporosis management over the past eight years.
Full Text Available Abstract Background Fever is an extremely common sign in paediatric patients and the most common cause for a child to be taken to the doctor. The literature indicates that physicians and parents have too many misconceptions and conflicting results about fever management. In this study we aim to identify knowledge, attitudes and misconceptions of primary care physicians regarding fever in children. Methods This cross-sectional study was conducted in April-May 2010 involving primary care physicians (n=80. The physicians were surveyed using a self-administered questionnaire. Descriptive statistics were used. Results In our study only 10% of the physicians knew that a body temperature of above 37.2°C according to an auxiliary measurement is defined as fever. Only 26.2% of the physicians took into consideration signs and symptoms other than fever to prescribe antipyretics. 85% of the physicians prescribed antipyretics to control fever or prevent complications of fever especially febrile seizures. Most of the physicians (76.3% in this study reported that the height of fever may be used as an indicator for severe bacterial infection. A great majority of physicians (91.3% stated that they advised parents to alternate the use of ibuprofen and paracetamol. Conclusions There were misconceptions about the management and complications of fever. There is a perceived need to improve the recognition, assessment, and management of fever with regards to underlying illnesses in children.
Tabrizi, Jafar-Sadegh; Farahbakhsh, Mostafa; Shahgoli, Javad; Rahbar, Mohammad Reza; Naghavi-Behzad, Mohammad; Ahadi, Hamid-Reza; Azami-Aghdash, Saber
Excellence and quality models are comprehensive methods for improving the quality of healthcare. The aim of this study was to design excellence and quality model for training centers of primary health care using Delphi method. In this study, Delphi method was used. First, comprehensive information were collected using literature review. In extracted references, 39 models were identified from 34 countries and related sub-criteria and standards were extracted from 34 models (from primary 39 models). Then primary pattern including 8 criteria, 55 sub-criteria, and 236 standards was developed as a Delphi questionnaire and evaluated in four stages by 9 specialists of health care system in Tabriz and 50 specialists from all around the country. Designed primary model (8 criteria, 55 sub-criteria, and 236 standards) were concluded with 8 criteria, 45 sub-criteria, and 192 standards after 4 stages of evaluations by specialists. Major criteria of the model are leadership, strategic and operational planning, resource management, information analysis, human resources management, process management, costumer results, and functional results, where the top score was assigned as 1000 by specialists. Functional results had the maximum score of 195 whereas planning had the minimum score of 60. Furthermore the most and the least sub-criteria was for leadership with 10 sub-criteria and strategic planning with 3 sub-criteria, respectively. The model that introduced in this research has been designed following 34 reference models of the world. This model could provide a proper frame for managers of health system in improving quality.
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.
Background Workers in Primary Health Care are often exposed to stressful conditions at work. This study investigated the association between adverse psychosocial work conditions and poor quality of life among Primary Health Care workers. Methods This cross-sectional study included all 797 Primary Health Care workers of a medium-sized city, Brazil: doctors, nurses, nursing technicians and nursing assistants, dentists, oral health technicians, and auxiliary oral hygienists, and community health workers. Data were collected by interviews. Quality of life was assessed using the WHOQOL-BREF; general quality of life, as well as the physical, psychological, social and environmental domains were considered, with scores from 0 to 100. Higher scores indicate a better quality of life. Poor quality of life was defined by the lowest quartiles of the WHOQOL score distributions for each of the domains. Adverse psychosocial work conditions were investigated by the Effort-Reward Imbalance model. Associations were verified using multiple logistic regression. Results Poor quality of life was observed in 117 (15.4%) workers. Workers with imbalanced effort-reward (high effort/low reward) had an increased probability of general poor quality of life (OR = 1.91; 1.07–3.42), and in the physical (OR = 1.62; 1.02–2.66), and environmental (OR = 2.39; 1.37–4.16) domains; those with low effort/low reward demonstrated a greater probability of poor quality of life in the social domain (OR = 1.82; 1.00–3.30). Workers with overcommitment at work had an increased likelihood of poor quality of life in the physical (OR = 1.55, 1.06–2.26) and environmental (OR = 1.69; 1.08–2.65) domains. These associations were independent of individual characteristics, job characteristics, lifestyle, perception of general health, or psychological and biological functions. Conclusions There is an association between adverse psychosocial work conditions and poor quality of life among
Teles, Mariza Alves Barbosa; Barbosa, Mirna Rossi; Vargas, Andréa Maria Duarte; Gomes, Viviane Elizângela; Ferreira, Efigênia Ferreira e; Martins, Andréa Maria Eleutério de Barros Lima; Ferreira, Raquel Conceição
Workers in Primary Health Care are often exposed to stressful conditions at work. This study investigated the association between adverse psychosocial work conditions and poor quality of life among Primary Health Care workers. This cross-sectional study included all 797 Primary Health Care workers of a medium-sized city, Brazil: doctors, nurses, nursing technicians and nursing assistants, dentists, oral health technicians, and auxiliary oral hygienists, and community health workers. Data were collected by interviews. Quality of life was assessed using the WHOQOL-BREF; general quality of life, as well as the physical, psychological, social and environmental domains were considered, with scores from 0 to 100. Higher scores indicate a better quality of life. Poor quality of life was defined by the lowest quartiles of the WHOQOL score distributions for each of the domains. Adverse psychosocial work conditions were investigated by the Effort-Reward Imbalance model. Associations were verified using multiple logistic regression. Poor quality of life was observed in 117 (15.4%) workers. Workers with imbalanced effort-reward (high effort/low reward) had an increased probability of general poor quality of life (OR = 1.91; 1.07–3.42), and in the physical (OR = 1.62; 1.02–2.66), and environmental (OR = 2.39; 1.37–4.16) domains; those with low effort/low reward demonstrated a greater probability of poor quality of life in the social domain (OR = 1.82; 1.00–3.30). Workers with overcommitment at work had an increased likelihood of poor quality of life in the physical (OR = 1.55, 1.06–2.26) and environmental (OR = 1.69; 1.08–2.65) domains. These associations were independent of individual characteristics, job characteristics, lifestyle, perception of general health, or psychological and biological functions. There is an association between adverse psychosocial work conditions and poor quality of life among Primary Health Care workers.
Full Text Available Abstract Background Psychosocial stress may account for the higher prevalence of depression in women and in individuals with a low educational background. The aim of this study was to analyse the association between depression and socio-demographic data, psychosocial stressors and lifestyle circumstances from a gender perspective in a relatively affluent primary care setting. Methods Patients, aged 18- 75 years, visiting a drop-in clinic at a primary care health centre were screened with Beck's Depression Inventory (BDI. The physicians used also targeted screening with BDI. A questionnaire on socio-demographic data, psychosocial stressors and use of alcohol and tobacco was distributed. Among patients, who scored BDI ≥10, DSM-IV-criteria were used to diagnose depression. Of the 404 participants, 48 men and 76 women were diagnosed with depression. The reference group consisted of patients with BDI score Results The same three psychosocial stressors: feeling very stressed, perceived poor physical health and being dissatisfied with one's family situation were associated with depression equally in men and women. The negative predictive values of the main effect models in men and women were 90.7% and 76.5%, respectively. Being dissatisfied with one's work situation had high ORs in both men and women. Unemployment and smoking were associated with depression in men only. Conclusions Three questions, frequently asked by physicians, which involve patient's family and working situation as well as perceived stress and physical health, could be used as depression indicators in early detection of depression in men and women in primary health care.
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...... the inter-professional nature of the discipline, the book also features a section on cross-nation organisations and primary care networks supporting research. National perspectives are offered from researchers in 20 countries that form part of the World Organization of Family Doctors, providing case...... histories from research-rich to resource-poor nations that illustrate the range of research development and capacity building. This book argues the importance of primary care research, especially to policy makers, decision makers and funders in informing best practice, training primary health care providers...
Jorm, Louisa R; Shepherd, Leah C; Rogers, Kris D; Blyth, Fiona M
Abstract Background Available evidence suggests that smokers have a lower propensity than others to use primary care services. But previous studies have incorporated only limited adjustment for confounding and mediating factors such as income, access to services and health status. We used data from a large prospective cohort study (the 45 and Up Study), linked to administrative claims data, to quantify the relationship between smoking status and use of primary care services, including specifi...
Tonkin-Crine, Sarah; Santer, Miriam; Leydon, Geraldine M; Murtagh, Fliss E M; Farrington, Ken; Caskey, Fergus; Rayner, Hugh; Roderick, Paul
Chronic kidney disease (CKD) has become a significant part of the GP's workload since the introduction of the National Institute for Health and Care Excellence guidelines in 2008. Patients with advanced CKD (stages G4 and G5) often have comorbidities, varied disease progression, and are likely to be older. GPs may experience difficulties with management decisions for patients with advanced CKD, including when to refer to nephrology. To explore GPs' views of managing patients with advanced CKD and referral to secondary care. Qualitative study with GPs in four areas of England: London, Bristol, Birmingham, and Stevenage. Semi-structured interviews with 19 GPs. Transcribed interviews were thematically analysed. GPs had little experience of managing patients with advanced CKD, including those on dialysis or having conservative care (treatment without dialysis or a transplant), and welcomed guidance. Some GPs referred patients based on renal function alone and some used wider criteria including age and multimorbidity. GPs reported a tension between national guidance and local advice, and some had learnt from experience that patients were discharged back to primary care. GPs with more experience of managing CKD referred patients later, or sometimes not at all, if there were no additional problems and if dialysis was seen as not in the patient's interests. GPs want guidance on managing older patients with advanced CKD and comorbidities, which better incorporates agreement between local and national recommendations to clarify referral criteria. GPs are not generally aware of conservative care programmes provided by renal units, however, they appear happy to contribute to such care or alternatively, lead conservative management with input from renal teams. © British Journal of General Practice 2015.
Fink, Per; ?rnb?l, Eva; Christensen, Kaj Sparle
BACKGROUND: Hypochondriasis is prevalent in primary care, but the diagnosis is hampered by its stigmatizing label and lack of valid diagnostic criteria. Recently, new empirically established criteria for Health anxiety were introduced. Little is known about Health anxiety's impact on longitudinal outcome, and this study aimed to examine impact on self-rated health and health care costs. METHODOLOGY/PRINCIPAL FINDINGS: 1785 consecutive primary care patients aged 18-65 consulting their family p...
Journal of Community Medicine and Primary Health Care. ... Ladoke Akintola University of Technology, PMB 4400, Osogbo, Osun State. ... weak management and poor adherence to the basic infrastructure e.g. primary, secondary and tertiary.
Laberge, Maude; Wodchis, Walter P; Barnsley, Jan; Laporte, Audrey
Background The purpose of this study is to analyze the relationship between newly introduced primary care models in Ontario, Canada, and patients? primary care and total health care costs. A specific focus is on the payment mechanisms for primary care physicians, i.e. fee-for-service (FFS), enhanced-FFS, and blended capitation, and whether providers practiced as part of a multidisciplinary team. Methods Utilization data for a one year period was measured using administrative databases for a 1...
Wakerman, John; Sparrow, Lisa; Thomas, Susan L; Humphreys, John S; Jones, Mike
Improved Primary Health Care (PHC) utilisation is central to reducing the unacceptable morbidity and mortality rates characterising populations living in remote communities. Despite poorer health, significant inequity characterises the funding of PHC services in Australia's most remote areas. This pilot study sought to ascertain what funding is required to ensure equitable access to sustainable, high quality primary health care irrespective of geographical remoteness of communities. High performing remote Primary Health Care (PHC) services were selected using improvement measures from the Australian Primary Care Collaboratives Program and validated by health experts. Eleven PHC services provided data relating to the types of services provided, level of service utilisation, human resources, operating and capital expenses. A further four services that provide visiting PHC to remote communities provided information on the level and cost of these services. Demographic data for service catchment areas (including estimated resident population, age, Indigenous status, English spoken at home and workforce participation) were obtained from the Australian Bureau of Statistics 2011 census. Formal statistical inference (p-values) were derived in the linear regression via the nonparametric bootstrap. A direct linear relationship was observed between the total cost of resident PHC services and population, while cost per capita decreased with increasing population. Services in smaller communities had a higher number of nursing staff per 1000 residents and provided more consultations per capita than those in larger communities. The number of days of visiting services received by a community each year also increased with population. A linear regression with bootstrapped statistical inference predicted a significant regression equation where the cost of resident services per annum is equal to $1,251,893.92 + ($1698.83 x population) and the cost of resident and visiting services is
Client Satisfaction with Antenatal Care Services in Primary Health Care. Centres in Sabon ... important information about how well clinicians and the population of women within child bearing. 8 ..... model. Health and Quality of Life outcomes.
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...
Samsiah, A; Othman, Noordin; Jamshed, Shazia; Hassali, Mohamed Azmi
To explore and understand participants' perceptions and attitudes towards the reporting of medication errors (MEs). A qualitative study using in-depth interviews of 31 healthcare practitioners from nine publicly funded, primary care clinics in three states in peninsular Malaysia was conducted for this study. The participants included family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. The interviews were audiotaped and transcribed verbatim. Analysis of the data was guided by the framework approach. Six themes and 28 codes were identified. Despite the availability of a reporting system, most of the participants agreed that MEs were underreported. The nature of the error plays an important role in determining the reporting. The reporting system, organisational factors, provider factors, reporter's burden and benefit of reporting also were identified. Healthcare practitioners in primary care clinics understood the importance of reporting MEs to improve patient safety. Their perceptions and attitudes towards reporting of MEs were influenced by many factors which affect the decision-making process of whether or not to report. Although the process is complex, it primarily is determined by the severity of the outcome of the errors. The participants voluntarily report the errors if they are familiar with the reporting system, what error to report, when to report and what form to use.
Verstappen, Wim; Gaal, Sander; Esmail, Aneez; Wensing, Michel
ABSTRACT Background: To improve patient safety it is necessary to identify the causes of patient safety incidents, devise solutions and measure the (cost-) effectiveness of improvement efforts. Objective: This paper provides a broad overview with practical guidance on how to improve patient safety. Methods: We used modified online Delphi procedures to reach consensus on methods to improve patient safety and to identify important features of patient safety management in primary care. Two pilot studies were carried out to assess the value of prospective risk analysis (PRA), as a means of identifying the causes of a patient safety incident. Results: A range of different methods can be used to improve patient safety but they have to be contextually specific. Practice organization, culture, diagnostic errors and medication safety were found to be important domains for further improvement. Improvement strategies for patient safety could benefit from insights gained from research on implementation of evidence-based practice. Patient involvement and prospective risk analysis are two promising and innovative strategies for improving patient safety in primary care. Conclusion: A range of methods is available to improve patient safety, but there is no ‘magic bullet.’ Besides better use of the available methods, it is important to use new and potentially more effective strategies, such as prospective risk analysis. PMID:26339837
Foster, Michele; Burridge, Letitia; Donald, Maria; Zhang, Jianzhen; Jackson, Claire
Service delivery innovation is at the heart of efforts to combat the growing burden of chronic disease and escalating healthcare expenditure. Small-scale, locally-led service delivery innovation is a valuable source of learning about the complexities of change and the actions of local change agents. This exploratory qualitative study captures the perspectives of clinicians and managers involved in a general practitioner-led integrated diabetes care innovation. Data on these change agents' perspectives on the local innovation and how it works in the local context were collected through focus groups and semi-structured interviews at two primary health care sites. Transcribed data were analysed thematically. Normalization Process Theory provided a framework to explore perspectives on the individual and collective work involved in putting the innovation into practice in local service delivery contexts. Twelve primary health care clinicians, hospital-based medical specialists and practice managers participated in the study, which represented the majority involved in the innovation at the two sites. The thematic analysis highlighted three main themes of local innovation work: 1) trusting and embedding new professional relationships; 2) synchronizing services and resources; and 3) reconciling realities of innovation work. As a whole, the findings show that while locally-led service delivery innovation is designed to respond to local problems, convincing others to trust change and managing the boundary tensions is core to local work, particularly when it challenges taken-for-granted practices and relationships. Despite this, the findings also show that local innovators can and do act in both discretionary and creative ways to progress the innovation. The use of Normalization Process Theory uncovered some critical professional, organizational and structural factors early in the progression of the innovation. The key to local service delivery innovation lies in building
Full Text Available Abstract Background Rural communities throughout Australia are experiencing demographic ageing, increasing burden of chronic diseases, and de-population. Many are struggling to maintain viable health care services due to lack of infrastructure and workforce shortages. Hence, they face significant health disadvantages compared with urban regions. Primary health care yields the best health outcomes in situations characterised by limited resources. However, few rigorous longitudinal evaluations have been conducted to systematise them; assess their transferability; or assess sustainability amidst dynamic health policy environments. This paper describes the study protocol of a comprehensive longitudinal evaluation of a successful primary health care service in a small rural Australian community to assess its performance, sustainability, and responsiveness to changing community needs and health system requirements. Methods/Design The evaluation framework aims to examine the health service over a six-year period in terms of: (a Structural domains (health service performance; sustainability; and quality of care; (b Process domains (health service utilisation and satisfaction; and (c Outcome domains (health behaviours, health outcomes and community viability. Significant international research guided the development of unambiguous reliable indicators for each domain that can be routinely and unobtrusively collected. Data are to be collected and analysed for trends from a range of sources: audits, community surveys, interviews and focus group discussions. Discussion This iterative evaluation framework and methodology aims to ensure the ongoing monitoring of service activity and health outcomes that allows researchers, providers and administrators to assess the extent to which health service objectives are met; the factors that helped or hindered achievements; what worked or did not work well and why; what aspects of the service could be improved and how
Borgermans, L.D.A.; Goderis, G.; Broeke, C.V.; Mathieu, C.; Aertgeerts, B.; Verbeke, G.; Carbonez, A.; Ivanova, A.; Grol, R.P.T.M.; Heyrman, J.
ABSTRACT: BACKGROUND: Most quality improvement programs in diabetes care incorporate aspects of clinician education, performance feedback, patient education, care management, and diabetes care teams to support primary care physicians. Few studies have applied all of these dimensions to address
Scarpaci, Joseph L.
Primary medical care in Chile: accessibility under military rule [Front Cover] [Front Matter] [Title Page] Contents Tables Figures Preface Chapter 1: Introduction Chapter 2: The Restructuring of Medical Care Financing in Chile Chapter 3: Inflation and Medical Care Accessibility Chapter 4: Help......-Seeking Behavior of the Urban Poor Chapter 5: Spatial Organization and Medical Care Accessibility Chapter 6: Conclusion...
Huijg, J.M.; Crone, M.R.; Verheijden, M.W.; Zouwe, N. van der; Middelkoop, B.J.; Gebhardt, W.A.
Background: The introduction of efficacious physical activity interventions in primary health care is a complex process. Understanding factors influencing the process can enhance the development of effective introduction strategies. This Delphi study aimed to identify factors most relevant for the
Scammon, Debra L; Tomoaia-Cotisel, Andrada; Day, Rachel L; Day, Julie; Kim, Jaewhan; Waitzman, Norman J; Farrell, Timothy W; Magill, Michael K
To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. Convergent case study mixed methods design. Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence. © Health Research and Educational Trust.
Davy, Zowie; Middlemass, Jo; Siriwardena, Aloysius N
Insomnia is common leading to patients with sleep problems often presenting to primary care services including general practice, community pharmacies and community mental health teams. Little is known about how health professionals in primary care respond to patients with insomnia. We aimed to explore health professionals' and patients' experiences and perceptions of the management of insomnia in primary care. We used a qualitative design and thematic approach. Primary care in Nottinghamshire and Lincolnshire. We undertook focus groups and one-to-one interviews with a purposive sample of health professionals and adults with insomnia. We interviewed 28 patients and 23 health professionals. Practitioners focused on treating the cause of insomnia rather than the insomnia itself. They described providing stepped care for insomnia, but this focused on sleep hygiene which patients often disregarded, rather than cognitive behavioural therapy for insomnia (CBT-I). Practitioners were ambivalent towards hypnotic drugs but often colluded with patients to prescribe to avoid confrontation or express empathy. Patients sometimes took hypnotics in ways that were not intended, for example together with over-the-counter medication. Practitioners and patients were sometimes but not always concerned about addiction. Practitioners sometimes prescribed despite these concerns but at other times withdrew hypnotics abruptly without treating insomnia. Both patients and practitioners wanted more options and better training for the management of insomnia in primary care. A better understanding of the current approaches and difficulties in the management of insomnia will help to inform more therapeutic options and health professional training. © 2013 John Wiley & Sons Ltd.
Bos, Elisabeth; Alinaghizadeh, Hassan; Saarikoski, Mikko; Kaila, Päivi
Clinical placement plays a key role in education intended to develop nursing and caregiving skills. Studies of nursing students' clinical learning experiences show that these dimensions affect learning processes: (i) supervisory relationship, (ii) pedagogical atmosphere, (iii) management leadership style, (iv) premises of nursing care on the ward, and (v) nursing teachers' roles. Few empirical studies address the probability of an association between these dimensions and factors such as student (a) motivation, (b) satisfaction with clinical placement, and (c) experiences with professional role models. The study aimed to investigate factors associated with the five dimensions in clinical learning environments within primary health care units. The Swedish version of Clinical Learning Environment, Supervision and Teacher, a validated evaluation scale, was administered to 356 graduating nursing students after four or five weeks clinical placement in primary health care units. Response rate was 84%. Multivariate analysis of variance is determined if the five dimensions are associated with factors a, b, and c above. The analysis revealed a statistically significant association with the five dimensions and two factors: students' motivation and experiences with professional role models. The satisfaction factor had a statistically significant association (effect size was high) with all dimensions; this clearly indicates that students experienced satisfaction. These questionnaire results show that a good clinical learning experience constitutes a complex whole (totality) that involves several interacting factors. Supervisory relationship and pedagogical atmosphere particularly influenced students' satisfaction and motivation. These results provide valuable decision-support material for clinical education planning, implementation, and management. Copyright © 2014 Elsevier Ltd. All rights reserved.
Johnston, Sharon; Wong, Sabrina T; Blackman, Stephanie; Chau, Leena W; Grool, Anne M; Hogg, William
Recruiting family physicians into primary care research studies requires researchers to continually manage information coming in, going out, and coming in again. In many research groups, Microsoft Excel and Access are the usual data management tools, but they are very basic and do not support any automation, linking, or reminder systems to manage and integrate recruitment information and processes. We explored whether a commercial customer relationship management (CRM) software program - designed for sales people in businesses to improve customer relations and communications - could be used to make the research recruitment system faster, more effective, and more efficient. We found that while there was potential for long-term studies, it simply did not adapt effectively enough for our shorter study and recruitment budget. The amount of training required to master the software and our need for ongoing flexible and timely support were greater than the benefit of using CRM software for our study.
Full Text Available Chronic kidney disease (CKD is commonly managed in primary care, but most guidelines have a secondary care perspective emphasizing the risk of end-stage kidney disease (ESKD and need for renal replacement therapy. In this prospective cohort study, we sought to study in detail the natural history of CKD in primary care to better inform the appropriate emphasis for future guidance.In this study, 1,741 people with CKD stage 3 were individually recruited from 32 primary care practices in Derbyshire, United Kingdom. Study visits were undertaken at baseline, year 1, and year 5. Binomial logistic regression and Cox proportional hazards models were used to model progression, CKD remission, and all-cause mortality. We used Kidney Disease: Improving Global Outcomes (KDIGO criteria to define CKD progression and defined CKD remission as the absence of diagnostic criteria (estimated glomerular filtration rate [eGFR] >60 ml/min/1.73 m2 and urine albumin-to-creatinine ratio [uACR] <3 mg/mmol at any study visit. Participants were predominantly elderly (mean ± standard deviation (SD age 72.9 ± 9.0 y, with relatively mild reduction in GFR (mean ± SD eGFR 53.5 ± 11.8 mL/min/1,73 m2 and a low prevalence of albuminuria (16.9%. After 5 y, 247 participants (14.2% had died, most of cardiovascular causes. Only 4 (0.2% developed ESKD, but 308 (17.7% evidenced CKD progression by KDIGO criteria. Stable CKD was observed in 593 participants (34.1%, and 336 (19.3% met the criteria for remission. Remission at baseline and year 1 was associated with a high likelihood of remission at year 5 (odds ratio [OR] = 23.6, 95% CI 16.5-33.9 relative to participants with no remission at baseline and year 1 study visits. Multivariable analyses confirmed eGFR and albuminuria as key risk factors for predicting adverse as well as positive outcomes. Limitations of this study include reliance on GFR estimated using the Modification of Diet in Renal Disease study (MDRD equation for
Girard, Ariane; Hudon, Catherine; Poitras, Marie-Eve; Roberge, Pasquale; Chouinard, Maud-Christine
To describe nursing activities in primary care with patients affected by physical chronic disease and common mental disorders. Patients in primary care who are affected by physical chronic disease and common mental disorders such as anxiety and depression require care and follow-up based on their physical and mental health condition. Primary care nurses are increasingly expected to contribute to the care and follow-up of this growing clientele. However, little is known about the actual activities carried out by primary care nurses in providing this service in the Province of Quebec (Canada). A qualitative descriptive study was conducted. Data were obtained through semistructured individual interviews with 13 nurses practising among patients with physical chronic disease in seven Family Medicine Groups in Quebec (Canada). Participants described five activity domains: assessment of physical and mental health condition, care planning, interprofessional collaboration, therapeutic relationship and health promotion. The full potential of primary care nurses is not always exploited, and some activities could be improved. Evidence for including nurses in collaborative care for patients affected by physical chronic disease and common mental disorders has been shown but is not fully implemented in Family Medicine Groups. Future research should emphasise collaboration among mental health professionals, primary care nurses and family physicians in the care of patients with physical chronic disease and common mental disorders. Primary care nurses would benefit from gaining more knowledge about common mental disorders and from identifying the resources they need to contribute to managing them in an interdisciplinary team. © 2016 John Wiley & Sons Ltd.
Usta, Jinan; Feder, Gene; Antoun, Jumana
Domestic violence (DV) is highly prevalent in the developing and developed world. Healthcare systems internationally are still not adequately addressing the needs of patients experiencing violence. To explore physicians' attitudes about responding to DV, their perception of the physician's role, and the factors that influence their response. Qualitative study using individual interviews among primary care practitioners working in Lebanon. Primary care clinicians practising for >5 years and with >100 patient consultations a week were interviewed. Physicians were asked about their practice when encountering women disclosing abuse, their opinion about the engagement of the health services with DV, their potential role, and the anticipated reaction of patients and society to this extended role. Physicians felt that they were well positioned to play a pivotal role in addressing DV; yet they had concerns related to personal safety, worry about losing patients, and opposing the norms of a largely conservative society. Several physicians justified DV or blamed the survivor rather than the perpetrator for triggering the violent behaviour. Moreover, religion was perceived as sanctioning DV. Perceived cultural norms and religious beliefs seem to be major barriers to physicians responding to DV in Lebanon, and possibly in the Arab world more generally. Financial concerns also need to be addressed to encourage physicians to address DV. © British Journal of General Practice 2014.
Usta, Jinan; Feder, Gene; Antoun, Jumana
Background Domestic violence (DV) is highly prevalent in the developing and developed world. Healthcare systems internationally are still not adequately addressing the needs of patients experiencing violence. Aim To explore physicians’ attitudes about responding to DV, their perception of the physician’s role, and the factors that influence their response. Design and setting Qualitative study using individual interviews among primary care practitioners working in Lebanon. Method Primary care clinicians practising for >5 years and with >100 patient consultations a week were interviewed. Physicians were asked about their practice when encountering women disclosing abuse, their opinion about the engagement of the health services with DV, their potential role, and the anticipated reaction of patients and society to this extended role. Results Physicians felt that they were well positioned to play a pivotal role in addressing DV; yet they had concerns related to personal safety, worry about losing patients, and opposing the norms of a largely conservative society. Several physicians justified DV or blamed the survivor rather than the perpetrator for triggering the violent behaviour. Moreover, religion was perceived as sanctioning DV. Conclusion Perceived cultural norms and religious beliefs seem to be major barriers to physicians responding to DV in Lebanon, and possibly in the Arab world more generally. Financial concerns also need to be addressed to encourage physicians to address DV. PMID:24868068
Background This mixed methods study was designed to explore the acceptability and impact of feedback of team performance data to primary care interdisciplinary teams. Methods Seven interdisciplinary teams were offered a one-hour, facilitated performance feedback session presenting data from a comprehensive, previously-conducted evaluation, selecting highlights such as performance on chronic disease management, access, patient satisfaction and team function. Results Several recurrent themes emerged from participants' surveys and two rounds of interviews within three months of the feedback session. Team performance measurement and feedback was welcomed across teams and disciplines. This feedback could build the team, the culture, and the capacity for quality improvement. However, existing performance indicators do not equally reflect the role of different disciplines within an interdisciplinary team. Finally, the effect of team performance feedback on intentions to improve performance was hindered by a poor understanding of how the team could use the data. Conclusions The findings further our understanding of how performance feedback may engage interdisciplinary team members in improving the quality of primary care and the unique challenges specific to these settings. There is a need to develop a shared sense of responsibility and agenda for quality improvement. Therefore, more efforts to develop flexible and interactive performance-reporting structures (that better reflect contributions from all team members) in which teams could specify the information and audience may assist in promoting quality improvement. PMID:21443806
Chuh, Antonio A T; Lee, Albert; Molinari, Nicolas
To investigate the epidemiology of pityriasis rosea in primary care settings in Hong Kong and to analyze for temporal clustering. Retrospective epidemiologic study. Six primary care teaching practices affiliated with a university. Patients Forty-one patients with pityriasis rosea, 564 patients with atopic dermatitis (negative control condition), and 35 patients with scabies (positive control condition). We retrieved all records of patients with pityriasis rosea, atopic dermatitis, or scabies diagnosed in 3 years. We analyzed temporal clustering by a method based on a regression model. The monthly incidence of pityriasis rosea is negatively but insignificantly correlated with mean air temperature (gamma s = -0.41, P =.19) and mean total rainfall (gamma s = -0.34, P =.27). Three statistically significant clusters with 7, 6, and 7 cases were identified (P =.03), occurring in the second coldest month in the year (February), the second hottest month (July), and a temperate month (April), respectively. For atopic dermatitis (negative control condition), the nonclustering regression model was selected by Akaike information criteria. For scabies (positive control condition), 1 cluster of 20 cases was detected (P =.03). Significant temporal clustering independent of seasonal variation occurred in our series of patients with pityriasis rosea. This may be indicative of an infectious cause.
Wang, Manli; Fang, Haiqing; Bishwajit, Ghose; Xiang, Yuanxi; Fu, Hang; Feng, Zhanchun
China's Ministry of Health has enacted Rural Primary Health Care Program (2001-2010) (HCP) guidelines to improve the quality of people's health. However, the program's success in Western China remains unevaluated. Thus, this study aims to begin to fill that gap by analyzing the provision and utilization of Rural Primary Health Care (RPHC) in Western China. A cross-sectional study was conducted to collect secondary data on the socio-economic characteristics, system construction, services use and implementation of RPHC, and the residents' health status of the sampled areas. Four hundred counties from 31 provinces in China were selected via stratified random sampling, including 171 counties from 12 Western provinces. Twenty-seven analysis indicators, covering system construction, services use and implementation of RPHC were chosen to assess Western China's primary health quality. Analysis of Variance (ANOVA) and Least Significant Difference (LSD) methods were used to measure the RPHC disparities between Western and Eastern and Central China. Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) was used to rank Western, Eastern and Central internal provinces regarding quality of their RPHC. Of the 27 indicators, 13 (48.15%) were below the standard in Western China. These focused on rural health service system construction, Chinese medicine services, and public health. In the comparison between Western, Central and Eastern China, 12 indicators had statistical significance (p China, all indicators were statistically significant (p China overall. Western China's RPHC has proceeded well, but remains weaker than that of Eastern and Central China. Differences within Western internal provinces threaten the successful implementation of RPHC.
Full Text Available Abstract Background Missed appointments are known to interfere with appropriate care and to misspend medical and administrative resources. The aim of this study was to test the effectiveness of a sequential intervention reminding patients of their upcoming appointment and to identify the profile of patients missing their appointments. Methods We conducted a randomised controlled study in an urban primary care clinic at the Geneva University Hospitals serving a majority of vulnerable patients. All patients booked in a primary care or HIV clinic at the Geneva University Hospitals were sent a reminder 48 hrs prior to their appointment according to the following sequential intervention: 1. Phone call (fixed or mobile reminder; 2. If no phone response: a Short Message Service (SMS reminder; 3. If no available mobile phone number: a postal reminder. The rate of missed appointment, the cost of the intervention, and the profile of patients missing their appointment were recorded. Results 2123 patients were included: 1052 in the intervention group, 1071 in the control group. Only 61.7% patients had a mobile phone recorded at the clinic. The sequential intervention significantly reduced the rate of missed appointments: 11.4% (n = 122 in the control group and 7.8% (n = 82 in the intervention group (p 1year (OR 2.2; CI: 1.15-4.2, substance abuse (2.09, CI 1.21-3.61, and being an asylum seeker (OR 2.73: CI 1.22-6.09. Conclusion A practical reminder system can significantly increase patient attendance at medical outpatient clinics. An intervention focused on specific patient characteristics could further increase the effectiveness of appointment reminders.
Bradbury-Jones, Caroline; Clark, Maria; Taylor, Julie
The aim of this study was to report the findings of a qualitative case study that investigated abused women's experiences of an identification and referral intervention and to discuss the implications for nurses, specifically those working in primary and community care. Domestic violence and abuse is a significant public health issue globally but it is a hidden problem that is under-reported. In the UK, Identification and Referral to Improve Safety is a primary care-based intervention that has been found to increase referral rates of abused women to support and safety services. This paper reports on the findings of an evaluation study of two sites in England. Qualitative study with a case study design. In line with case study design, the entire evaluation study employed multiple data collection methods. We report on the qualitative interviews with women referred through the programme. The aim was to elicit their experiences of the three aspects of the intervention: identification; referral; safety. Data collection took place March 2016. Ten women took part. Eight had exited the abusive relationship but two remained with the partner who had perpetrated the abuse. Women were overwhelmingly positive about the programme and irrespective of whether they had remained or exited the relationship all reported perceptions of increased safety and improved health. Nurses have an important role to play in identifying domestic violence and abuse and in referral and safety planning. As part of a portfolio of domestic violence and abuse interventions, those that empower women to take control of their safety (such as Identification and Referral to Improve Safety) are important. © 2017 John Wiley & Sons Ltd.
Robert L Grant
Full Text Available Dementia is one of the most disabling and burdensome diseases. Incontinence in people with dementia is distressing, adds to carer burden, and influences decisions to relocate people to care homes. Successful and safe management of incontinence in people with dementia presents additional challenges. The aim of this study was to investigate the rates of first diagnosis in primary care of urinary and faecal incontinence among people aged 60-89 with dementia, and the use of medication or indwelling catheters for urinary incontinence.We extracted data on 54,816 people aged 60-89 with dementia and an age-gender stratified sample of 205,795 people without dementia from 2001 to 2010 from The Health Improvement Network (THIN, a United Kingdom primary care database. THIN includes data on patients and primary care consultations but does not identify care home residents. Rate ratios were adjusted for age, sex, and co-morbidity using multilevel Poisson regression. The rates of first diagnosis per 1,000 person-years at risk (95% confidence interval for urinary incontinence in the dementia cohort, among men and women, respectively, were 42.3 (40.9-43.8 and 33.5 (32.6-34.5. In the non-dementia cohort, the rates were 19.8 (19.4-20.3 and 18.6 (18.2-18.9. The rates of first diagnosis for faecal incontinence in the dementia cohort were 11.1 (10.4-11.9 and 10.1 (9.6-10.6. In the non-dementia cohort, the rates were 3.1 (2.9-3.3 and 3.6 (3.5-3.8. The adjusted rate ratio for first diagnosis of urinary incontinence was 3.2 (2.7-3.7 in men and 2.7 (2.3-3.2 in women, and for faecal incontinence was 6.0 (5.1-7.0 in men and 4.5 (3.8-5.2 in women. The adjusted rate ratio for pharmacological treatment of urinary incontinence was 2.2 (1.4-3.7 for both genders, and for indwelling urinary catheters was 1.6 (1.3-1.9 in men and 2.3 (1.9-2.8 in women.Compared with those without a dementia diagnosis, those with a dementia diagnosis have approximately three times the rate of
van der Vleuten Cees
Full Text Available Abstract Background Available evidence suggests that improvements in genetics education are needed to prepare primary care providers for the impact of ongoing rapid advances in genomics. Postgraduate (physician training and master (midwifery training programmes in primary care and public health are failing to meet these perceived educational needs. The aim of this study was to explore the role of genetics in primary care (i.e. family medicine and midwifery care and the need for education in this area as perceived by primary care providers, patient advocacy groups and clinical genetics professionals. Methods Forty-four participants took part in three types of focus groups: mono-disciplinary groups of general practitioners and midwives, respectively and multidisciplinary groups composed of a diverse set of experts. The focus group sessions were audio-taped, transcribed verbatim and analysed using content analysis. Recurrent themes were identified. Results Four themes emerged regarding the educational needs and the role of genetics in primary care: (1 genetics knowledge, (2 family history, (3 ethical dilemmas and psychosocial effects in relation to genetics and (4 insight into the organisation and role of clinical genetics services. These themes reflect a shift in the role of genetics in primary care with implications for education. Although all focus group participants acknowledged the importance of genetics education, general practitioners felt this need more urgently than midwives and more strongly emphasized their perceived knowledge deficiencies. Conclusion The responsibilities of primary care providers with regard to genetics require further study. The results of this study will help to develop effective genetics education strategies to improve primary care providers' competencies in this area. More research into the educational priorities in genetics is needed to design courses that are suitable for postgraduate and master programmes for
Davey, Christopher J; Slade, Sarah V; Shickle, Darren
To identify a minimum list of metrics of international relevance to public health, research and service development which can be extracted from practice management systems and electronic patient records in primary optometric practice. A two stage modified Delphi technique was used. Stage 1 categorised metrics that may be recorded as being part of a primary eye examination by their importance to research using the results from a previous survey of 40 vision science and public health academics. Delphi stage 2 then gauged the opinion of a panel of seven vision science academics and achieved consensus on contentious metrics and methods of grading/classification. A consensus regarding inclusion and response categories was achieved for nearly all metrics. A recommendation was made of 53 metrics which would be appropriate in a minimum data set. This minimum data set should be easily integrated into clinical practice yet allow vital data to be collected internationally from primary care optometry. It should not be mistaken for a clinical guideline and should not add workload to the optometrist. A pilot study incorporating an additional Delphi stage prior to implementation is advisable to refine some response categories. © 2017 The Authors. Ophthalmic and Physiological Optics published by John Wiley & Sons Ltd on behalf of College of Optometrists.
Feemster Kristen A
Full Text Available Abstract Background Despite national recommendations, as of 2009 human papillomavirus (HPV vaccination rates were low with Methods Between March and June, 2010, we conducted qualitative interviews with 20 adolescent-mother-clinician triads (60 individual interviews directly after a preventive visit with the initial HPV vaccine due. Interviews followed a guide based on published HPV literature, involved 9 practices, and continued until saturation of the primary themes was achieved. Purposive sampling balanced adolescent ages and practice type (urban resident teaching versus non-teaching. Using a modified grounded theory approach, we analyzed data with NVivo8 software both within and across triads to generate primary themes. Results The study population was comprised of 20 mothers (12 Black, 9 Conclusions Programs to improve HPV vaccine delivery in primary care should focus on promoting effective parent-clinician communication. Research is needed to evaluate strategies to help clinicians engage reluctant parents and passive teens in discussion and measure the impact of distinct clinician decision making approaches on HPV vaccine delivery.
Zimlichman, Eyal; Mandel, Dror; Mimouni, Francis B; Vinker, Shlomo; Kochba, Ilan; Kreiss, Yitshak; Lahad, Amnon
The health system of the medical corps of the Israel Defense Force is based primarily upon primary healthcare. In recent years, health management organizations have considered the primary care physician responsible for assessing the overall health needs of the patient and, accordingly, introduced the term "gatekeeper." To describe and analyze how PCPs in the IDF view their roles as primary care providers and to characterize how they perceive the quality of the medical care that they provide. We conducted a survey using a questionnaire that was mailed or faxed to a representative sample of PCPs. The questionnaire included demographic background, professional background, statements on self-perception issues, and ranking of roles as a PCP in the IDF. Statements concerning commitment to the patient were ranked higher than statements concerning commitment to the military organization. Most physicians perceive the quality of the medical care service that they provide as high; they also stated that they do not receive adequate continuous medical education. Our survey shows that PCPs in the IDF, like civilian family physicians, perceive their primary obligation as serving the needs of their patients but are yet to take on the full role of "gatekeepers" in the IDF's healthcare system. We conclude that the Medical Corps should implement appropriate steps to ensure that PCPs are prepared to take on a more prominent role as "gatekeepers" and providers of high quality primary medical care.
MacNaughton, Kate; Chreim, Samia; Bourgeault, Ivy Lynn
The move towards enhancing teamwork and interprofessional collaboration in health care raises issues regarding the management of professional boundaries and the relationship among health care providers. This qualitative study explores how roles are constructed within interprofessional health care teams. It focuses on elucidating the different types of role boundaries, the influences on role construction and the implications for professionals and patients. A comparative case study was conducted to examine the dynamics of role construction on two interprofessional primary health care teams. The data collection included interviews and non-participant observation of team meetings. Thematic content analysis was used to code and analyze the data and a conceptual model was developed to represent the emergent findings. The findings indicate that role boundaries can be organized around interprofessional interactions (giving rise to autonomous or collaborative roles) as well as the distribution of tasks (giving rise to interchangeable or differentiated roles). Different influences on role construction were identified. They are categorized as structural (characteristics of the workplace), interpersonal (dynamics between team members such as trust and leadership) and individual dynamics (personal attributes). The implications of role construction were found to include professional satisfaction and more favourable wait times for patients. A model that integrates these different elements was developed. Based on the results of this study, we argue that autonomy may be an important element of interprofessional team functioning. Counter-intuitive as this may sound, we found that empowering team members to develop autonomy can enhance collaborative interactions. We also argue that while more interchangeable roles could help to lessen the workloads of team members, they could also increase the potential for power struggles because the roles of various professions would become less
Martín-Fernández, Jesús; Gómez-Gascón, Tomás; Oliva-Moreno, Juan; del Cura-González, María Isabel; Domínguez-Bidagor, Julia; Beamud-Lagos, Milagros; Sanz-Cuesta, Teresa
Identify the economic value the user attributes to the visit to the family physician, in a setting of a National Health System, by the Willingness to Pay (WTP) expressed. Economic evaluation study, by the contingent valuation method. Questions were asked about WTP using a payment card format. Interviews were conducted with 451 subjects, in areas with different socioeconomic characteristics. An ordered probit was used to evaluate model's validity. Median WTP expressed was euro18 (interquartile range euro8-28), not including "zero-answers" of thirty-four subjects (7.5%). This value represents 2% of average adjusted family incomes. Patients with higher incomes or with chronic illnesses presented a probability of 5-14 percentage points of expressing a high WTP. For every point of increase of patient satisfaction, the probability of presenting a WTP in the lowest range decreases 7.0 percentage points. Subjects with a low education level and those older than 65 expressed a lower WTP. Accessibility, risk perception, nationality and having private insurance were not related to the WTP expressed. Users of primary care have a clear perception of the economic value of care received from the family physician, even in a framework of providing services financed by taxes and without cost at the moment of use. This value increases in subjects with higher incomes, with greater need for care, or more satisfied.
Full Text Available Objectives: To determine the unit cost of curative care provided at Primary Health Centers (PHCs and to examine the variation in unit cost in different PHCs. Materials and Methods: The present study was carried out in three PHCs of Ahmedabad district namely Sanathal, Nandej, and Uperdal, between 1 April, 2006 and 31 March, 2007. For estimating the cost of a health program, information on all the physical and human resources that were basic inputs to the PHC services were collected and grouped into two categories, non-recurrent (capital resources vehicles, buildings, etc. and recurrent resources (salaries, drugs, vaccines, contraceptives, maintenance, etc.. To generate the required data, two types of schedules were developed, daily time schedule and PHC/SC (Subcenter information schedule. Results: The unit cost of curative care was lowest (Rs. 29.43 for the Sanathal PHC and highest (Rs. 88.26 for the Uperdal PHC, followed by the Nandej PHC with Rs. 40.88, implying severe underutilization of curative care at the Uperdal PHC. Conclusions: Location of health facilities is a problem at many places. As relocation is not possible or even feasible, strengthening of infrastructure and facilities at these centers can be taken up immediately.
Regina W S Sit
Full Text Available Chronic low back pain is a serious global health problem. There is substantial evidence that physicians' attitudes towards and beliefs about chronic low back pain can influence their subsequent management of the condition.(1 to evaluate the attitudes and beliefs towards chronic low back pain among primary care physicians in Asia; (2 to study the cultural differences and other factors that are associated with these attitudes and beliefs.A cross sectional online survey was sent to primary care physicians who are members of the Hong Kong College of Family Physician (HKCFP. The Pain Attitudes and Beliefs Scale for Physiotherapist (PABS-PT was used as the questionnaire to determine the biomedical and biopsychosocial orientation of the participants.The mean Biomedical (BM score was 34.8+/-6.1; the mean biopsychosocial (BPS score was 35.6 (+/- 4.8. Both scores were higher than those of European doctors. Family medicine specialists had a lower biomedical score than General practitioners. Physicians working in the public sector tended to have low BM and low BPS scores; whereas physicians working in private practice tended to have high BM and high BPS scores.The lack of concordance in the pain explanatory models used by private and public sector may have a detrimental effect on patients who are under the care of both parties. The uncertain treatment orientation may have a negative influence on patients' attitudes and beliefs, thus contributing to the tension and, perhaps, even ailing mental state of a person with chronic LBP.
Tim Scott J
Full Text Available Abstract Background The study is designed to assess the organisational and human resource challenges faced by Primary Care Trusts (PCTs. Its objectives are to: specify the organisational and human resources challenges faced by PCTs in fulfilling the roles envisaged in government and local policy; examine how PCTs are addressing these challenges, in particular, to describe the organisational forms they have adopted, and the OD/HR strategies and initiatives they have planned or in place; assess how effective these structures, strategies and initiatives have been in enabling the PCTs to meet the organisational and human resources challenges they face; identify the factors, both internal to the PCT and in the wider health community, which have contributed to the success or failure of different structures, strategies and initiatives. Methods The study will be undertaken in three stages. In Stage 1 the key literature on public sector and NHS organisational development and human resources management will be reviewed, and discussions will be held with key researchers and policy makers working in this area. Stage 2 will focus on detailed case studies in six PCTs designed to examine the organisational and human resources challenges they face. Data will be collected using semi-structured interviews, group discussion, site visits, observation of key meetings and examination of local documentation. The findings from the case study PCTs will be cross checked with a Reference Group of up to 20 other PCG/Ts, and key officers working in organisational development or primary care at local, regional and national level. In Stage 3 analysis of findings from the preparatory work, the case studies and the feedback from the Reference Group will be used to identify practical lessons for PCTs, key messages for policy makers, and contributions to further theoretical development.
Ellner, Andrew L; Phillips, Russell S
The United States has the most expensive, technologically advanced, and sub-specialized healthcare system in the world, yet it has worse population health status than any other high-income country. Rising healthcare costs, high rates of waste, the continued trend towards chronic non-communicable disease, and the growth of new market entrants that compete with primary care services have set the stage for fundamental change in all of healthcare, driven by a revolution in primary care. We believe that the coming primary care revolution ought to be guided by the following design principles: 1) Payment must adequately support primary care and reward value, including non-visit-based care. 2) Relationships will serve as the bedrock of value in primary care, and will increasingly be fostered by teams, improved clinical operations, and technology, with patients and non-physicians assuming an ever-increasing role in most aspects of healthcare. 3) Generalist physicians will increasingly focus on high-acuity and high-complexity presentations, and primary care teams will increasingly manage conditions that specialists managed in the past. 4) Primary care will refocus on whole-person care, and address health behaviors as well as vision, hearing, dental, and social services. Design based on these principles should lead to higher-value healthcare, but will require new approaches to workforce training.
Asaria, Miqdad; Cookson, Richard; Fleetcroft, Robert; Ali, Shehzad
To measure changes in socioeconomic inequality in the distribution of family physicians (general practitioners (GPs)) relative to need in England from 2004/2005 to 2013/2014. Whole-population small area longitudinal data linkage study. England from 2004/2005 to 2013/2014. 32,482 lower layer super output areas (neighbourhoods of 1500 people on average). Slope index of inequality (SII) between the most and least deprived small areas in annual full-time equivalent GPs (FTE GPs) per 100,000 need adjusted population. In 2004/2005, inequality in primary care supply as measured by the SII in FTE GPs was 4.2 (95% CI 3.1 to 5.3) GPs per 100,000. By 2013/2014, this SII had fallen to -0.7 (95% CI -2.5 to 1.1) GPs per 100,000. The number of FTE GPs per 100,000 serving the most deprived fifth of small areas increased over this period from 54.0 to 60.5, while increasing from 57.2 to 59.9 in the least deprived fifth, so that by the end of the study period there were more GPs per 100,000 need adjusted population in the most deprived areas than in the least deprived. The increase in GP supply in the most deprived fifth of neighbourhoods was larger in areas that received targeted investment for establishing new practices under the 'Equitable Access to Primary Medical Care'. There was a substantial reduction in socioeconomic inequality in family physician supply associated with national policy. This policy may not have completely eliminated socioeconomic inequality in family physician supply since existing need adjustment formulae do not fully capture the additional burden of multimorbidity in deprived neighbourhoods. The small area approach introduced in this study can be used routinely to monitor socioeconomic inequality of access to primary care and to indicate workforce shortages in particular neighbourhoods. http://creativecommons.org/licenses/by/4.0. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to
Atanes, Ana C M; Andreoni, Solange; Hirayama, Marcio S; Montero-Marin, Jesús; Barros, Viviam V; Ronzani, Telmo M; Kozasa, Eliza H; Soler, Joaquim; Cebolla, Ausiàs; Garcia-Campayo, Javier; Demarzo, Marcelo M P
Primary health care professionals (PHPs) usually report high levels of distress and burnout symptoms related to job strain. Mindfulness, defined as non-judgmental-present-moment awareness, seems to be a moderator in the causal association between life stressors and well-being. This study aimed to verify correlations among self-reported mindfulness, perceived stress (PS), and subjective well-being (SW) in Brazilian PHPs. We performed a correlational cross-sectional study in a purposive sample of Brazilian PHPs (physicians, nurses, nursing assistants, and community health workers), working in community-oriented primary care programs (known locally as "Family Health Programs"). We used validated self-reporting instruments: the Mindful Attention Awareness Scale (MAAS), the Perceived Stress Scale (PSS), and the Subjective Well-being Scale (SWS). We performed a multivariate analysis of variance (MANOVA), through regression coefficients (beta) in relation to the professional category (nursing assistant), in addition to the length of time in the same job (under than 6 months) that had indicated the lowest level of PS. Participants (n=450) comprised community health workers (65.8%), nursing assistants (18%), registered nurses (10.0%), and doctors (family physicians) (6.0%); 94% were female and 83.1% had worked in the same position for more than one year. MANOVA regression analysis showed differences across professional categories and length of time in the same job position in relation to mindfulness, PS, and SW. Nurses demonstrated lower levels of mindfulness, higher PS, and SW negative affect, as well as lower SW positive affect. Being at work for 1 year or longer showed a clear association with higher PS and lower SW positive affect, and no significance with mindfulness levels. Pearson's coefficient values indicated strong negative correlations between mindfulness and PS, and medium correlations between mindfulness and SW. In this study, there were clear correlations
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
Burn, Anne-Marie; Fleming, Jane; Brayne, Carol; Fox, Chris; Bunn, Frances
In 2012-2013, the English National Health Service mandated hospitals to conduct systematic case-finding of people with dementia among older people with unplanned admissions. The method was not defined. The aim of this study was to understand current approaches to dementia case-finding in acute hospitals in England and explore the views of healthcare professionals on perceived benefits and challenges. Qualitative study involving interviews, focus groups and thematic content analysis. Primary care and secondary care across six counties in the East of England. Hospital staff involved in dementia case-finding and primary care staff in the catchment areas of those hospitals. We recruited 23 hospital staff and 36 primary care staff, including 30 general practitioners (GPs). Analysis resulted in three themes: (1) lack of consistent approaches in case-finding processes, (2) barriers between primary care and secondary care which impact on case-finding outcomes and (3) perceptions of rationale, aims and impacts of case-finding. The study shows that there were variations in how well hospitals recorded and reported outcomes to GPs. Barriers between primary care and secondary care, including GPs' lack of access to hospital investigations and lack of clarity about roles and responsibilities, impacted case-finding outcomes. Staff in secondary care were more positive about the initiative than primary care staff, and there were conflicting priorities for primary care and secondary care regarding case-finding. The study suggests a more evidence-based approach was needed to justify approaches to dementia case-finding. Information communicated to primary care from hospitals needs to be comprehensive, appropriate and consistent before GPs can effectively plan further investigation, treatment or care. Follow-up in primary care further requires access to options for postdiagnostic support. There is a need to evaluate the outcomes for patients and the economic impact on health and care
Aim To determine the effectiveness of primary care chaplaincy (PCC) when used as the sole intervention, with outcomes being compared directly with those of antidepressants. This was to be carried out in a homogenous study population reflective of certain demographics in the United Kingdom. Increasing numbers of patients are living with long-term conditions and 'modern maladies' and are experiencing loss of well-being and depression. There is an increasing move to utilise non-pharmacological interventions such as 'talking therapies' within this context. Chaplaincy is one such 'talking therapy' but within primary care its evidence base is sparse with only one quantitative study to date. There is therefore a need to evaluate PCC excluding those co-prescribed antidepressants, as this is not evidenced in the literature as yet. PCC also needs to be directly compared with the use of antidepressants to justify its use as a valid alternative treatment for loss of well-being and depression. This was a retrospective observational study based on routinely collected data. There were 107 patients in the PCC group and 106 in the antidepressant group. Socio-demographic data were collected. Their pre- and post-intervention (either chaplaincy or antidepressant) well-being was assessed, by the Warwick-Edinburgh Mental Well-being Scale (WEMWBS) which is a validated Likert scale. Findings The majority of both groups were female with both groups showing marked ethnic homogeneity. PCC was associated with a significant and clinically meaningful improvement in well-being at a mean follow-up of 80 days. This treatment effect was maintained after those co-prescribed antidepressants were removed. PCC was associated with an improvement in well-being similar to that of antidepressants with no significant difference between the two groups.
Fernald, Douglas H; Dickinson, L Miriam; Froshaug, Desireé B; Balasubramanian, Bijal A; Holtrop, Jodi Summers; Krist, Alex H; Glasgow, Russell E; Green, Larry A
Four health behaviors--smoking, risky drinking, physical inactivity, and unhealthy diets--contribute substantially to health care burden and are common among primary care patients. However, there is insufficient evidence to recommend broadly brief interventions to address all 4 of these in frontline primary care. This study took advantage of a multinetwork initiative to reflect on health behavior outcomes and the challenges of using a common set of measures to assess health behavior-change strategies for multiple health behaviors in routine primary care practice. Standardized, brief practical health behavior and quality of life measures used across 7 practice-based research networks (PBRNs) with independent primary care interventions in 54 primary care practices between August 2005 and December 2007 were analyzed. Mixed-effects longitudinal models assessed whether intervention patients improved diet, physical activity, smoking, alcohol consumption, and unhealthy days over time. Separate analyses were conducted for each intervention. Of 4463 adults, 2199 had follow-up data, and all available data were used in longitudinal analyses. Adjusting for age, race/ethnicity, education, and baseline body mass index where available, diet scores improved significantly in 5 of 7 networks (P practically in PBRNs testing diverse strategies to improve behaviors; however, variations in implementation, instrumentation performance, and some features of study design overwhelmed potential cross-PBRN comparisons. For common measures to be useful for comparisons across practices or PBRNs, greater standardization of study designs and careful attention to practicable implementation strategies are necessary.
Patel, Shireen; Kai, Joe; Atha, Christopher; Avery, Anthony; Guo, Boliang; James, Marilyn; Malins, Samuel; Sampson, Christopher James; Stubley, Michelle; Morriss, Richard K.
Background. Most frequent attendance in primary care is temporary, but persistent frequent attendance is expensive and may be suitable for psychological intervention. To plan appropriate intervention and service delivery, there is a need for research involving standardized psychiatric interviews with assessment of physical health and health status.\\ud \\ud Objective. To compare the mental and physical health characteristics and health status of persistent frequent attenders (FAs) in primary ca...
Sood, Rishi K; Bocour, Angelica; Kumar, Supriya; Guclu, Hasan; Potter, Margaret; Shah, Tanya B
Assess Hurricane Sandy's impact on primary care providers' services in the Rockaways. In-person surveys were conducted in 2014. A list of 46 health care sites in the area of interest was compiled and each site was called to offer participation in our survey. Respondents included physicians and practice administrators who remained familiar with Sandy-related operational challenges. Of the 40 sites that opted in, most had been in their current location for more than 10 years (73%) and were a small practice (1 or 2 physicians) before Hurricane Sandy (75%). All but 2 (95%) had to temporarily close or relocate. All sites experienced electrical problems that impacted landline, fax, and Internet. Less than one-quarter (n = 9) reported having a plan for continuity of services before Hurricane Sandy, and 43% reported having a plan poststorm. The majority (80%) did not report coordinating with other primary care stakeholders or receiving support from government agencies during the Sandy response. Hurricane Sandy significantly disrupted access to primary care in the Rockaways. Severe impact to site operations and infrastructure forced many practices to relocate. Greater emergency response and recovery planning is needed, including with government agencies, to minimize disruptions of access to primary care during disaster recovery. (Disaster Med Public Health Preparedness. 2016;10:492-495).
BACKGROUND: Although multimorbidity has important implications for patient care in general practice, limited research has examined chronic illness and health service utilisation among problem drug users. This study aimed to determine chronic illness prevalence and health service utilisation among problem drug users attending primary care for methadone treatment, to compare these rates with matched \\'controls\\' and to develop and pilot test a valid study instrument. METHODS: A cross-sectional study of patients attending three large urban general practices in Dublin, Ireland for methadone treatment was conducted, and this sample was compared with a control group matched by practice, age, gender and General Medical Services (GMS) status. RESULTS: Data were collected on 114 patients. Fifty-seven patients were on methadone treatment, of whom 52(91%) had at least one chronic illness (other then substance use) and 39(68%) were prescribed at least one regular medication. Frequent utilisation of primary care services and secondary care services in the previous six months was observed among patients on methadone treatment and controls, although the former had significantly higher chronic illness prevalence and primary care contact rates. The study instrument facilitated data collection that was feasible and with minimal inter-observer variation. CONCLUSION: Multimorbidity is common among problem drug users attending general practice for methadone treatment. Primary care may therefore have an important role in primary and secondary prevention of chronic illnesses among this population. This study offers a feasible study instrument for further work on this issue. (238 words).
BACKGROUND: Although multimorbidity has important implications for patient care in general practice, limited research has examined chronic illness and health service utilisation among problem drug users. This study aimed to determine chronic illness prevalence and health service utilisation among problem drug users attending primary care for methadone treatment, to compare these rates with matched \\'controls\\' and to develop and pilot test a valid study instrument. METHODS: A cross-sectional study of patients attending three large urban general practices in Dublin, Ireland for methadone treatment was conducted, and this sample was compared with a control group matched by practice, age, gender and General Medical Services (GMS) status. RESULTS: Data were collected on 114 patients. Fifty-seven patients were on methadone treatment, of whom 52(91%) had at least one chronic illness (other then substance use) and 39(68%) were prescribed at least one regular medication. Frequent utilisation of primary care services and secondary care services in the previous six months was observed among patients on methadone treatment and controls, although the former had significantly higher chronic illness prevalence and primary care contact rates. The study instrument facilitated data collection that was feasible and with minimal inter-observer variation. CONCLUSION: Multimorbidity is common among problem drug users attending general practice for methadone treatment. Primary care may therefore have an important role in primary and secondary prevention of chronic illnesses among this population. This study offers a feasible study instrument for further work on this issue. (238 words).
Abstract Background Many western countries have policies of dispersal and direct provision accommodation (state-funded accommodation in an institutional centre) for asylum seekers. Most research focuses on its effect on the asylum seeking population. Little is known about the impact of direct provision accommodation on organisation and delivery of local primary care and social care services in the community. The aim of this research is to explore this issue. Methods In 2005 a direct provision accommodation centre was opened in a rural area in Ireland. A retrospective qualitative case study was designed comprising in-depth interviews with 37 relevant stakeholders. Thematic analysis following the principles of framework analysis was applied. Results There was lack of advance notification to primary care and social care professionals and the community about the new accommodation centre. This caused anxiety and stress among relevant stakeholders. There was insufficient time to plan and prepare appropriate primary care and social care for the residents, causing a significant strain on service delivery. There was lack of clarity about how primary care and social care needs of the incoming residents were to be addressed. Interdisciplinary support systems developed informally between healthcare professionals. This ensured that residents of the accommodation centre were appropriately cared for. Conclusions Direct provision accommodation impacts on the organisation and delivery of local primary care and social care services. There needs to be sufficient advance notification and inter-agency, inter-professional dialogue to manage this. Primary care and social care professionals working with asylum seekers should have access to training to enhance their skills for working in cross-cultural consultations.
Pieper, Hans-Olaf; Clerkin, Pauline; MacFarlane, Anne
Many western countries have policies of dispersal and direct provision accommodation (state-funded accommodation in an institutional centre) for asylum seekers. Most research focuses on its effect on the asylum seeking population. Little is known about the impact of direct provision accommodation on organisation and delivery of local primary care and social care services in the community. The aim of this research is to explore this issue. In 2005 a direct provision accommodation centre was opened in a rural area in Ireland. A retrospective qualitative case study was designed comprising in-depth interviews with 37 relevant stakeholders. Thematic analysis following the principles of framework analysis was applied. There was lack of advance notification to primary care and social care professionals and the community about the new accommodation centre. This caused anxiety and stress among relevant stakeholders. There was insufficient time to plan and prepare appropriate primary care and social care for the residents, causing a significant strain on service delivery. There was lack of clarity about how primary care and social care needs of the incoming residents were to be addressed. Interdisciplinary support systems developed informally between healthcare professionals. This ensured that residents of the accommodation centre were appropriately cared for. Direct provision accommodation impacts on the organisation and delivery of local primary care and social care services. There needs to be sufficient advance notification and inter-agency, inter-professional dialogue to manage this. Primary care and social care professionals working with asylum seekers should have access to training to enhance their skills for working in cross-cultural consultations.
Full Text Available Abstract Background Many western countries have policies of dispersal and direct provision accommodation (state-funded accommodation in an institutional centre for asylum seekers. Most research focuses on its effect on the asylum seeking population. Little is known about the impact of direct provision accommodation on organisation and delivery of local primary care and social care services in the community. The aim of this research is to explore this issue. Methods In 2005 a direct provision accommodation centre was opened in a rural area in Ireland. A retrospective qualitative case study was designed comprising in-depth interviews with 37 relevant stakeholders. Thematic analysis following the principles of framework analysis was applied. Results There was lack of advance notification to primary care and social care professionals and the community about the new accommodation centre. This caused anxiety and stress among relevant stakeholders. There was insufficient time to plan and prepare appropriate primary care and social care for the residents, causing a significant strain on service delivery. There was lack of clarity about how primary care and social care needs of the incoming residents were to be addressed. Interdisciplinary support systems developed informally between healthcare professionals. This ensured that residents of the accommodation centre were appropriately cared for. Conclusions Direct provision accommodation impacts on the organisation and delivery of local primary care and social care services. There needs to be sufficient advance notification and inter-agency, inter-professional dialogue to manage this. Primary care and social care professionals working with asylum seekers should have access to training to enhance their skills for working in cross-cultural consultations.
Adams, Geoffrey; Gulliford, Martin; Ukoumunne, Obioha; Chinn, Susan; Campbell, Michael
To evaluate the extent to which structural variation between English general practices is accounted for at higher organisational levels in the National Health Service (NHS). We analysed data for 11 structural characteristics of all general practices in England. These included characteristics of general practitioners (GPs), the practice list and the services provided by practices. A four-level random effects model was used for analysis and components of variance were estimated at the levels of practice, primary care group (PCG), health authority and region. The proportion of single-handed practices ranged from 0% to 74% at PCG level and from 14% to 43% in different regions. The proportion of practices providing diabetes services ranged from 0% to 100% at PCG level and from 71% to 96% in different regions. The list size per GP ranged from 1314 to 2704 patients per GP at PCG level and from 1721 to 2225 at regional level. Across the 11 variables analysed, components of variance at general practice level accounted for between 43% and 95% of the total variance. The PCG level accounted for between 1% and 29%, the health authority level for between 2% and 15% and the regional level for between 0% and 13% of the total variance. Adjusting for an index of deprivation and the supply of GPs gave a median 8% decrease in the sum of variance components. Geographical and organisational variation in the structure of primary care services should be considered in designing studies in health systems such as the English NHS. Stratified designs may be used to increase study efficiency, but variation between areas may sometimes compromise generalisability.
Valentijn, Pim P; Vrijhoef, Hubertus J M; Ruwaard, Dirk; de Bont, Antoinette; Arends, Rosa Y; Bruijnzeels, Marc A
Forming partnerships is a prominent strategy used to promote integrated service delivery across health and social service systems. Evidence about the collaboration process upon which partnerships evolve has rarely been addressed in an integrated-care setting. This study explores the longitudinal relationship of the collaboration process and the influence on the final perceived success of a partnership in such a setting. The collaboration process through which partnerships evolve is based on a conceptual framework which identifies five themes: shared ambition, interests and mutual gains, relationship dynamics, organisational dynamics and process management. Fifty-nine out of 69 partnerships from a national programme in the Netherlands participated in this survey study. At baseline, 338 steering committee members responded, and they returned 320 questionnaires at follow-up. Multiple-regression-analyses were conducted to explore the relationship between the baseline as well as the change in the collaboration process and the final success of the partnerships. Mutual gains and process management were the most significant baseline predictors for the final success of the partnership. A positive change in the relationship dynamics had a significant effect on the final success of a partnership. Insight into the collaboration process of integrated primary care partnerships offers a potentially powerful way of predicting their success. Our findings underscore the importance of monitoring the collaboration process during the development of the partnerships in order to achieve their full collaborative advantage.
Zou, Yaming; Zhang, Xiao; Hao, Yuantao; Shi, Leiyu; Hu, Ruwei
The primary care in China can be provided by general practitioners (GPs) and other physicians (non-GPs). However, China's general practice system has never been really established. Chinese patients tend to consider the quality of primary care provided by GPs much lower than that of non-GPs. Besides, many GPs presently prefer leaving their own positions and seeking better development in big hospitals, which has made the already weak GP system weaker. Yet, few studies have specially compared the quality of primary care provided by Chinese GPs and other physicians and no studies have explored the independent predictors of Chinese GPs' intentions to stay on their current job. In this study, we aimed to compare the quality of primary care offered by GPs with non-GPs and to explore the independent predictors of GPs' future work intentions. This cross-sectional study applied multi-stage random cluster sampling methodology. The data were collected from November 2013 to September 2014 in Guangdong Province. In total, 401 effective questionnaires were selected from the physicians. Quality of primary care was assessed using the Primary Care Assessment Tool (PCAT) Provider Part, representing six primary care domains: ongoing care, coordination (i.e., referrals and information systems), comprehensiveness (i.e., service available and service provided), family-centeredness, community orientation and cultural competence. Of 401 participating physicians, 163 (40.6 %) were GPs. The total PCAT score was 26.32 ± 2.24 which was the sum score of the six domains and represent the quality of primary care. GPs achieved significantly different total scores and scores on three individual scales: comprehensiveness: service available, comprehensiveness: service provided and community orientation. Multiple linear regressions revealed GPs had a higher total score and scores for comprehensiveness: service provided and community orientation after adjusting for sociodemographic characteristics
Goh, Teik T; Eccles, Martin P
Attributes of teams could affect the quality of care delivered in primary care. The aim of this study was to systematically review studies conducted within the UK NHS primary care that have measured team climate using the Team Climate Inventory (TCI), and to describe, if reported, the relationship between the TCI and measures of quality of care. The databases MEDLINE, EMBASE, and CINAHL were searched. The reference lists of included article were checked and one relevant journal was hand-searched. Eight papers were included. Three studies used a random sample; the remaining five used convenience or purposive samples. Six studies were cross sectional surveys, whilst two were before and after studies. Four studies examined the relationship between team climate and quality of care. Only one study found a positive association between team climate and higher quality care in patients with diabetes, positive patient satisfaction and self-reported effectiveness. While the TCI has been used to measure team attributes in primary care settings in the UK it is difficult to generalise from these data. A small number of studies reported higher TCI scores being associated with only certain aspects of quality of care; reasons for the pattern of association are unclear. There are a number of methodological challenges to conducting such studies in routine service settings. Further research is needed in order to understand how to measure team functioning in relation to quality of care.
Goh Teik T
Full Text Available Abstract Background Attributes of teams could affect the quality of care delivered in primary care. The aim of this study was to systematically review studies conducted within the UK NHS primary care that have measured team climate using the Team Climate Inventory (TCI, and to describe, if reported, the relationship between the TCI and measures of quality of care. Findings The databases MEDLINE, EMBASE, and CINAHL were searched. The reference lists of included article were checked and one relevant journal was hand-searched. Eight papers were included. Three studies used a random sample; the remaining five used convenience or purposive samples. Six studies were cross sectional surveys, whilst two were before and after studies. Four studies examined the relationship between team climate and quality of care. Only one study found a positive association between team climate and higher quality care in patients with diabetes, positive patient satisfaction and self-reported effectiveness. Conclusion While the TCI has been used to measure team attributes in primary care settings in the UK it is difficult to generalise from these data. A small number of studies reported higher TCI scores being associated with only certain aspects of quality of care; reasons for the pattern of association are unclear. There are a number of methodological challenges to conducting such studies in routine service settings. Further research is needed in order to understand how to measure team functioning in relation to quality of care.
Czabanowska, Katarzyna; Burazeri, Genc; Klemenc-Ketis, Zalika; Kijowska, Violetta; Tomasik, Tomasz; Brand, Helmut
in which general practice/family medicine operates and, eventually, this gap analysis will set out strategically important areas for collaborative efforts related to QI in primary care. The authors consider that the study should be extended to other European countries to help identify most required competencies that GPs/FDs should possess in Europe and thus stir system and educational debate around QI curricula and training for primary care in Europe.
Weltermann, Birgitta; Kersting, Christine
Care for seniors is complex because patients often have more than one disease, one medication, and one physician. It is a key challenge for primary care physicians to structure the various aspects of each patient's care, to integrate each patient's preferences, and to maintain a long-term overview. This article describes the design for the development and feasibility testing of the clinical decision support system (CDSS) eCare*Seniors© which is electronic health record (EHR)-based allowing for a long-term, comprehensive, evidence-based, and patient preference-oriented management of multimorbid seniors. This mixed-methods study is designed in three steps. First, focus groups and practice observations will be conducted to develop criteria for software design from a physicians' and practice assistants' perspective. Second, based on these criteria, a CDSS prototype will be developed. Third, the prototype's feasibility will be tested by five primary care practices in the care of 30 multimorbid seniors. Primary outcome is the usability of the software measured by the validated system usability scale (SUS) after 3 months. Secondary outcomes are the (a) willingness to routinely use the CDSS, (b) degree of utilization of the CDSS, (c) acceptance of the CDSS, (d) willingness of the physicians to purchase the CDSS, and (e) willingness of the practice assistants to use the CDSS in the long term. These outcomes will be measured using semi-structured interviews and software usage data. If the SUS score reaches ≥70 %, feasibility testing will be judged successful. Otherwise, the CDSS prototype will be refined according to the users' needs and retested by the physicians and practice assistants until it is fully adapted to their requirements and reaches a usability score ≥70 %. The study will support the development of a CDSS which is primary care-defined, user-friendly, easy-to-comprehend, workflow-oriented, and comprehensive. The software will assist physicians and
Fagnan, Lyle J; Walunas, Theresa L; Parchman, Michael L; Dickinson, Caitlin L; Murphy, Katrina M; Howell, Ross; Jackson, Kathryn L; Madden, Margaret B; Ciesla, James R; Mazurek, Kathryn D; Kho, Abel N; Solberg, Leif I
The methods and costs to enroll small primary care practices in large, regional quality improvement initiatives are unknown. We describe the recruitment approach, cost, and resources required to recruit and enroll 500 practices in the Northwest and Midwest regional cooperatives participating in the Agency for Healthcare Research and Quality (AHRQ)-funded initiative, EvidenceNOW: Advancing Heart Health in Primary Care. The project management team of each cooperative tracked data on recruitment methods used for identifying and connecting with practices. We developed a cost-of-recruitment template and used it to record personnel time and associated costs of travel and communication materials. A total of 3,669 practices were contacted during the 14- to 18-month recruitment period, resulting in 484 enrolled practices across the 6 states served by the 2 cooperatives. The average number of interactions per enrolled practice was 7, with a total of 29,100 hours and a total cost of $2.675 million, or $5,529 per enrolled practice. Prior partnerships predicted recruiting almost 1 in 3 of these practices as contrasted to 1 in 20 practices without a previous relationship or warm hand-off. Recruitment of practices for large-scale practice quality improvement transformation initiatives is difficult and costly. The cost of recruiting practices without existing partnerships is expensive, costing 7 times more than reaching out to familiar practices. Investigators initiating and studying practice quality improvement initiatives should budget adequate funds to support high-touch recruitment strategies, including building trusted relationships over a long time frame, for a year or more. © 2018 Annals of Family Medicine, Inc.
Clark, Christopher E; Taylor, Rod S; Shore, Angela C; Campbell, John L
To determine whether a difference in systolic blood pressure readings between arms can predict a reduced event free survival after 10 years. Cohort study. Rural general practice in Devon, United Kingdom. 230 people receiving treatment for hypertension in primary care. Bilateral blood pressure measurements recorded at three successive surgery attendances. Cardiovascular events and deaths from all causes during a median follow-up of 9.8 years. At recruitment 24% (55/230) of participants had a mean interarm difference in systolic blood pressure of 10 mm Hg or more and 9% (21/230) of 15 mm Hg or more; these differences were associated with an increased risk of all cause mortality (adjusted hazard ratio 3.6, 95% confidence interval 2.0 to 6.5 and 3.1, 1.6 to 6.0, respectively). The risk of death was also increased in 183 participants without pre-existing cardiovascular disease with an interarm difference in systolic blood pressure of 10 mm Hg or more or 15 mm Hg or more (2.6, 1.4 to 4.8 and 2.7, 1.3 to 5.4). An interarm difference in diastolic blood pressure of 10 mm Hg or more was weakly associated with an increased risk of cardiovascular events or death. Differences in systolic blood pressure between arms can predict an increased risk of cardiovascular events and all cause mortality over 10 years in people with hypertension. This difference could be a valuable indicator of increased cardiovascular risk. Bilateral blood pressure measurements should become a routine part of cardiovascular assessment in primary care.
Lindenmeyer, Antje; Redwood, Sabi; Griffith, Laura; Teladia, Zaheera; Phillimore, Jenny
The main objectives of the study were to explore the experiences of primary care professionals providing care to recent migrants in a superdiverse city and to elicit barriers and facilitators to meeting migrants' care needs. This paper focuses on a strong emergent theme: participants' descriptions and understandings of creating a fit between patients and practices. An exploratory, qualitative study based on the thematic analysis of semistructured interviews. A purposive sample of 10 practices. We interviewed 6 general practitioners, 5 nurses and 6 administrative staff; those based at the same practice opted to be interviewed together. 10 interviewees were from an ethnic minority background; some discussed their own experiences of migration. Creating a fit between patients and practice was complex and could be problematic. Some participants defined this in a positive way (reaching out, creating rapport) while others also focused on ways in which patients did not fit in, for example, different expectations or lack of medical records. A small but vocal minority put the responsibility to fit in on to migrant patients. Some participants believed that practice staff and patients sharing a language could contribute to achieving a fit but others outlined the disadvantages of over-reliance on language concordance. A clearly articulated, team-based strategy to create bridges between practice and patients was often seen as preferable. Although participants agreed that a fit between patients and practice was desirable, some aimed to adapt to the needs of recently arrived migrants, while others thought that it was the responsibility of migrants to adapt to practice needs; a few viewed migrant patients as a burden to the system. Practices wishing to improve fit might consider developing strategies such as introducing link workers and other 'bridging' people; however, they could also aim to foster a general stance of openness to diversity. Published by the BMJ Publishing Group
nurse conflict and poor teamwork. This may threaten attempts to re-engineer primary health care in order to increase the presence of doctors at clinic level. The discipline of family medicine can make a difference, but reorganisation of the system ...
Lower respiratory tract infections (LRTI) are among the most common diseases presented in primary care. When the general practitioner (GP) diagnoses an LRTI he or she is confronted with important clinical dilemmas concerning treatment and prognosis. Especially elderly are of importance, as the
Klein Woolthuis, E.P.; Grauw, W.J.C. de; Gerwen, W.H.E.M. van; Hoogen, H.J.M. van den; Lisdonk, E.H. van de; Metsemakers, J.F.M.; Weel, C. van
PURPOSE: In screening for type 2 diabetes, guidelines recommend targeting high-risk individuals. Our objectives were to assess the yield of opportunistic targeted screening for type 2 diabetes in primary care and to assess the diagnostic value of various risk factors. METHODS: In 11 family practices
Ruiz, Jorge G.; Qadri, S. Sobiya; Nader, Samir; Wang, Jia; Lawler, Timothy; Hagenlocker, Brian; Roos, Bernard A.
Clinicians managing older patients with chronic pain play an important role. This paper explores the attitudes of primary care clinicians (PCPs) toward chronic nonmalignant pain management and their experiences using a clinical decision support system. Our investigation followed a qualitative approach based on grounded theory. Twenty-one PCPs…
Full Text Available An association between depression and coronary heart disease is now accepted but there has been little primary care research on this topic. The UPBEAT-UK studies are centred on a cohort of primary patients with coronary heart disease assessed every six months for up to four years. The aim of this research was to determine the prevalence and associations of depression in this cohort at baseline.Participants with coronary heart disease were recruited from general practice registers and assessed for cardiac symptoms, depression, quality of life and social problems.803 people participated. 42% had a documented history of myocardial infarction, 54% a diagnosis of ischaemic heart disease or angina. 44% still experienced chest pain. 7% had an ICD-10 defined depressive disorder. Factors independently associated with this diagnosis were problems living alone (OR 5.49, 95% CI 2.11-13.30, problems carrying out usual activities (OR 3.71, 95% CI 1.93-7.14, experiencing chest pain (OR 3.27, 95% CI 1.58-6.76, other pains or discomfort (OR 3.39, 95% CI 1.42-8.10, younger age (OR 0.95 per year 95% CI 0.92-0.98.Problems living alone, chest pain and disability are important predictors of depression in this population.
Breysse, Cécile; Guillot, Pascale; Berrut, Gilles
Most of the elderly have vitamin D deficiency, which is defined as a serum level below 30 ng/mL. To identify the characteristics of patients over 65 receiving vitamin D supplements by their primary care physician. A descriptive and transverse study was performed on patients over 65 years old admitted to Care Following at the La Croix Rouge in Nantes from September 2012 to February 2013. The criteria for vitamin D supplementation, the type (vitamin D2 or D3, continuous prescription or not, route of administration) and starting date of vitamin D supplementation were identified. Serum 25-hydroxyvitamin D (25OHD) was measured at admission. Of 163 patients included, 44% received vitamin D supplements (n=71). The patient aged over 80 benefited more often from vitamin D supplementation (p=0.019), so did women (p=0.034), patients with fractures (p=0.05), patients with osteoporosis treatments (pvitamin D supplementation less often than the others (p=0.046). The dosage of the vitamin D was normal for 28% of patients (n=46). The prescription of vitamin D supplements to the elderly is still too scarce and should be encouraged, especially in non-bone indications.
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
Full Text Available Abstract Background Internet-administered cognitive behavioural therapy (ICBT has been found to be effective for a range of anxiety disorders. However, most studies have focused on one specific primary diagnosis and co-morbidity has not been considered. In primary care settings, patients with anxiety often suffer from more than one psychiatric condition, making it difficult to disseminate ICBT for specific conditions. The aim of this study will be to investigate if ICBT tailored according to symptom profile can be a feasible treatment for primary care patients with anxiety disorders. It is a randomised controlled trial aimed to evaluate the treatment against an active control group. Methods Participants with anxiety disorders and co-morbid conditions (N = 128, will be recruited from a primary care population. The Clinical Outcome in Routine Evaluation (CORE-OM will serve as the primary outcome measure. Secondary measures include self-reported depression, anxiety, quality of life and loss of production and the use of health care. All assessments will be collected via the Internet and measure points will be baseline, post treatment and 12 months post treatment. Discussion This trial will add to the body of knowledge on the effectiveness of ICBT for anxiety disorders in primary care. The trial will also add knowledge on the long term effects of ICBT when delivered for regular clinic patients Trial Registration ClinicalTrials.gov: NCT01390168
Pavlič, Danica R; Sever, Maja; Klemenc-Ketiš, Zalika; Švab, Igor; Vainieri, Milena; Seghieri, Chiara; Maksuti, Alem
AimWe sought to examine strength of primary care service delivery as measured by selected process indicators by general practitioners from 31 European countries plus Australia, Canada, and New Zealand. We explored the relation between strength of service delivery and healthcare expenditures. The strength of a country's primary care is determined by the degree of development of a combination of core primary care dimensions in the context of its healthcare system. This study analyses the strength of service delivery in primary care as measured through process indicators in 31 European countries plus Australia, New Zealand, and Canada. A comparative cross-sectional study design was applied using the QUALICOPC GP database. Data on the strength of primary healthcare were collected using a standardized GP questionnaire, which included 60 questions divided into 10 dimensions related to process, structure, and outcomes. A total of 6734 general practitioners participated. Data on healthcare expenditure were obtained from World Bank statistics. We conducted a correlation analysis to analyse the relationship between strength and healthcare expenditures.FindingsOur findings show that the strength of service delivery parameters is less than optimal in some countries, and there are substantial variations among countries. Continuity and comprehensiveness of care are significantly positively related to national healthcare expenditures; however, coordination of care is not.
Manniën, Judith; Klomp, Trudy; Wiegers, Therese; Pereboom, Monique; Brug, Johannes; de Jonge, Ank; van der Meijde, Margreeth; Hutton, Eileen; Schellevis, Francois; Spelten, Evelien
In the Netherlands, midwives are autonomous medical practitioners and 78% of pregnant women start their maternity care with a primary care midwife. Scientific research to support evidence-based practice in primary care midwifery in the Netherlands has been sparse. This paper describes the research design and methodology of the multicenter multidisciplinary prospective DELIVER study which is the first large-scale study evaluating the quality and provision of primary midwifery care. Between September 2009 and April 2011, data were collected from clients and their partners, midwives and other healthcare professionals across the Netherlands. Clients from twenty midwifery practices received up to three questionnaires to assess the expectations and experiences of clients (e.g. quality of care, prenatal screening, emotions, health, and lifestyle). These client data were linked to data from the Netherlands Perinatal Register and electronic client records kept by midwives. Midwives and practice assistants from the twenty participating practices recorded work-related activities in a diary for one week, to assess workload. Besides, the midwives were asked to complete a questionnaire, to gain insight into collaboration of midwives with other care providers, their tasks and attitude towards their job, and the quality of the care they provide. Another questionnaire was sent to all Dutch midwifery practices which reveals information regarding the organisation of midwifery practices, provision of preconception care, collaboration with other care providers, and provision of care to ethnic minorities. Data at client, midwife and practice level can be linked. Additionally, partners of pregnant women and other care providers were asked about their expectations and experiences regarding the care delivered by midwives and in six practices client consults were videotaped to objectively assess daily practice. In total, 7685 clients completed at least one questionnaire, 136 midwives and
Full Text Available Abstract Background In the Netherlands, midwives are autonomous medical practitioners and 78% of pregnant women start their maternity care with a primary care midwife. Scientific research to support evidence-based practice in primary care midwifery in the Netherlands has been sparse. This paper describes the research design and methodology of the multicenter multidisciplinary prospective DELIVER study which is the first large-scale study evaluating the quality and provision of primary midwifery care. Methods/Design Between September 2009 and April 2011, data were collected from clients and their partners, midwives and other healthcare professionals across the Netherlands. Clients from twenty midwifery practices received up to three questionnaires to assess the expectations and experiences of clients (e.g. quality of care, prenatal screening, emotions, health, and lifestyle. These client data were linked to data from the Netherlands Perinatal Register and electronic client records kept by midwives. Midwives and practice assistants from the twenty participating practices recorded work-related activities in a diary for one week, to assess workload. Besides, the midwives were asked to complete a questionnaire, to gain insight into collaboration of midwives with other care providers, their tasks and attitude towards their job, and the quality of the care they provide. Another questionnaire was sent to all Dutch midwifery practices which reveals information regarding the organisation of midwifery practices, provision of preconception care, collaboration with other care providers, and provision of care to ethnic minorities. Data at client, midwife and practice level can be linked. Additionally, partners of pregnant women and other care providers were asked about their expectations and experiences regarding the care delivered by midwives and in six practices client consults were videotaped to objectively assess daily practice. Discussion In total, 7685
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)
Whitford, David L
BACKGROUND: Stroke is a major cause of mortality and morbidity with potential for improved care and prevention through general practice. A national survey was undertaken to determine current resources and needs for optimal stroke prevention and care. METHODS: Postal survey of random sample of general practitioners undertaken (N = 204; 46% response). Topics included practice organisation, primary prevention, acute management, secondary prevention, long-term care and rehabilitation. RESULTS: Service organisation for both primary and secondary prevention was poor. Home management of acute stroke patients was used at some stage by 50% of responders, accounting for 7.3% of all stroke patients. Being in a structured cardiovascular management scheme, a training practice, a larger practice, or a practice employing a practice nurse were associated with structures and processes likely to support stroke prevention and care. CONCLUSION: General practices were not fulfilling their potential to provide stroke prevention and long-term management. Systems of structured stroke management in general practice are essential to comprehensive national programmes of stroke care.
Full Text Available Abstract Background Stroke is a major cause of mortality and morbidity with potential for improved care and prevention through general practice. A national survey was undertaken to determine current resources and needs for optimal stroke prevention and care. Methods Postal survey of random sample of general practitioners undertaken (N = 204; 46% response. Topics included practice organisation, primary prevention, acute management, secondary prevention, long-term care and rehabilitation. Results Service organisation for both primary and secondary prevention was poor. Home management of acute stroke patients was used at some stage by 50% of responders, accounting for 7.3% of all stroke patients. Being in a structured cardiovascular management scheme, a training practice, a larger practice, or a practice employing a practice nurse were associated with structures and processes likely to support stroke prevention and care. Conclusion General practices were not fulfilling their potential to provide stroke prevention and long-term management. Systems of structured stroke management in general practice are essential to comprehensive national programmes of stroke care.
Full Text Available This study is a prospective randomized double-blind controlled trial whose aim was to investigate the clinical effects of aromatic essential oils in patients with upper respiratory tract infections. The trial was conducted in six primary care clinics in northern Israel. A spray containing aromatic essential oils of five plants (Eucalyptus citriodora, Eucalyptus globulus, Mentha piperita, Origanum syriacum, and Rosmarinus officinalisas applied 5 times a day for 3 days and compared with a placebo spray. The main outcome measure was patient assessment of the change in severity of the most debilitating symptom (sore throat, hoarseness or cough. Sixty patients participated in the study (26 in the study group and 34 in the control group. Intention-to-treat analysis showed that 20 minutes following the spray use, participants in the study group reported a greater improvement in symptom severity compared to participants in the placebo group (=.019. There was no difference in symptom severity between the two groups after 3 days of treatment (=.042. In conclusion, spray application of five aromatic plants reported in this study brings about significant and immediate improvement in symptoms of upper respiratory ailment. This effect is not significant after 3 days of treatment.
Carrillo, I; Ferrús, L; Silvestre, C; Pérez-Pérez, P; Torijano, M L; Iglesias-Alonso, F; Astier, P; Olivera, G; Maderuelo-Fernández, J A
To identify the Spanish studies conducted since 2014 on second victims. Its main objective was to identify a global response to the second victim problem, assessing the impact of adverse events (AE) on caregivers and developing of a set of tools to reduce their impact. Descriptive studies in which a sample of managers and safety coordinators from Hospitals and Primary Care were surveyed to determine the activities being carried out as regards second victims, as well as a sample of health professionals to describe their experience as a second victims. Qualitative studies are included to design a guide of recommended actions following an AE, an online awareness program on this phenomenon, an application (app) with activities on safety that are the responsibility of the managers, and a web tool for the analysis of AEs. A total of 1,493 professionals (managers, safety coordinators and caregivers) from eight Spanish regions participated. The guide of recommendations, the online program, and the developed applications are accessible on the website: www.segundasvictimas.es, which has received more than 2,500 visits in one year. Study results represent a starting point in the study of the second victim phenomenon in Spain. The tools developed raise the awareness of the medical healthcare community about this problem, and provide professionals with basic skills to manage the impact of AEs. Copyright © 2016 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.
Moosa, Shabir; Wojczewski, Silvia; Hoffmann, Kathryn; Poppe, Annelien; Nkomazana, Oathokwa; Peersman, Wim; Willcox, Merlin; Derese, Anselme; Mant, David
Many low-income and middle-income countries globally are now pursuing ambitious plans for universal primary care, but are failing to deliver adequate care quality because of intractable human resource problems. To understand why migrant nurses and doctors from sub-Saharan Africa did not wish to take up available posts in primary and first-contact care in their home countries. Qualitative study of migrant health workers to Europe (UK, Belgium, and Austria) or southern Africa (Botswana and South Africa) from sub-Saharan Africa. Semi-structured interviews with 66 health workers (24 nurses and 42 doctors) from 18 countries between July 2011 and April 2012. Transcripts were analysed thematically using a framework approach. The reasons given for choosing not to work in primary care were grouped into three main analytic streams: poor working environment, difficult living experiences, and poor career path. Responders described a lack of basic medicines and equipment, an unmanageable workload, and lack of professional support. Many had concerns about personal security, living conditions (such as education for children), and poor income. Primary care was seen as lower status than hospital medicine, with lack of specialist training opportunities and more exposure to corruption. Clinicians are reluctant to work in the conditions they currently experience in primary care in sub-Saharan Africa and these conditions tend to get worse as poverty and need for primary care increases. This inverse primary care law undermines achievement of universal health coverage. Policy experience from countries outside Africa shows that it is not immutable. © British Journal of General Practice 2014.
Galvin, Sandra; Callan, Aoife; Cormican, Martin; Duane, Sinead; Bennett, Kathleen; Murphy, Andrew W; Vellinga, Akke
The increase in the spread of antimicrobial resistance (AMR) in bacterial pathogens and limited availability of new antimicrobials places immense pressure on general practitioners (GPs) to prescribe appropriately. Currently, electronic antimicrobial prescribing data is not routinely collected from GPs in Ireland for surveillance purposes to assess regional specific fluctuations or trends in antimicrobial prescribing. The current study aimed to address this issue by assessing the feasibility of remotely extracting antimicrobial prescribing data from primary care practices in Ireland, for the purpose of assessing prescribing quality using the European Surveillance of Antimicrobial Consumption (ESAC) drug specific quality indicators. Participating practices (n = 30) uploaded data to the Irish Primary Care Research Network (IPCRN). The IPCRN data extraction facility is integrated within the practice patient management software system and permitted the extraction of anonymised patient prescriptions for a one year period, from October 2012 to October 2013. The quality of antimicrobial prescribing was evaluated using the twelve ESAC drug specific quality indicators using the defined daily dose (DDD) per 1,000 inhabitants per day (DID) methodology. National and European prescribing surveillance data (based on total pharmacy sales) was obtained for a comparative analysis. Antimicrobial prescriptions (n = 57,079) for 27,043 patients were obtained from the thirty study practices for a one year period. On average, study practices prescribed a greater proportion of quinolones (37 % increase), in summer compared with winter months, a variation which was not observed in national and European data. In comparison with national data, study practices prescribed higher proportions of β-lactamase-sensitive penicillins (4.98 % vs. 4.3 %) and a greater use of broad spectrum compared to narrow-spectrum antimicrobials (ratio = 9.98 vs. 6.26) was observed. Study practices exceeded the
Quarry industry has become a major means of livelihood in Ebonyi state, but insufficient data exists on their operations ... of Dust Mask among Crushers of Selected Quarry (Crushed ... Journal of Community Medicine and Primary Health Care.
3Department of Community and Primary Health Care, College of Medicine, University of Lagos, Idiaraba, ... Some of the participants (45.3%) carry out physical exercises such as walking ..... hypertension, continuous effective management of.
2Primary Health Care Department, Ikpoba Okha Local Government Area, Benin City, ... selected from each of the ten wards in the LGA using multistage sampling technique. ..... Knowledge of HIV/AIDS Insurance Companies in Lagos State.
Ahmedov, Mohir; Green, Judith; Azimov, Ravshan; Avezova, Guloyim; Inakov, Sherzod; Mamatkulov, Bahrom
Uzbekistan has a well-developed primary care system, with universal access to care, but faces challenges in improving the quality of clinical care provided. This study aimed to identify barriers to quality improvement by focusing on one common condition, Chronic Heart Failure (CHF), for which there are evidence-based international guidelines for management. To identify the challenges to improving the quality of care for CHF in line with such guidelines we took a qualitative approach, interviewing 15 physicians and 30 patients in detail about their experiences of CHF management. Despite recent improvements to the training of primary care physicians, their access to up-to-date information was limited, and they were disproportionately reliant on information from pharmaceutical companies. The main barriers to implementing international standards of care were: reluctance of physicians (and patients) to abandon ineffective interventions; enduring, system-wide incentives for clinically unnecessary hospitalization; and the lack of structural support for evidence-based health services improvement. Patients were in general positive about adherence to medications, but faced some problems in affording drugs and hospital care. Future interventions to strengthen primary care should be implemented with evaluations of their impact on the processes and outcomes of care for chronic conditions.
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
Lord, Paul A; Willis, Thomas A; Carder, Paul; West, Robert M; Foy, Robbie
Recruitment of representative samples in primary care research is essential to ensure high-quality, generalizable results. This is particularly important for research using routinely recorded patient data to examine the delivery of care. Yet little is known about how different recruitment strategies influence the characteristics of the practices included in research. We describe three approaches for recruiting practices to data-sharing studies, examining differences in recruitment levels and practice representativeness. We examined three studies that included varying populations of practices from West Yorkshire, UK. All used anonymized patient data to explore aspects of clinical practice. Recruitment strategies were 'opt-in', 'mixed opt-in and opt-out' and 'opt-out'. We compared aggregated practice data between recruited and not-recruited practices for practice list size, deprivation, chronic disease management, patient experience and rates of unplanned hospital admission. The opt-out strategy had the highest recruitment (80%), followed by mixed (70%) and opt-in (58%). Practices opting-in were larger (median 7153 versus 4722 patients, P = 0.03) than practices that declined to opt-in. Practices recruited by mixed approach were larger (median 7091 versus 5857 patients, P = 0.04) and had differences in the clinical quality measure (58.4% versus 53.9% of diabetic patients with HbA1c ≤ 59 mmol/mol, P Researchers should, with appropriate ethical safeguards, consider opt-out recruitment of practices for studies involving anonymized patient data sharing. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: email@example.com.
Full Text Available CONTEXT: Febrile children in primary care have a low risk for serious infection. Although several alarming signs and symptoms are proposed to have predictive value for serious infections, most are based on research in secondary care. The frequency of alarming signs/symptoms has not been established in primary care; however, in this setting differences in occurrence may influence their predictive value for serious infections. OBJECTIVE: To determine the frequency of alarming signs/symptoms in febrile children in primary care. DESIGN: Observational cohort study. Clinical information was registered in a semi-structured way and manually recoded. SETTING: General practitioners' out-of-hours service. SUBJECTS: Face-to-face patient contacts concerning children (aged ≤16 years with fever were eligible for inclusion. MAIN OUTCOME MEASURES: Frequency of 18 alarming signs and symptoms as reported in the literature. RESULTS: A total of 10,476 patient contacts were included. The frequency of alarming signs/symptoms ranged from n = 1 (ABC instability; 40°C as reported by the parents; 12.9% to 8,647 contacts (parental concern; 82.5%. CONCLUSION: Although the prevalence of specific alarming signs/symptoms is low in primary care, ≥50% of children have one or more alarming signs/symptoms. There is a need to determine the predictive value of alarming signs/symptoms not only for serious infections in primary care, but as well for increased risk of a complicated course of the illness.
McMahon, S; Cusack, T; O'Donoghue, G
With the global shift in health care from secondary to primary care, employment opportunities for newly qualified physiotherapists are likely to be in the primary care setting. However, to date, undergraduate physiotherapy clinical education has been centred around secondary care, focusing on acute services in large teaching hospitals. For contemporary physiotherapists to become effective first-contact primary care providers, they need to be exposed to the primary care environment during their undergraduate education. To explore the concept and identify perceived barriers and facilitators to providing physiotherapy undergraduate clinical placements in the primary healthcare setting A three-round Delphi survey was used. Participants were asked to answer open-ended questions with regard to: (i) student preparation for and (ii) provision of primary care placements (Round 1). Content analysis was employed to identify key themes. These themes generated statements for Round 2. In Round 2, participants were asked to rate their level of agreement/disagreement with the generated statements. In Round 3, a final rating process was conducted. Level of consensus was established as ≥70% agreement, with an interquartile range of ≤1. One hundred and ninety-eight primary care physiotherapy staff. Barriers identified included shortage of resources (e.g. staff) and a lack of tradition; in other words, students are not traditionally educated in the primary care setting. Response rates were 60% (120/198), 70% (84/120) and 76% (64/84) for Rounds 1, 2 and 3, respectively. All seven key facilitators identified reached consensus. They included additional support for staff taking students and motivated students. This study revealed that there is support for the provision of physiotherapy clinical education in the primary care setting. Through careful consideration with clear planning and collaboration with all stakeholders, it may be possible to convert the main barriers identified into
Full Text Available Anjali Bhagra,1 Husnain Syed,1 Darcy A Reed,1 Thomas H Poterucha,1 Stephen S Cha,2 Tammy J Baumgartner,1 Paul Y Takahashi1 1Department of Internal Medicine, 2Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA Background: Musculoskeletal joint pain of varied etiology can be diagnosed and treated with joint and soft-tissue corticosteroid injections. Purpose: The purpose of our study was to compare patients’ bodily pain and quality of life (QOL, in addition to the procedural benefit and patient satisfaction, before and after musculoskeletal injections in the office setting. Patients and methods: Patients were eligible for recruitment if they were over age 18 and had an injection for musculoskeletal pain from a primary care provider in an office procedural practice. Included in our analysis were knee joint/bursa, trochanteric bursa, and shoulder joint/bursa injection sites. The variables measured were pain, benefit from the injection, QOL physical and mental components, and patient satisfaction. This was a retrospective cohort study approved by the institutional review board. Results: Patients’ pain was assessed by the patients using a six-point Likert scale (none, very mild, mild, moderate, severe, and very severe. We noted that self-perception of pain decreased from 3.10 (± standard deviation at baseline 0.96 before to 2.36 (± standard deviation after the infection 1.21 (P = 0.0001 after the injection. In terms of the impact on QOL, our patients had a pre-injection physical score of 37.25 ± 8.39 and a mental score at 52.81 ± 8.98. After the injections, the physical score improved to 42.35 ± 9.07 (P = 0.0001 and the mental to 53.54 ± 8.20 (P = 0.0001 for the overall group. Ninety-six percent of the patients reported they were satisfied or extremely satisfied in the procedure clinic. Conclusion: In this study, we found significant pain relief and improved physical QOL in patients undergoing an injection in the knee
Adam, Rosalind; Wassell, Patrick; Murchie, Peter
Identifying why patients with cancer seek out-of-hours (OOH) primary medical care could highlight potential gaps in anticipatory cancer care. To explore the reasons for contact and the range and prevalence of presenting symptoms in patients with established cancer who presented to a primary care OOH department. A retrospective review of 950 anonymous case records for patients with cancer who contacted the OOH general practice service in Grampian, Scotland between 1 January 2010 and 31 December 2011. Subjects were identified by filtering the OOH computer database using the Read Codes 'neoplasm', 'terminal care', and 'terminal illness'. Consultations by patients without cancer and repeated consultations by the same patient were excluded. Data were anonymised. Case records were read independently by two authors who determined the presenting symptom(s). Anonymous case records were reviewed for 950 individuals. Eight hundred and fifty-two patients made contact because of a symptom. The remaining 97 were mostly administrative and data were missing for one patient. The most frequent symptoms were pain (n = 262/852, 30.8%); nausea/vomiting (n = 102/852, 12.0%); agitation (n = 53/852, 6.2%); breathlessness (n = 51/852, 6.0%); and fatigue (n = 48/852, 5.6%). Of the 262 patients who presented with pain, at least 127 (48.5%) had metastatic disease and 141 (53.8%) were already prescribed strong opiate medication. Almost one-third of patients with cancer seeking OOH primary medical care did so because of poorly controlled pain. Pain management should specifically be addressed during routine anticipatory care planning.
Vázquez-López, María Esther; Fernández, Gonzalo; Díaz, Pablo; Díez-Morrondo, Carolina; Pego-Reigosa, Robustiano; Coira-Nieto, Amparo
The main aim of this study was to determine the usefulness of an early diagnosis of Lyme disease (LD) in Primary Health Care Centres (PHCC) using the ELISA test as serological screening technique. A retrospective study (2006-2013) was performed in order to determine the anti-Borrelia seropositivity in 2,842 people at risk of having LD. The possible relationship between the environment and the area of residence with anti-Borrelia seropositivity was also studied according to the origin of the specimens (PHCC/Hospital). Overall, 15.2% of samples were positive to Borrelia spp. Seropositivity was significantly higher in samples sent by PHCC doctors than those sent by Hospital doctors. Seropositivity was significantly higher in rural than in urban populations and in those who live in mountainous or flat areas. The percentage of seropositivity has increased over the years. The role of the PHCC doctor is essential for achieving an early diagnosis of Lyme disease, as a higher percentage of seropositives was detected in samples submitted from PHCC. Furthermore, most early localised LD patients were diagnosed in PHCC, avoiding the appearance of sequelae. Therefore, detection of Borrelia specific antibodies using an ELISA assay is a useful screening test for patients at risk of LD. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.
Valentijn, Pim P; Ruwaard, Dirk; Vrijhoef, Hubertus J M; de Bont, Antoinette; Arends, Rosa Y; Bruijnzeels, Marc A
Collaborative partnerships are considered an essential strategy for integrating local disjointed health and social services. Currently, little evidence is available on how integrated care arrangements between professionals and organisations are achieved through the evolution of collaboration processes over time. The first aim was to develop a typology of integrated care projects (ICPs) based on the final degree of integration as perceived by multiple stakeholders. The second aim was to study how types of integration differ in changes of collaboration processes over time and final perceived effectiveness. A longitudinal mixed-methods study design based on two data sources (surveys and interviews) was used to identify the perceived degree of integration and patterns in collaboration among 42 ICPs in primary care in The Netherlands. We used cluster analysis to identify distinct subgroups of ICPs based on the final perceived degree of integration from a professional, organisational and system perspective. With the use of ANOVAs, the subgroups were contrasted based on: 1) changes in collaboration processes over time (shared ambition, interests and mutual gains, relationship dynamics, organisational dynamics and process management) and 2) final perceived effectiveness (i.e. rated success) at the professional, organisational and system levels. The ICPs were classified into three subgroups with: 'United Integration Perspectives (UIP)', 'Disunited Integration Perspectives (DIP)' and 'Professional-oriented Integration Perspectives (PIP)'. ICPs within the UIP subgroup made the strongest increase in trust-based (mutual gains and relationship dynamics) as well as control-based (organisational dynamics and process management) collaboration processes and had the highest overall effectiveness rates. On the other hand, ICPs with the DIP subgroup decreased on collaboration processes and had the lowest overall effectiveness rates. ICPs within the PIP subgroup increased in control
Background Chronic pelvic pain (CPP) has a prevalence similar to asthma and chronic back pain, but little is known about how general practitioners (GPs) and practice nurses manage women with this problem. A clearer understanding of current management is necessary to develop appropriate strategies, in keeping with current health care policy, for the supported self-management of patients with long term conditions. The aim of this study was to explore GPs' and practice nurses' understanding and perspectives on the management of chronic pelvic pain. Methods Data were collected using semi-structured interviews with a purposive sample of 21 GPs and 20 practice nurses, in three primary care trusts in the North West of England. Data were analysed using the principles of Framework analysis. Results Analysis suggests that women who present with CPP pose a challenge to GPs and practice nurses. CPP is not necessarily recognized as a diagnostic label and making the diagnosis was achieved only by exclusion. This contrasts with the relative acceptability of labels such as irritable bowel syndrome (IBS). GPs expressed elements of therapeutic nihilism about the condition. Despite practice nurses taking on increasing responsibilities for the management of patients with long term conditions, respondents did not feel that CPP was an area that they were comfortable in managing. Conclusions The study demonstrates an educational/training need for both GPs and practice nurses. GPs described a number of skills and clinical competencies which could be harnessed to develop a more targeted management strategy. There is potential to develop facilitated self- management for use in this patient group, given that this approach has been successful in patients with similar conditions such as IBS. PMID:20105323
Full Text Available Abstract Background Chronic pelvic pain (CPP has a prevalence similar to asthma and chronic back pain, but little is known about how general practitioners (GPs and practice nurses manage women with this problem. A clearer understanding of current management is necessary to develop appropriate strategies, in keeping with current health care policy, for the supported self-management of patients with long term conditions. The aim of this study was to explore GPs' and practice nurses' understanding and perspectives on the management of chronic pelvic pain. Methods Data were collected using semi-structured interviews with a purposive sample of 21 GPs and 20 practice nurses, in three primary care trusts in the North West of England. Data were analysed using the principles of Framework analysis. Results Analysis suggests that women who present with CPP pose a challenge to GPs and practice nurses. CPP is not necessarily recognized as a diagnostic label and making the diagnosis was achieved only by exclusion. This contrasts with the relative acceptability of labels such as irritable bowel syndrome (IBS. GPs expressed elements of therapeutic nihilism about the condition. Despite practice nurses taking on increasing responsibilities for the management of patients with long term conditions, respondents did not feel that CPP was an area that they were comfortable in managing. Conclusions The study demonstrates an educational/training need for both GPs and practice nurses. GPs described a number of skills and clinical competencies which could be harnessed to develop a more targeted management strategy. There is potential to develop facilitated self- management for use in this patient group, given that this approach has been successful in patients with similar conditions such as IBS.
Lezaic, Visnja; Marinkovic, Jelena; Milutinovic, Zoran; Jovanovic-Vasiljevic, Nada; Vujicic, Vesna; Pejovic, Branka; Kalabic, Snezana; Djukanovic, Ljubica
In 2009, Belgrade nephrologists and general practitioners from thirteen health centers carried out screening for chronic kidney disease (CKD). Three years later, medical records of patients from four health centers participating in the screening study were retrospectively analyzed in order to check whether general practitioners had continued to control patients at risk for CKD in accordance with the recommendations provided. The study included 460 patients who visited their doctor at least once in the three-year period. Data on blood pressure, ACEI use, estimated glomerular filtration rate (eGFR) and comorbidities were taken from patients' medical records. Blood pressure was not recorded in any of the three years in 42.8% and eGFR in 36.7% of the patients, but blood pressure was registered every year in 7.8% and eGFR in 4.3% of them. Over the three years, the relative number of patients with recorded blood pressure decreased from 41.7% to 17.8%, and with recorded eGFR from 41.7% to 21.5%. Multivariate linear regression found that Health Center, systolic and diastolic blood pressure and presence of hypertension were negatively associated with number of years with recorded blood pressure. Health Center, systolic blood pressure and sum of years with recorded eGFR below 60 ml/min/1.73m 2 were associated with number of years with recorded eGFR. Under-recording of blood pressure and eGFR in primary care health centers suggests lack of adherence to current guidelines and insufficient care of CKD patients. This implies the necessity for continuous education of physicians.
Huijg, Johanna M; van der Zouwe, Nicolette; Crone, Mathilde R; Verheijden, Marieke W; Middelkoop, Barend J C; Gebhardt, Winifred A
The introduction of efficacious physical activity (PA) interventions in routine primary health care (PHC) is a complex process. Understanding factors influencing the process can enhance the development of successful introduction strategies. The aim of this qualitative study was to explore stakeholders' perceptions on factors influencing the introduction, i.e., adoption, implementation, and continuation, of PA interventions in PHC. Twenty-eight semistructured interviews were held with intervention managers, PHC advisors, intervention providers, and referring general practitioners of five PA interventions delivered in PHC. A theoretical framework on the introduction of innovations in health care was used to guide the data collection. Influencing factors were identified using thematic analysis. Stakeholders reported preconditions for the introduction of PA interventions in PHC (e.g., support, resources, and networks and collaborations), in addition to characteristics of PA interventions (e.g., compatibility, flexibility, and intervention materials) and characteristics of PHC professionals (e.g., knowledge, positive attitudes, and beliefs about capabilities) perceived to enhance the introduction process. Furthermore, they proposed strategies for the development of PA interventions (e.g., involvement of future stakeholders, full development, and refinement) and strategies to introduce PA interventions in PHC (e.g., training, assistance, and reinforcement). The majority of the influencing factors were discussed specifically in relation to one or two stages. This study presents an overview of factors that are perceived to influence the introduction of PA interventions in PHC. It underscores the importance of taking these factors into account when designing introduction strategies and of giving special attention to the distinct stages of the process.
Grant, Sabrina; Greenfield, Sheila M; Nouwen, Arie; McManus, Richard J
Self-monitoring blood pressure (SMBP) is becoming an increasingly prevalent practice in UK primary care, yet there remains little conceptual understanding of why patients with hypertension engage in self-monitoring. To identify psychological factors or processes prompting the decision to self-monitor blood pressure. A qualitative study of patients previously participating in a survey study about SMBP from four general practices in the West Midlands. Taped and transcribed in-depth interviews with 16 patients (6 currently monitoring, 2 used to self-monitor, and 8 had never self-monitored). Thematic analysis was undertaken. Three main themes emerged: 'self' and 'living with hypertension' described the emotional element of living with an asymptomatic condition; 'self-monitoring behaviour and medication' described overall views about self-monitoring, current practice, reasons for monitoring, and the impact on medication adherence; and 'the GP-patient transaction' described the power relations affecting decisions to self-monitor. Self-monitoring was performed by some as a protective tool against the fears of a silent but serious condition, whereas others self-monitor simply out of curiosity. People who self-monitored tended not to discuss this with their nurse or GP, partly due to perceiving minimal or no interest from their clinician about home monitoring, and partly due to fear of being prescribed additional medication. The decision to self-monitor appeared often to be an individual choice with no schedule or systems to integrate it with other medical care. Better recognition by clinicians that patients are self-monitoring, perhaps utilising the results in shared decision-making, might help integrate it into daily practice. © British Journal of General Practice 2015.
Twinn, Sheila; Thompson, David R; Lopez, Violeta; Lee, Diana T F; Shiu, Ann T Y
Different factors have been shown to influence the development of models of advanced nursing practice (ANP) in primary-care settings. Although ANP is being developed in hospitals in Hong Kong, China, it remains undeveloped in primary care and little is known about the factors determining the development of such a model. The aims of the present study were to investigate the contribution of different models of nursing practice to the care provided in primary-care settings in Hong Kong, and to examine the determinants influencing the development of a model of ANP in such settings. A multiple case study design was selected using both qualitative and quantitative methods of data collection. Sampling methods reflected the population groups and stage of the case study. Sampling included a total population of 41 nurses from whom a secondary volunteer sample was drawn for face-to-face interviews. In each case study, a convenience sample of 70 patients were recruited, from whom 10 were selected purposively for a semi-structured telephone interview. An opportunistic sample of healthcare professionals was also selected. The within-case and cross-case analysis demonstrated four major determinants influencing the development of ANP: (1) current models of nursing practice; (2) the use of skills mix; (3) the perceived contribution of ANP to patient care; and (4) patients' expectations of care. The level of autonomy of individual nurses was considered particularly important. These determinants were used to develop a model of ANP for a primary-care setting. In conclusion, although the findings highlight the complexity determining the development and implementation of ANP in primary care, the proposed model suggests that definitions of advanced practice are appropriate to a range of practice models and cultural settings. However, the findings highlight the importance of assessing the effectiveness of such models in terms of cost and long-term patient outcomes.
Ramirez, Veronica; Johnson, Emily; Gonzalez, Cesar; Ramirez, Vanessa; Rubino, Barbara; Rossetti, Gina
There is significant potential for mobile health technology to improve health outcomes for patients with chronic diseases. However, there is a need for further development of mobile health technology that would help to improve the health of lower-income communities. The study objective was to assess mobile phone and app usage among a culturally diverse patient population, and to determine whether patients would be interested in using mobile health technology to help manage their chronic diseases. An observational study was conducted with patients of the Internal Medicine resident primary care clinics of Los Angeles County and University of Southern California (LAC+USC) Medical Center. Self-reported information regarding demographics, current mobile phone usage, current mobile health app and social media usage, barriers to using mobile phones or mobile health apps, and interest in using a mobile health app was collected. Ninety-one percent of patients owned a mobile phone, with 76% (169/223) of these reporting having a mobile phone with Internet capability. Fifty-seven percent of subjects used mobile apps on their mobile phones, and 32% (41/130) of these used mobile apps related to their health. Eighty-six percent (207/241) of respondents voiced interest in using a mobile app to improve their health, and 40% (88/221) stated they would use such an app daily. Patients stated they would find the mobile health app most useful for nutrition, exercise, and obtaining general information on medical conditions. Despite the fact that the majority of our primary care patients were of lower socioeconomic status, they utilized mobile phones with Internet and mobile app capabilities to a great extent. There was substantial interest among our patients in using mobile health technology to both manage chronic disease and improve overall health. Given that cultural, educational, and socioeconomic disparities strongly correlate with higher rates of chronic diseases such as obesity
2Department of Community Medicine & Primary Care, Faculty of Clinical Sciences, ... It may result from road traffic accident, near saving basic principles in emergency care that even drowning, electric ... (4.3%) at place of work, 8 (11.4%) at.
Journal of Community Medicine and Primary Health Care. 26 (1) 12-20 .... large proportions of the population work in the poor people use health care services far less than. 19 ... hypertension, cancers and road traffic accidents) below 1 dollar ...
Wee, Liang En; Lim, Li Yan; Shen, Tong; Lee, Elis Yuexian; Chia, Yet Hong; Tan, Andrew Yen Siong; Koh, Gerald Choon-Huat
Cost and misperceptions may discourage lower income Singaporeans from utilizing primary care. We investigated sources of primary care in a low-income Singaporean community in a mixed-methods study. Residents of a low-income public rental flat neighbourhood were asked for sociodemographic details and preferred source of primary care relative to their higher income neighbours. In the qualitative component, interviewers elicited, from patients and health care providers, barriers/enablers to seeking care from Western-trained doctors. Interviewees were selected via purposive sampling. Transcripts were analyzed thematically, and iterative analysis was carried out using established qualitative method. Participation was 89.8% (359/400). Only 11.1% (40/359) preferred to approach Western-trained doctors, 29.5% (106/359) preferred alternative medicine, 6.7% (24/359) approached family/friends and 52.6% (189/359) preferred self-reliance. Comparing against higher income neighbours, rental flat residents were more likely to turn to alternative medicine and family members but less likely to turn to Western-trained doctors (P Self-reliance was perceived as acceptable for 'small' illnesses but not for 'big' ones, communal spirit was cited as a reason for consulting family/friends and social distance from primary care practitioners was highlighted as a reason for not consulting Western-trained doctors. Western-trained physicians are not the first choice of lower income Singaporeans for seeking primary care. Knowledge, primary care characteristics and costs were identified as potential barriers/enablers.
Full Text Available Objective: To detect some common microbial agents of female genital discharges in order to improve the current syndromic management of abnormal vaginal discharge. Methods: A prospective study of female genital swabs collected from Primary Health Care Centres, Jos, and analysed for microscopy, culture and sensitivity in Jos University Teaching Hospital, December 2006 to December 2007 was carried out. Results: Microbial agents were detected in 70% (700 of a total 1 000 female genital swabs studied. Candida species peaked with 42.0% (420 out of the 1000 samples, followed by Gardnerella vaginalis, an agent of bacterial vaginosis with 26.0%. The distribution of abnormal vaginal discharge was highest in young adults aged 21 to 30 years. Conclusions: It is concluded that abnormal vaginal discharge is most prevalent in the young sexually active age group with Candida species as the commonest agent. We recommend prevention, early diagnosis and prompt treatment of infective female genital discharge in order to reduce the menace of HIV transmission.
Le Roux, Emma; Powell, Kingsley; Banks, Jonathan P; Ridd, Mathew J
Eczema is common among children, and in the UK the majority are managed by GPs. The most common cause of poor disease control is incorrect use of topical treatments. There is a lack of research into the challenges faced by GPs in diagnosing and managing this condition. To explore the experiences of GPs in assessing and managing children with eczema. Qualitative study in primary care in England. Semi-structured interviews with 15 GPs were audiorecorded, transcribed verbatim, and analysed thematically using the framework method. GPs described a paucity of dermatology training. Although most GPs were confident diagnosing uncomplicated eczema, they reported using a trial-and-error approach to prescribing emollients, and were uncertain about quantities of topical treatments to issue. Mild and moderate potency topical corticosteroids (TCS) were commonly used, but most GPs lacked confidence in recommending potent TCS, and viewed parents or carers to be fearful of using all strengths of TCS. GPs perceived adherence to treatments to be low, but provision of information to support self-care was variable. Routine review of medication use or disease control was uncommon, which GPs attributed to service constraints. Participants' views on the causes and management of eczema were perceived to be at odds with parents and carers, who were said to be overly focused on an underlying cause, such as allergy. GP uncertainty in managing eczema, lack of routine information and review, and perceived dissonance with parents around causation and management may be contributing to low concordance with treatments. © British Journal of General Practice 2018.
Fernald, Douglas H; Wearner, Robyn; Dickinson, W Perry
The Health Information Technology for Economic and Clinical Health Act of 2009 provides for incentive payments through Medicare and Medicaid for clinicians who implement electronic health records (EHRs) and use this technology meaningfully to improve patient care. There are few comprehensive descriptions of how primary care practices achieve the meaningful use of clinical data, including the formal stage 1 meaningful use requirements. Evaluation of the Colorado Beacon Consortium project included iterative qualitative analysis of practice narratives, provider and staff interviews, and separate focus groups with quality improvement (QI) advisors and staff from the regional health information exchange (HIE). Most practices described significant realignment of practice priorities and aims, which often required substantial education and training of physicians and staff. Re-engineering office processes, data collection protocols, EHRs, staff roles, and practice culture comprised the primary effort and commitment to attest to stage 1 meaningful use and subsequent meaningful use of clinical data. While realizing important benefits, practices bore a significant burden in learning the true capabilities of their EHRs with little effective support from vendors. Attestation was an important initial milestone in the process, but practices faced substantial ongoing work to use their data meaningfully for patient care and QI. Key resources were instrumental to these practices: local technical EHR expertise; collaborative learning mechanisms; and regular contact and support from QI advisors. Meeting the stage 1 requirements for incentives under Medicare and Medicaid meaningful use criteria is the first waypoint in a longer journey by primary care practices to the meaningful use of electronic data to continuously improve the care and health of their patients. The intensive re-engineering effort for stage 1 yielded practice changes consistent with larger practice aims and goals
Bulbin, David; Denio, Alfred E; Berger, Andrea; Brown, Jason; Maynard, Carson; Sharma, Tarun; Kirchner, H Lester; Ayoub, William T
To pilot a primary care gout management improvement intervention. Two large primary care sites were selected: one underwent the intervention, the other, a control, underwent no intervention. The intervention consisted of: engagement of intervention site staff, surveys of provider performance improvement preferences, and onsite live and enduring online education. Electronic Health Record reminders were constructed. Both the intervention and control sites had 3 quality measures assessed monthly: percent of gout patients treated with urate lowering therapy, percent of treated patients monitored with serum urate, and percent of treated patients at target serum urate ≤ 6.0 mg/dl. The intervention site providers received monthly reports comparing their measures against their peers. By 6 months, the intervention site significantly improved all 3 gout performance measures. Percentage treated increased from 54.4 to 61.1%, OR 1.19 (95% CI 1.08, 1.31 and p-value management program can significantly improve primary care gout management performance. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
Janke, E Amy; Ramirez, Michelle L; Haltzman, Brittany; Fritz, Megan; Kozak, Andrea T
The aim of this research is to examine perceptions of those with comorbid chronic pain and obesity regarding their experience of comorbidity management in primary care settings. Chronic pain and obesity are common comorbidities frequently managed in primary care settings. Evidence suggests individuals with this comorbidity may be at risk for suboptimal clinical interactions; however, treatment experiences and preferences of those with comorbid chronic pain and obesity have received little attention. Semi-structured interviews conducted with 30 primary care patients with mean body mass index=36.8 and comorbid persistent pain. The constant comparative method was used to analyze data. Participants discussed frustration with a perceived lack of information tailored to their needs and a desire for a personalized treatment experience. Participants found available medical approaches unsatisfying and sought a more holistic approach to management. Discussions also focused around the need for providers to initiate efforts at education and motivation enhancement and to show concern for and understanding of the unique difficulties associated with comorbidity. Findings suggest providers should engage in integrated communication regarding weight and pain, targeting this multimorbidity using methods aligned with priorities discussed by patients.
Quanbeck, Andrew R; Gustafson, David H; Marsch, Lisa A; McTavish, Fiona; Brown, Randall T; Mares, Marie-Louise; Johnson, Roberta; Glass, Joseph E; Atwood, Amy K; McDowell, Helene
Healthcare reform in the United States is encouraging Federally Qualified Health Centers and other primary-care practices to integrate treatment for addiction and other behavioral health conditions into their practices. The potential of mobile health technologies to manage addiction and comorbidities such as HIV in these settings is substantial but largely untested. This paper describes a protocol to evaluate the implementation of an E-Health integrated communication technology delivered via mobile phones, called Seva, into primary-care settings. Seva is an evidence-based system of addiction treatment and recovery support for patients and real-time caseload monitoring for clinicians. Our implementation strategy uses three models of organizational change: the Program Planning Model to promote acceptance and sustainability, the NIATx quality improvement model to create a welcoming environment for change, and Rogers's diffusion of innovations research, which facilitates adaptations of innovations to maximize their adoption potential. We will implement Seva and conduct an intensive, mixed-methods assessment at three diverse Federally Qualified Healthcare Centers in the United States. Our non-concurrent multiple-baseline design includes three periods - pretest (ending in four months of implementation preparation), active Seva implementation, and maintenance - with implementation staggered at six-month intervals across sites. The first site will serve as a pilot clinic. We will track the timing of intervention elements and assess study outcomes within each dimension of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, including effects on clinicians, patients, and practices. Our mixed-methods approach will include quantitative (e.g., interrupted time-series analysis of treatment attendance, with clinics as the unit of analysis) and qualitative (e.g., staff interviews regarding adaptations to implementation protocol) methods, and assessment of
Hedenrud, Tove M; Svensson, Staffan A; Wallerstedt, Susanna M
Psychotropic drug prescribing is problematic and knowledge of factors affecting the initiation and maintenance of such prescribing is incomplete. Such knowledge could provide a basis for the design of interventions to change prescribing patterns for psychotropics. The aim of this study was to explore the views of general practitioners (GPs), GP interns, and heads of primary care units on factors affecting the prescribing of psychotropic drugs in primary care. We performed four focus group discussions in Gothenburg, Sweden, with a total of 21 participants (GPs, GP interns, and heads of primary care units). The focus group discussions were transcribed verbatim and analyzed using manifest content analysis. Three different themes emerged from the focus group discussions. The first theme Seeking care for symptoms, reflects the participants' understanding of why patients approach primary care and comprised categories such as knowledge, attitudes, and society and the media. The second theme, Lacking a framework, resources, and treatment alternatives, which reflects the conditions for the physician-patient interaction, comprised categories such as economy and resources, technology, and organizational aspects. The third theme, Restricting or maintaining prescriptions, with the subthemes Individual factors and External influences, reflects the physicians' internal decision making and comprised categories such as emotions, knowledge, and pharmaceutical industry. The results of the present study indicate that a variety of factors may affect the prescribing of psychotropic medications in primary care. Many factors were related to characteristics of the patient, the physician or their interaction, rather than the patients' medical needs per se. The results may be useful for interventions to improve psychotropic prescribing in primary care.
Full Text Available Abstract Background There is evidence to suggest that delivery of diabetes self-management support by diabetes educators in primary care may improve patient care processes and patient clinical outcomes; however, the evaluation of such a model in primary care is nonexistent in Canada. This article describes the design for the evaluation of the implementation of Mobile Diabetes Education Teams (MDETs in primary care settings in Canada. Methods/design This study will use a non-blinded, cluster-randomized controlled trial stepped wedge design to evaluate the Mobile Diabetes Education Teams' intervention in improving patient clinical and care process outcomes. A total of 1,200 patient charts at participating primary care sites will be reviewed for data extraction. Eligible patients will be those aged ≥18, who have type 2 diabetes and a hemoglobin A1c (HbA1c of ≥8%. Clusters (that is, primary care sites will be randomized to the intervention and control group using a block randomization procedure within practice size as the blocking factor. A stepped wedge design will be used to sequentially roll out the intervention so that all clusters eventually receive the intervention. The time at which each cluster begins the intervention is randomized to one of the four roll out periods (0, 6, 12, and 18 months. Clusters that are randomized into the intervention later will act as the control for those receiving the intervention earlier. The primary outcome measure will be the difference in the proportion of patients who achieve the recommended HbA1c target of ≤7% between intervention and control groups. Qualitative work (in-depth interviews with primary care physicians, MDET educators and patients; and MDET educators’ field notes and debriefing sessions will be undertaken to assess the implementation process and effectiveness of the MDET intervention. Trial registration ClinicalTrials.gov NCT01553266
de Jonge, Ank; Stuijt, Rosan; Eijke, Iva; Westerman, Marjan J
Continuity of care during labour is important for women. Women with an intrapartum referral from primary to secondary care look back more negatively on their birh experience compared to those who are not referred. It is not clear which aspects of care contribute to this negative birth experience. This study aimed to explore in-depth the experiences of women who were referred during labour from primary to secondary care with regard to the different aspects of continuity of care. A qualitative interview study was conducted in the Netherlands among women who were in primary care at the onset of labour and were referred to secondary care before the baby was born. Through purposive sampling 27 women were selected. Of these, nine women planned their birth at home, two in an alongside midwifery unit and 16 in hospital. Thematic analysis was used. Continuity of care was a very important issue for women because it contributed to their feeling of safety during labour. Important details were sometimes not handed over between professionals within and between primary and secondary care, in particular about women's personal preferences. In case of referral of care from primary to secondary care, it was important for women that midwives handed over the care in person and stayed until they felt safe with the hospital team. Personal continuity of care, in which case the midwife stayed until the end of labour, was highly appreciated but not always expected.Fear of transportion during or after labour was a reason for women to choose hospital birth but also to opt for home birth. Choice of place of birth emerged as a fluid concept; most women planned their place of birth during pregnancy and were aware that they would spend some time at home and possibly some time in hospital. In case of referral from primary to secondary care during labour, midwives should hand over their care in person and preferrably stay with women throughout labour. Planned place of birth should be regarded as a
The CUPCIG (CAM-Use in Primary Care in Germany) Study:Part I-Pain. Study Protocol of a Pilot-trial to Assess Feasibility, Acceptability and Perceived Effectiveness of CAM in Pain Disorders in Primary Care.
Schencking, Martin; Sönnichsen, Andreas; Bassüner, Susanne; Redaelli, Marcus
There is limited valid data available on CAM procedures for chronic joint and neuropathic pain in primary care in Germany. Indiviual CAM qualifications of the general practitioners (GPs) and the potential of cost reduction through CAM treatment are almost unknown. The aim of this pilot trial preceding the main study is to examine the survey mode, to estimate the response rate by GPs with or without an additional qualification for CAM, and to identify the status quo in therapeutic approaches for chronic pain disorders in primary care. This is a cross-sectional study with an ex post facto design among German GPs consisting of 2 parts: In a first step, a pilot trial precedes the main study targeting 200 GPs with and 200 GPs without additional qualification in CAM in a selected region. The results of the CUPCIG study comprise the distribution of pain types treated in primary care practices, the GPs' attitude toward complementary pain therapy, pharmacological or CAM treatment, the estimate of cost reduction through CAM treatment of pain, the application of diverse CAM procedures, and biographical data. The CUPCIG study serves to compile pain therapy approaches in primary care in Germany with respect to the individual CAM expertise of the GPs. © 2015 S. Karger GmbH, Freiburg.
Mosaku, Kolawole S; Wallymahmed, Akhtar H
World Health Organization (WHO) recommends integration of mental health services into primary health services; however attitude of primary health care workers is one barrier to this. A cross sectional survey using the Community Attitudes towards Mental Illness (CAMI) was done. One hundred and twenty primary care workers were randomly selected from three local government areas. Descriptive and inferential statistics were used in analyses. The results showed that most primary health care workers hold a benevolent (mean = 2.47, SD = 0.52) attitude towards the mentally ill. Workers with 10 years or more experience tend to have less authoritarian (t = 3.19, p = 0.01) and less social restrictive (t = 3.90, p = 0.01) attitudes towards the mentally ill. There were no significant differences in attitude by gender, marital status, or designation of health care workers. The study showed that primary care workers have attitudes similar to that seen in the general population.
project implementation. Discussion This pragmatic, stepped-wedge randomized controlled trial with both quantitative and process evaluations demonstrates innovative methods of implementing large-scale quality improvement and evidence-based approaches to care delivery. This is the first Canadian study to examine the impact of a large-scale multifaceted cardiovascular quality-improvement program in primary care. It is anticipated that through the evaluation of IDOCC, we will demonstrate an effective, practical, and sustainable means of improving the cardiovascular health of patients across Canada. Trial Registration ClinicalTrials.gov: NCT00574808
Hunt, D; Churchill, R
Anorexia is a leading cause of adolescent hospital admission and death from psychiatric disorder. Despite the potential role of general practitioners in diagnosis, appropriate referral and coordinating treatment, few existing studies provide fine-grained accounts of GPs' beliefs about anorexia. To identify GPs' understandings and experiences of diagnosing and managing patients with anorexia in primary care. Case-based focus groups with co-working general practitioners in the East Midlands region of England were used to explore attitudes towards issues common to patients with eating disorders. Group discussions were transcribed and analysed using corpus linguistic and discourse analytic approaches. Participants' discussion focused on related issues of making hesitant diagnoses, the utility of the body mass index, making referrals and overcoming patient resistance. Therapeutic relationships with patients with anorexia are considered highly complex, with participants using diagnostic tests as rhetorical strategies to help manage communicative obstacles. Overcoming patient repudiation and securing referrals are particular challenges with this patient group. Successfully negotiating these problems appears to require advanced communication skills.
Tam-Tham, Helen; Hemmelgarn, Brenda; Campbell, David; Thomas, Chandra; Quinn, Robert; Fruetel, Karen; King-Shier, Kathryn
Guideline committees have identified the need for research to inform the provision of conservative care for older adults with stage 5 chronic kidney disease (CKD) who have a high burden of comorbidity or functional impairment. We will use both qualitative and quantitative methodologies to provide a comprehensive understanding of barriers and facilitators to care for these patients in primary care. Our objectives are to (1) interview primary care physicians to determine their perspectives of conservative care for older adults with stage 5 CKD and (2) survey primary care physicians to determine the prevalence of key barriers and facilitators to provision of conservative care for older adults with stage 5 CKD. A sequential exploratory mixed methods design was adopted for this study. The first phase of the study will involve fundamental qualitative description and the second phase will be a cross-sectional population-based survey. The research is conducted in Alberta, Canada. The participants are primary care physicians with experience in providing care for older adults with stage 5 CKD not planning on initiating dialysis. The first objective will be achieved by undertaking interviews with primary care physicians from southern Alberta. Participants will be selected purposively to include physicians with a range of characteristics (e.g., age, gender, and location of clinical practice). Interviews will be recorded, transcribed verbatim, and analyzed using conventional content analysis to generate themes. The second objective will be achieved by undertaking a population-based survey of primary care physicians in Alberta. The questionnaire will be developed based on the findings from the qualitative interviews and pilot tested for face and content validity. Physicians will be provided multiple options to complete the questionnaire including mail, fax, and online methods. Descriptive statistics and associations between demographic factors and barriers and facilitators to
Van Son, Gabrielle E.; Hoek, Hans W.; Van Hoeken, Daphne; Schellevis, Francois G.; Van Furth, Eric F.
Objective To investigate primary care utilization between patients with an eating disorder (ED) and other patient groups, and between the ED subgroups anorexia nervosa (AN) and bulimia nervosa (BN). Method The present study was an observational casecontrol study. In total, 167 patients with ED were
Son, G.E. van; Hoek, H.W.; Hoeken, D. van; Schellevis, F.G.; Furth, E.F. van
Objective: To investigate primary care utilization between patients with an eating disorder (ED) and other patient groups, and between the ED subgroups anorexia nervosa (AN) and bulimia nervosa (BN). Method: The present study was an observational case–control study. In total, 167 patients with ED
Prins, Marijn A.; Verhaak, Peter F. M.; Hilbink-Smolders, Mirrian; Spreeuwenberg, Peter; Laurant, Miranda G. H.; van der Meer, Klaas; van Marwijk, Harm W. J.; Penninx, Brenda W. J. H.; Bensing, Jozien M.
Background: There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general
Prins, M.A.; Verhaak, P.F.; Hilbink-Smolders, M.; Spreeuwenberg, P.; Laurant, M.G.; van der Meer, K.; van Marwijk, H.W.J.; Penninx, B.W.J.H.; Bensing, J.M.
Background: There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general
Prins, M.A.; Verhaak, P.F.M.; Hilbink-Smolders, M.; Spreeuwenberg, P.; Laurant, M.G.H.; Meer, K. van der; Marwijk, H.W.J. van; Penninx, B.W.J.H.; Bensing, J.M.
Background: There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general
Bujold, Mathieu; Pluye, Pierre; Légaré, France; Haggerty, Jeannie; Gore, Genevieve C; Sherif, Reem El; Poitras, Marie-Eve; Beaulieu, Marie-Claude; Beaulieu, Marie-Dominique; Bush, Paula L; Couturier, Yves; Débarges, Beatrice; Gagnon, Justin; Giguère, Anik; Grad, Roland; Granikov, Vera; Goulet, Serge; Hudon, Catherine; Kremer, Bernardo; Kröger, Edeltraut; Kudrina, Irina; Lebouché, Bertrand; Loignon, Christine; Lussier, Marie-Therese; Martello, Cristiano; Nguyen, Quynh; Pratt, Rebekah; Rihoux, Benoit; Rosenberg, Ellen; Samson, Isabelle; Senn, Nicolas; Li Tang, David; Tsujimoto, Masashi; Vedel, Isabelle; Ventelou, Bruno; Wensing, Michel
Patients with complex care needs (PCCNs) often suffer from combinations of multiple chronic conditions, mental health problems, drug interactions and social vulnerability, which can lead to healthcare services overuse, underuse or misuse. Typically, PCCNs face interactional issues and unmet decisional needs regarding possible options in a cascade of interrelated decisions involving different stakeholders (themselves, their families, their caregivers, their healthcare practitioners). Gaps in knowledge, values clarification and social support in situations where options need to be deliberated hamper effective decision support interventions. This review aims to (1) assess decisional needs of PCCNs from the perspective of stakeholders, (2) build a taxonomy of these decisional needs and (3) prioritise decisional needs with knowledge users (clinicians, patients and managers). This review will be based on the interprofessional shared decision making (IP-SDM) model and the Ottawa Decision Support Framework. Applying a participatory research approach, we will identify potentially relevant studies through a comprehensive literature search; select relevant ones using eligibility criteria inspired from our previous scoping review on PCCNs; appraise quality using the Mixed Methods Appraisal Tool; conduct a three-step synthesis (sequential exploratory mixed methods design) to build taxonomy of key decisional needs; and integrate these results with those of a parallel PCCNs' qualitative decisional need assessment (semistructured interviews and focus group with stakeholders). This systematic review, together with the qualitative study (approved by the Centre Intégré Universitaire de Santé et Service Sociaux du Saguenay-Lac-Saint-Jean ethical committee), will produce a working taxonomy of key decisional needs (ontological contribution), to inform the subsequent user-centred design of a support tool for addressing PCCNs' decisional needs (practical contribution). We will adapt
Kaur, Gurpreet; Tee, Guat Hiong; Ariaratnam, Suthahar; Krishnapillai, Ambigga S; China, Karuthan
Background Diabetes mellitus is a highly prevalent condition in Malaysia, increasing from 11.6% in 2006 to 15.2% in 2011 among individuals 18 years and above. Co-morbid depression in diabetics is associated with hyperglycemia, diabetic complications and increased health care costs. The aims of this study are to determine the prevalence and predictors of depression, anxiety and stress symptoms in Type II diabetics attending government primary care facilities in the urban area of Klang Valley, ...
Almalki Mohammed J; FitzGerald Gerry; Clark Michele
Abstract Background Quality of work life (QWL) is defined as the extent to which an employee is satisfied with personal and working needs through participating in the workplace while achieving the goals of the organization. QWL has been found to influence the commitment and productivity of employees in health care organizations, as well as in other industries. However, reliable information on the QWL of primary health care (PHC) nurses is limited. The purpose of this study was to assess the Q...
Full Text Available Background The electronic medical records software of the Catalan Institute of Health has recently incorporated an electronic version of clinical practice guidelines (e-CPGs. This study aims to assess the impact of the implementation of e-CPGs on the diagnosis, treatment, control and management of hypercholesterolaemia, diabetes mellitus type 2 and hypertension.Methods Eligible study participants are those aged 35–74 years assigned to family practitioners (FPs of the Catalan Institute of Health. Routinely collected data from electronic primary care registries covering 80% of the Catalan population will be analysed using two approaches: (1 a cross-sectional study to describe the characteristics of the sample before e-CPG implementation; (2 a controlled before-and-after study with 1-year follow-up to ascertain the effect of e-CPG implementation. Patients of FPs who regularly use the e-CPGs will constitute the intervention group; the control group will comprise patients assigned to FPs not regularly using the e-CPG. The outcomes are: (1 suspected and confirmed diagnoses, (2 control of clinical variables, (3 requests for tests and (4 proportions of patients with adequate drug prescriptions.Results This protocol should represent a reproducible process to assess the impact of the implementation of e-CPGs. We anticipate reporting results in late 2013.Conclusion This project will assess the effectiveness of e-CPGs to improve clinical decisions and healthcare procedures in the three disorders analysed. The results will shed light on the use of evidence-based medicine to improve clinical practice of FPs.
Roche, M A; Duffield, C; Smith, J; Kelly, D; Cook, R; Bichel-Findlay, J; Saunders, C; Carter, D J
To explore the primary healthcare needs and health service use of homeless men in inner Sydney. People experiencing homelessness have greater health needs than the general population and place high demands on tertiary care, which is expensive and may not be the optimum service for their needs. Accessible, approachable and affordable primary healthcare services could improve the health of homeless persons and potentially decrease costs to the healthcare system. A multimethod design using a cross-sectional survey (n = 40) and administrative data (n = 2 707 daily summaries) collected from a nurse-led primary healthcare clinic for homeless men in Sydney. Survey respondents were aged 27-76 years. Health problems reflected multimorbidity, with mental health issues present in almost all respondents. The majority had attended the clinic more than 20 times in the past year and said the services, treatments and referrals helped them avoid the emergency department. Administrative data indicated that medication administration was the most frequent service provided. Referrals to other health services doubled over the 7-year period. Multiple morbidities, particularly mental health issues, are associated with homelessness. A proactive approach by nurses including preventative services appeared to overcome barriers to health service use. This nurse-led primary healthcare clinic highlights the importance of providing services to homeless men with multiple comorbidities. Respect and trust in addition to easy access to health services appear to be important facilitators of health service use. A greater number of primary health services that collaborate with specialist services, including nurse-led clinics, may facilitate health care for persons who are homeless, reducing the burden on acute services. © 2017 International Council of Nurses.
Abos Mendizabal, Galder; Nuño Solinís, Roberto; Zaballa González, Irune
A virtual professional community of practice (VCoP), HOBE+, has been set up to foster and facilitate innovation in primary care. It is aimed at all primary care professionals of the Basque Public Health Service (Osakidetza) in the provinces of Biscay and Araba. HOBE + is a VCoP that incorporates innovation management from the generation of ideas to their implementation in primary care practice. We used a case study method, based on the data provided by the technology platform that supports the VCoP, and from a survey completed by HOBE + users. The target population was all primary care staff (including all professional categories) from Araba and Biscay provinces of the Basque Country (Spain), who represent the target users of the VCoP. From a total of 5190 professionals across all the professional categories invited to join, 1627 (31.3%) actually registered in the VCoP and, during the study period, 90 (5.5% of the registered users) participated actively in some way. The total number of ideas proposed by the registered users was 133. Of these, 23 ideas (17.2%) are being implemented. Finally, 80% of the users who answered the satisfaction survey about their experience with HOBE + considered the initiative useful in order to achieve continuous improvement and real innovation in clinical and managerial processes. The experience shows that it is possible to create a virtual CoP for innovation in primary care where professionals from different professional categories propose ideas for innovation that are ultimately implemented.This manuscript objectives are to assess the process of developing and implementing a VCoP open to all primary care professionals in Osakidetza, including the take-up, participation and use of this VCoP in the first 15 months after its launch in October 2011. In addition, the usefulness of the VCoP was assessed through a survey gathering the opinions of the professionals involved.
Wong, Carmen Ka Man; Liu, Zhaomin; Butler, Chris C; Wong, Samuel Yeung Shan; Fung, Alice; Chan, Dicken; Yip, Benjamin Hon Kei; Kung, Kenny
Acute cough is a common reason to prescribe antibiotics in primary care. This study aimed to explore help-seeking and antibiotic prescribing for acute cough in Chinese primary care population. This is a prospective multicentre observational study that included adults presenting with acute cough. Clinicians recorded patients' presenting symptoms, examination findings and medication prescription. Patients completed symptom diaries for up to 28 days by charting their symptom severity and recovery. Adjusted binary logistic regression models identified factors independently associated with antibiotic prescription. Primary care clinicians (n=19) recruited 455 patients. A total of 321 patients (70.5%) returned their completed symptom diaries. Concern about illness severity (41.6%) and obtaining a prescription for symptomatic medications (45.9%), rather than obtaining a prescription for antibiotics, were the main reasons for consulting. Antibiotics were prescribed for 6.8% (n=31) of patients, of which amoxicillin was the most common antimicrobial prescribed (61.3%), as it was associated with clinicians' perception of benefit from antibiotic treatment (odds ratio (OR): 25.9, 95% confidence interval (CI): 6.7-101.1), patients' expectation for antibiotics (OR: 5.1, 95% CI: 1.7-11.6), anticipation (OR: 5.1, 95% CI: 1.6-15.0) and request for antibiotics (OR 15.7, 95% CI: 5.0-49.4), as well as the severity of respiratory symptoms (cough, sputum, short of breath and wheeze OR: 2.7-3.7, all Pantibiotic prescription rates between private primary care clinicians and public primary care clinicians (17.4 vs 1.6%, P=0.00). Symptomatic medication was prescribed in 98.0% of patients. Mean recovery was 9 days for cough and 10 days for all symptoms, which was not significantly associated with antibiotic treatment. Although overall antibiotic-prescribing rates were low, there was a higher rate of antibiotic prescribing among private primary care clinicians, which warrants further
Millán Núñez-Cortés, J; de la Figuera von Wichmann, M; Rodríguez de Miguel, M; Orera Peña, M L; Labrador Barba, E; Lería Gelabert, M
Cardiovascular diseases are the main cause of death in the Spanish population. The detection and control of cardiovascular risk factors are fundamental in the prevention of cardiovascular disease. The main objectives of this study are to analyse the attitudes and therapeutic decisions of Primary Care (PC) physicians when treating hypertension (HT) and diabetes mellitus type 2 (DM2), with the aim of establishing the situation and eventually proposing improvement strategies. A national ecological, multicentre, cross-sectional, and descriptive study was conducted in 2013. A questionnaire was used and 1,028 PC physicians took part in the study. A total of 92.9% of the investigators consulted have indicated that they follow the guidelines for evaluation, treatment, and diagnosis of HT, and 91.4% in the case of diabetes. The latter is diagnosed as a casual finding, while HT is diagnosed through active investigation in patients with other risk factors. Combined therapy takes more than 6 months to take effect in patients with HT, and between 8 and 9 months in diabetic patients. The percentage of non-compliance is similar (10-40%) in both pathologies. Around half the physicians questioned considered interaction with the specialist to be good or excellent (46% HT and 57.3% DM2). Clinical practices in PC for HT and DM2 have some basic criteria in common. The interaction with the specialist is good, but there is a considerable margin for improvement. Copyright © 2016 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
Davies-Kershaw, Hilary; Petersen, Irene; Nazareth, Irwin; Stevenson, Fiona
Drug misuse is a serious public health problem. Evidence from previous epidemiological studies show that GPs are recording drug misuse in electronic patient records (EPR). However, although the recording trends are similar to national surveys, recording rates are much lower. To explore the factors that influence GPs to record drug misuse in the EPR, and to gain a clearer understanding of the gap between the amount of drug misuse recorded in primary care and that in national surveys and other studies. A semi-structured qualitative interview study of GPs working in general practices across England. Purposive sampling was employed to recruit 12 GPs, both with and without a special interest in drug misuse, from across England. Semi-structured face-to-face interviews were conducted to consider whether and why GPs record drug misuse, which methods GPs use for recording, GPs' actions if a patient asks for the information not to be recorded, and GPs' actions if they think a patient misuses drugs but does not disclose the information. Resulting data were analysed using a combination of inductive and deductive thematic analysis. The complexity of asking about drug misuse preceded GPs' decision to record. They described how the context of the general practice protocols, interaction between GP and patient, and the questioning process affected whether, how, and in which circumstances they asked about drug use. This led to GPs making a clinical decision on whether, who, and how to record in the EPR. When making decisions about whether or not to record drug misuse, GPs face complex choices. Aside from their own views, they reported feelings of pressure from the general practice environment in which they worked and their clinical commissioning group, as well as government policies. © British Journal of General Practice 2018.
Schepman, Sanneke; Valentijn, Pim; Bruijnzeels, Marc; Maaijen, Marlies; de Bakker, Dinny; Batenburg, Ronald; de Bont, Antoinette
The need for organisational development in primary care has increased as it is accepted as a means of curbing rising costs and responding to demographic transitions. It is only within such inter-organisational networks that small-scale practices can offer treatment to complex patients and continuity of care. The aim of this paper is to explore, through the experience of professionals and patients, whether, and how, project management and network governance can improve the outcomes of projects which promote inter-organisational collaboration in primary care. This paper describes a study of projects aimed at improving inter-organisational collaboration in Dutch primary care. The projects' success in project management and network governance was monitored by interviewing project leaders and board members on the one hand, and improvement in the collaboration by surveying professionals and patients on the other. Both qualitative and quantitative methods were applied to assess the projects. These were analysed, finally, using multi-level models in order to account for the variation in the projects, professionals and patients. Successful network governance was associated positively with the professionals' satisfaction with the collaboration; but not with improvements in the quality of care as experienced by patients. Neither patients nor professionals perceived successful project management as associated with the outcomes of the collaboration projects. This study shows that network governance in particular makes a difference to the outcomes of inter-organisational collaboration in primary care. However, project management is not a predictor for successful inter-organisational collaboration in primary care.
Full Text Available Abstract Background Ethnic minorities with depression are more likely to seek mental health care through primary care providers (PCPs than mental health specialists. However, both provider and patient-specific challenges exist. PCP-specific challenges include unfamiliarity with depressive symptom profiles in diverse patient populations, limited time to address mental health, and limited referral options for mental health care. Patient-specific challenges include stigma around mental health issues and reluctance to seek mental health treatment. To address these issues, we implemented a multi-component intervention for Asian American and Latino American primary care patients with depression at Massachusetts General Hospital (MGH. Methods/Design We propose a randomized controlled trial to evaluate a culturally appropriate intervention to improve the diagnosis and treatment of depression in our target population. Our goals are to facilitate a primary care providers' ability to provide appropriate, culturally informed care of depression, and b patients' knowledge of and resources for receiving treatment for depression. Our two-year long intervention targets Asian American and Latino American adult (18 years of age or older primary care patients at MGH screening positive for symptoms of depression. All eligible patients in the intervention arm of the study who screen positive will be offered a culturally focused psychiatric (CFP consultation. Patients will meet with a study clinician and receive toolkits that include psychoeducational booklets, worksheets and community resources. Within two weeks of the initial consultation, patients will attend a follow-up visit with the CFP clinicians. Primary outcomes will determine the feasibility and cost associated with implementation of the service, and evaluate patient and provider satisfaction with the CFP service. Exploratory aims will describe the study population at screening, recruitment, and enrollment
Tuzovic, Sven; Kuppelwieser, Volker
From retail health clinics and online appointment scheduling to (mobile) kiosks that enable patient check-in and automate the collection of copays and open balances, convenience has become an important topic in the health care sector over the last few years. While service convenience has also gained much interest in academia, one common limitation is that authors have adopted a "goods-centered" perspective focusing primarily on retail settings. Results of this exploratory study reveal that health care service convenience encompasses seven different dimensions: decision, access, scheduling, registration and check-in, transaction, care delivery, and postconsultation convenience. Implications and future research suggestions are discussed.
Lee, Samantha; Waters, Flavie; Briffa, Kathy; Fary, Robyn E
stakeholders, and for physiotherapists to be well equipped with skills and knowledge in mental health to facilitate greater involvement. [Lee S, Waters F, Briffa K, Fary RE (2017) Limited interface between physiotherapy primary care and people with severe mental illness: a qualitative study. Journal of Physiotherapy 63: 168-174]. Copyright © 2017. Published by Elsevier B.V.
Toft, Tomas; Fink, Per; Oernboel, Eva; Christensen, Kaj; Frostholm, Lisbeth; Olesen, Frede
Prevalence and co-occurrence of mental disorders is high among patients consulting their family general practitioner (GP) for a new health problem, but data on diagnostics and socio-demographics are sketchy. A cross-sectional two-phase epidemiological study. A total of 1785 consecutive patients with new complaints, aged 18-65 years, consulting 28 family practices during March-April 2000 in Aarhus County, Denmark were screened, in the waiting room, for mental and somatic symptoms with SCL-8 and SCL-Somatization questionnaires, for illness worry with Whitely-7 and for alcohol dependency with CAGE. In a stratified random sample of 701 patients, physician interviewers established ICD-10 diagnoses using the SCAN interview. Prevalence was calculated using weighted logistic regression, thus correcting for sample skewness. Half of the patients fulfilled criteria for an ICD-10 mental disorders and a third of these for more than one group of disorders. Women had higher prevalence of somatization disorder and overall mental disorders than men. Men had higher prevalence of alcohol abuse and hypochondriasis than women. Psychiatric morbidity tended to increase with age. Prevalence of somatoform disorders was 35.9% (95% CI 30.4-41.9), anxiety disorders 164% (95% CI 12.7-20.9), mood disorders 13.5% (95% CI 11.1-16.3), organic mental disorders 3.1% (95% CI 1.6-5.7) and alcohol abuse 2.2% (95% CI 1.5-3.1). Co-morbidities between these groups were highest for anxiety disorders, where 89% also had another mental diagnosis, and lowest for somatoform disorders with 39%. ICD-10 mental disorders are very prevalent in primary care and there is a high co-occurrence between most disorders. Somatoform disorders, however, more often than not exist without other mental disorders.
Full Text Available Abstract Background Recruiting to primary care studies is complex. With the current drive to increase numbers of patients involved in primary care studies, we need to know more about successful recruitment approaches. There is limited evidence on recruitment to focus group studies, particularly when no natural grouping exists and where participants do not regularly meet. The aim of this paper is to reflect on recruitment to a focus group study comparing the methods used with existing evidence using a resource for research recruitment, PROSPeR (Planning Recruitment Options: Strategies for Primary Care. Methods The focus group formed part of modelling a complex intervention in primary care in the Resources for Effective Sleep Treatment (REST study. Despite a considered approach at the design stage, there were a number of difficulties with recruitment. The recruitment strategy and subsequent revisions are detailed. Results The researchers' modifications to recruitment, justifications and evidence from the literature in support of them are presented. Contrary evidence is used to analyse why some aspects were unsuccessful and evidence is used to suggest improvements. Recruitment to focus group studies should be considered in two distinct phases; getting potential participants to contact the researcher, and converting those contacts into attendance. The difficulty of recruitment in primary care is underemphasised in the literature especially where people do not regularly come together, typified by this case study of patients with sleep problems. Conclusion We recommend training GPs and nurses to recruit patients during consultations. Multiple recruitment methods should be employed from the outset and the need to build topic related non-financial incentives into the group meeting should be considered. Recruitment should be monitored regularly with barriers addressed iteratively as a study progresses.
Martinez-Laguna, Daniel; Soria-Castro, Alberto; Carbonell-Abella, Cristina; Orozco-López, Pilar; Estrada-Laza, Pilar; Nogues, Xavier; Díez-Perez, Adolfo; Prieto-Alhambra, Daniel
Electronic medical records databases use pre-specified lists of diagnostic codes to identify fractures. These codes, however, are not specific enough to disentangle traumatic from fragility-related fractures. We report on the proportion of fragility fractures identified in a random sample of coded fractures in SIDIAP. Patients≥50 years old with any fracture recorded in 2012 (as per pre-specified ICD-10 codes) and alive at the time of recruitment were eligible for this retrospective observational study in 6 primary care centres contributing to the SIDIAP database (www.sidiap.org). Those with previous fracture/s, non-responders, and those with dementia or a serious psychiatric disease were excluded. Data on fracture type (traumatic vs fragility), skeletal site, and basic patient characteristics were collected. Of 491/616 (79.7%) patients with a registered fracture in 2012 who were contacted, 331 (349 fractures) were included. The most common fractures were forearm (82), ribs (38), and humerus (32), and 225/349 (64.5%) were fragility fractures, with higher proportions for classic osteoporotic sites: hip, 91.7%; spine, 87.7%; and major fractures, 80.5%. This proportion was higher in women, the elderly, and patients with a previously coded diagnosis of osteoporosis. More than 4 in 5 major fractures recorded in SIDIAP are due to fragility (non-traumatic), with higher proportions for hip (92%) and vertebral (88%) fracture, and a lower proportion for fractures other than major ones. Our data support the validity of SIDIAP for the study of the epidemiology of osteoporotic fractures. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.
Valk, Mark J.; Hoes, Arno W.; Mosterd, Arend; Landman, Marcel A.; Broekhuizen, Berna D L; Rutten, Frans H.
BACKGROUND: Heart failure (HF) is mainly detected and managed in primary care, but the care is considered suboptimal. We present the rationale, design and baseline results of the Treatment Optimisation in Primary care of Heart failure in the Utrecht region (TOPHU) study. In this study we assess the
Full Text Available Introduction. We studied whether primary care teams respond to financial group bonuses by improving the recording of diagnoses, whether this intervention leads to diagnoses reflecting the anticipated distribution of diseases, and how the recording of a significant chronic disease, diabetes, alters after the application of these bonuses. Methods. We performed an observational register-based retrospective quasi-experimental follow-up study with before-and-after setting and two control groups in primary healthcare of a Finnish town. We studied the rate of recorded diagnoses in visits to general practitioners with interrupted time series analysis. The distribution of these diagnoses was also recorded. Results. After group bonuses, the rate of recording diagnoses increased by 17.9% (95% CI: 13.6–22.3 but not in either of the controls (−2.0 to −0.3%. The increase in the rate of recorded diagnoses in the care teams varied between 14.9% (4.7–25.2 and 33.7% (26.6–41.3. The distribution of recorded diagnoses resembled the respective distribution of diagnoses in the former studies of diagnoses made in primary care. The rate of recorded diagnoses of diabetes did not increase just after the intervention. Conclusions. In primary care, the completeness of diagnosis recording can be, to varying degrees, influenced by group bonuses without guarantee that recording of clinically significant chronic diseases is improved.
Koning, N.R; Moons, L.N.G; Büchner, F.L.; Helsper, C.W.; ten Teije, A.C.M.; Numans, M.E.
Background Early diagnosis of colorectal cancer (CRC) is likely to reduce burden of disease and improve treatment success. Estimation of the individual patient risk for CRC diagnostic determinants in a primary care setting has not been very successful as yet. The aim of our study is to improve
Weijnen, C. F.; Numans, M. E.; de Wit, N. J.; Smout, A. J.; Moons, K. G.; Verheij, T. J.; Hoes, A. W.
OBJECTIVES: To develop an easily applicable diagnostic scoring method to determine the presence of peptic ulcers in dyspeptic patients in a primary care setting; to evaluate whether Helicobacter pylori testing adds value to history taking. Design: Cross sectional study. SETTING: General
Sollie, Annet; Sijmons, Rolf H.; Helsper, Charles W.; Numans, Mattijs E.
Objectives: To assess quality and reusability of coded cancer diagnoses in routine primary care data. To identify factors that influence data quality and areas for improvement. Methods: A dynamic cohort study in a Dutch network database containing 250,000 anonymized electronic medical records (EMRs)
Giraud, Violaine; Beauchet, Alain; Gomis, Thierry; Chinet, Thierry
COPD is a frequent but underdiagnosed disease whose diagnosis relies on the spirometric demonstration of bronchial obstruction. Spirometry use by general practitioners could represent the first line in COPD diagnosis. Because duration of spirometry is retarding its development in primary care, we decided to measure the time it requires in the primary-care context in France. Ten volunteer general practitioners were trained during two 3-hour theoretical and practical continuing education sessions. Then, from October 2013 to May 2014, they included patients without any known respiratory disease but at risk of developing COPD (age: ≥40 years, smoker: ≥20 pack-years). The duration of spirometry and its quality were evaluated according to the following acceptability criteria: 1) expiration ≥6 seconds or reaching a plateau; 2) good start with an early peak flow, curve peaked on top and not flat; 3) no artifacts; and 4) reproducibility criteria, ie, forced expiratory volume in 1 second and forced vital capacity differences between the two best spirometry curves ≤0.15 L. Quality of the spirograms was defined as optimal when all the criteria were met and acceptable when all the criteria were satisfied except the reproducibility criterion, otherwise, it was unacceptable. For the 152 patients included, the 142 assessable spirometries lasted for 15.2±5.9 minutes. Acceptability criteria 1-3, respectively, were satisfied for 90.1%, 89.4%, and 91.5% of patients and reproducibility criterion 4 for 56.3%. Quality was considered optimal for 58.5% of the curves and acceptable for 30.2%. The duration of spirometry renders it poorly compatible with the current primary-care practice in France other than for dedicated consultations. Moreover, the quality of spirometry needs to be improved.
Rosenberg, Adam A; Kamin, Carol; Glicken, Anita Duhl; Jones, M Douglas
Resident training in pediatrics currently entails similar training for all residents in a fragmented curriculum with relatively little attention to the career plans of individual residents. To explore strengths and gaps in training for residents planning a career in primary care pediatrics and to present strategies for addressing the gaps. Surveys were sent to all graduates of the University of Colorado Denver Pediatric Residency Program (2003-2006) 3 years after completion of training. Respondents were asked to evaluate aspects of their training, using a 5-point Likert scale and evaluating each item ranging from "not at all well prepared" to "extremely well prepared" for their future career. In addition, focus groups were conducted with practitioners in 8 pediatric practices in Colorado. Sessions were transcribed and hand coded by 2 independent coders. Survey data identified training in behavior and development (mean score, 3.72), quality improvement and patient safety strategies (mean, 3.57), and practice management (mean, 2.46) as the weakest aspects of training. Focus groups identified deficiencies in training in mental health, practice management, behavioral medicine, and orthopedics. Deficiencies noted in curriculum structure were lack of residents' long-term continuity of relationships with patients; the need for additional training in knowledge, skills, and attitudes needed for primary care (perhaps even a fourth year of training); and a training structure that facilitates greater resident autonomy to foster development of clinical capability and self-confidence. Important gaps were identified in the primary care training of pediatric residents. These data support the need to develop more career-focused training.
Full Text Available Digital services are often regarded as a solution to the growing demands on primary care services. Provision of a tool offering advice to support self-management as well as the ability to digitally consult with a General Practitioner (GP has the potential to alleviate some of the pressure on primary care. This paper reports on a Phase II, 6-month evaluation of eConsult, a web-based triage and consultation system that was piloted across 11 GP practices across Scotland. Through a multi-method approach the evaluation explored eConsult use across practices, exposing both barriers and facilitators to its adoption. Findings suggest that expectations that eConsult would offer an additional and alternative method of accessing GP services were largely met. However, there is less certainty that it has fulfilled expectations of promoting self-help. In addition, low uptake meant that evaluation of current effectiveness was difficult for practices to quantify. The presence of an eConsult champion(s within the practice was seen to be a significant factor in ensuring successful integration of the tool. A lack of patient and staff engagement, insufficient support and lack of protocols around processes were seen as barriers to its success.
Flarup, Lone; Moth, Grete; Christensen, Morten Bondo
INTRODUCTION: The primary care out-of-hours (OOH) service is of considerable importance; it is the main provider of freely accessible medical advice outside daytime hours, and it covers 75% of the active time in the healthcare system. Although the OOH handles three million contacts annually, only...... little is known about the reasons for encounter, the performed clinical work and the patient perspectives. MATERIAL AND METHODS: During a one-year period (2010- 2011), data on patient contacts were collected using pop-up questionnaires integrated into the existing IT system. The questions explored...
Snyder, Barbara K; Burack, Gail D; Petrova, Anna
Despite published guidelines on the need to provide comprehensive care to lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) youth, there has been limited research related to the deliverance of primary health care to this population. The goals of this study were to learn about LGBTQ youth's experiences with their primary care physicians and to identify areas for improvement. Youth attending 1 of 5 community-based programs completed a written questionnaire and participated in a focus group discussion regarding experiences at primary care visits, including topics discussed, counselling received, and physician communication. Most of the youth did not feel their health care needs were well met. The majority acknowledged poor patient-provider communication, disrespect, and lack of discussions about important topics such as sexual and emotional health. Participants cited concerns about confidentiality and inappropriate comments as barriers to care. Youth expressed a strong desire to have physicians be more aware of their needs and concerns.
Gorter, K.J.; Wens, J.; Khunti, K.
indicators, UKPDS-risk engine, psychological and general well-being. RESULTS: We included 103 participants from 22 GPs in 11 countries. Central data and laboratory samples were successfully collected. Of the participants 54% were female, mean age was 66 years and mean duration of diabetes was 9.6 years......BACKGROUND: European studies on quality of diabetes care in an unselected primary care diabetes population are scarce. RESEARCH QUESTION: To test the feasibility of the set-up and logistics of a cross-sectional EUropean study on Care and Complications in patients with type 2 diabetes (T2DM......) in Primary Care (EUCCLID) in 12 European countries. METHOD: One rural and one urban practice from each country participated. The central coordinating centre randomly selected five patients from each practice. Patient characteristics were assessed including medical history, anthropometric measures, quality...
Toivo, Terhi; Dimitrow, Maarit; Puustinen, Juha; Savela, Eeva; Pelkonen, Katariina; Kiuru, Valtteri; Suominen, Tuula; Kinnunen, Sirkka; Uunimäki, Mira; Kivelä, Sirkka-Liisa; Leikola, Saija; Airaksinen, Marja
The magnitude of safety risks related to medications of the older adults has been evidenced by numerous studies, but less is known of how to manage and prevent these risks in different health care settings. The aim of this study was to coordinate resources for prospective medication risk management of home care clients ≥ 65 years in primary care and to develop a study design for demonstrating effectiveness of the procedure. Health care units involved in the study are from primary care in Lohja, Southern Finland: home care (191 consented clients), the public healthcare center, and a private community pharmacy. System based risk management theory and action research method was applied to construct the collaborative procedure utilizing each profession's existing resources in medication risk management of older home care clients. An inventory of clinical measures in usual clinical practice and systematic review of rigorous study designs was utilized in effectiveness study design. The new coordinated medication management model (CoMM) has the following 5 stages: 1) practical nurses are trained to identify clinically significant drug-related problems (DRPs) during home visits and report those to the clinical pharmacist. Clinical pharmacist prepares the cases for 2) an interprofessional triage meeting (50-70 cases/meeting of 2 h) where decisions are made on further action, e.g., more detailed medication reviews, 3) community pharmacists conduct necessary medication reviews and each patients' physician makes final decisions on medication changes needed. The final stages concern 4) implementation and 5) follow-up of medication changes. Randomized controlled trial (RCT) was developed to demonstrate the effectiveness of the procedure. The developed procedure is feasible for screening and reviewing medications of a high number of older home care clients to identify clients with severe DRPs and provide interventions to solve them utilizing existing primary care resources
Goldie, Christine; Brown, Jenny
Obesity is a complex problem and often difficult to tackle in primary care. A year-long pilot of a practice nurse-led scheme that used a holistic approach towards self-care in obesity management was set up to reduce the cardiovascular risk of patients who were obese and improve their quality of life. This person-centred approach may offer an important tool in the management of these patients in the GP surgery.
van der Plas, Annicka G M; Vissers, Kris C; Francke, Anneke L; Donker, Gé A; Jansen, Wim J J; Deliens, Luc; Onwuteaka-Philipsen, Bregje D
Case managers have been introduced in primary palliative care in the Netherlands; these are nurses with expertise in palliative care who offer support to patients and informal carers in addition to the care provided by the general practitioner (GP) and home-care nurse. To compare cancer patients with and without additional support from a case manager on: 1) the patients' general characteristics, 2) characteristics of care and support given by the GP, 3) palliative care outcomes. This article is based on questionnaire data provided by GPs participating in two different studies: the Sentimelc study (280 cancer patients) and the Capalca study (167 cancer patients). The Sentimelc study is a mortality follow-back study amongst a representative sample of GPs that monitors the care provided via GPs to a general population of end-of-life patients. Data from 2011 and 2012 were analysed. The Capalca study is a prospective study investigating the implementation and outcome of the support provided by case managers in primary palliative care. Data were gathered between March 2011 and December 2013. The GP is more likely to know the preferred place of death (OR 7.06; CI 3.47-14.36), the place of death is more likely to be at the home (OR 2.16; CI 1.33-3.51) and less likely to be the hospital (OR 0.26; CI 0.13-0.52), and there are fewer hospitalisations in the last 30 days of life (none: OR 1.99; CI 1.12-3.56 and one: OR 0.54; CI 0.30-0.96), when cancer patients receive additional support from a case manager compared with patients receiving the standard GP care. Involvement of a case manager has added value in addition to palliative care provided by the GP, even though the role of the case manager is 'only' advisory and he or she does not provide hands-on care or prescribe medication.
Cha, Hye Jung; Kim, Jun Won; Suh, Chang Ok; Kim, Jin Seok; Cheong, June Won; Lee, Jeong Shim; Keum, Ki Chang; Lee, Chang Geol; Cho, Jae Ho [Yonsei University College of Medicine, Seoul (Korea, Republic of)
The aim of this study was to analyze the patterns of care and treatment outcomes in patients with primary thyroid lymphoma (PTL) in a single institution. Medical records of 29 patients with PTL treated between April 1994 and February 2012 were retrospectively reviewed. Diagnosis was confirmed by biopsy (n = 17) or thyroidectomy (n = 12). Treatment modality and outcome were analyzed according to lymphoma grade. The median follow-up was 43.2 months (range, 3.8 to 220.8 months). The median age at diagnosis was 57 years (range, 21 to 83 years) and 24 (82.8%) patients were female. Twenty-five (86.2%) patients had PTL with stage IEA and IIEA. There were 8 (27.6%) patients with mucosa-associated lymphoid tissue (MALT) lymphoma and the remaining patients had high-grade lymphoma. Patients were treated with surgery (n = 2), chemotherapy (n = 7), radiotherapy (n = 3) alone, or a combination of these methods (n = 17). Treatment modalities evolved over time and a combination of modalities was preferred, especially for the treatment of high-grade lymphoma in recent years. There was no death or relapse among MALT lymphoma patients. Among high-grade lymphoma patients, 5-year overall survival (OS) and 5-year progression-free survival (PFS) were 75.6% and 73.9%, respectively. Complete remission after initial treatment was the only significant prognostic factor for OS (p = 0.037) and PFS (p = 0.003). Patients with PTL showed a favorable outcome, especially with MALT lymphoma. Radiotherapy alone for MALT lymphoma and chemotherapy followed by radiotherapy for high-grade lymphoma can be effective treatment options for PTL.
O'Brien, Kathryn; Stanton, Naomi; Edwards, Adrian; Hood, Kerenza; Butler, Christopher C
Due to the non-specific nature of symptoms of UTI in children and low levels of urine sampling, the prevalence of UTI amongst acutely ill children in primary care is unknown. To undertake an exploratory study of acutely ill children consulting in primary care, determine the feasibility of obtaining urine samples, and describe presenting symptoms and signs, and the proportion with UTI. Exploratory, observational study. Four general practices in South Wales. A total of 99 sequential attendees with acute illness aged less than five years. UTI defined by >10(5) organisms/ml on laboratory culture of urine. Urine samples were obtained in 75 (76%) children. Three (4%) met microbiological criteria for UTI. GPs indicated they would not normally have obtained urine samples in any of these three children. However, all had received antibiotics for suspected alternative infections. Urine sample collection is feasible from the majority of acutely ill children in primary care, including infants. Some cases of UTI may be missed if children thought to have an alternative site of infection are excluded from urine sampling. A larger study is needed to more accurately determine the prevalence of UTI in children consulting with acute illness in primary care, and to explore which symptoms and signs might help clinicians effectively target urine sampling.
Quanjel, Tessa C C; Struijs, Jeroen N; Spreeuwenberg, Marieke D; Baan, Caroline A; Ruwaard, Dirk
In an attempt to deal with the pressures on the healthcare system and to guarantee sustainability, changes are needed. This study is focused on a cardiology Primary Care Plus intervention in which cardiologists provide consultations with patients in a primary care setting in order to prevent unnecessary referrals to the hospital. This study explores which patients with non-acute and low-complexity cardiology-related health complaints should be excluded from Primary Care Plus and referred directly to specialist care in the hospital. This is a retrospective observational study based on quantitative data. Data collected between January 1 and December 31, 2015 were extracted from the electronic medical record system. Logistic regression analyses were used to select patient groups that should be excluded from referral to Primary Care Plus. In total, 1525 patients were included in the analyses. Results showed that male patients, older patients, those with the referral indication 'Stable Angina Pectoris' or 'Dyspnoea' and patients whose reason for referral was 'To confirm disease' or 'Screening of unclear pathology' had a significantly higher probability of being referred to hospital care after Primary Care Plus. To achieve efficiency one should exclude patient groups with a significantly higher probability of being referred to hospital care after Primary Care Plus. NTR6629 (Data registered: 25-08-2017) (registered retrospectively).
Baker, Richard; Willars, Janet; McNicol, Sarah; Dixon-Woods, Mary; McKee, Lorna
Although the predominant model of general practice in the UK National Health Service (NHS) remains the small partnership owned and run by general practitioners (GPs), new types of provider are emerging. We sought to characterize the quality and safety systems and processes used in one large, privately owned company providing primary care through a chain of over 50 general practices in England. Senior staff with responsibility for policy on quality and safety were interviewed. We also undertook ethnographic observation in non-clinical areas and interviews with staff in three practices. A small senior executive team set policy and strategy on quality and safety, including a systematic incident reporting and investigation system and processes for disseminating learning with a strong emphasis on customer focus. Standardization of systems was possible because of the large number of practices. Policies appeared generally well implemented at practice level. However, there was some evidence of high staff turnover, particularly of GPs. This caused problems for continuity of care and challenges in inducting new GPs in the company's systems and procedures. A model of primary care delivery based on a corporate chain may be useful in standardizing policies and procedures, facilitating implementation of systems, and relieving clinical staff of administrative duties. However, the model also poses some risks, including those relating to stability. Provider forms that retain the long term, personal commitment of staff to their practices, such as federations or networks, should also be investigated; they may offer the benefits of a corporate chain combined with the greater continuity and stability of the more traditional general practice.
Prior, Anders; Vestergaard, Mogens; Larsen, Karen Kjær; Fenger-Grøn, Morten
Mental stress is common in the general population. Mounting evidence suggests that mental stress is associated with multimorbidity, suboptimal care and increased mortality. Delivering healthcare in a biopsychosocial context is key for general practitioners (GPs), but it remains unclear how persons with high levels of perceived stress are managed in primary care. We aimed to describe the association between perceived stress and primary care services by focusing on mental health-related activities and markers of elective/acute care while accounting for mental-physical multimorbidity. Population-based cohort study. Primary healthcare in Denmark. 118 410 participants from the Danish National Health Survey 2010 followed for 1 year. Information on perceived stress and lifestyle was obtained from a survey questionnaire. Information on multimorbidity was obtained from health registers. General daytime consultations, out-of-hours services, mental health-related services and chronic care services in primary care obtained from health registers. Perceived stress levels were associated with primary care activity in a dose-response relation when adjusted for underlying conditions, lifestyle and socioeconomic factors. In the highest stress quintile, 6.8% attended GP talk therapy (highest vs lowest quintile, adjusted incidence rate ratios (IRR): 4.96, 95% CI 4.20 to 5.86), 3.3% consulted a psychologist (IRR: 6.49, 95% CI 4.90 to 8.58), 21.5% redeemed an antidepressant prescription (IRR: 4.62, 95% CI 4.03 to 5.31), 23.8% attended annual chronic care consultations (IRR: 1.22, 95% CI 1.16 to 1.29) and 26.1% used out-of-hours services (IRR: 1.47, 95% CI 1.51 to 1.68). For those with multimorbidity, stress was associated with more out-of-hours services, but not with more chronic care services. Persons with high stress levels generally had higher use of primary healthcare, 4-6 times higher use of mental health-related services (most often in the form of psychotropic drug
Rhodes, Penny; Campbell, Stephen; Sanders, Caroline
Patient safety research has tended to focus on hospital settings, although most clinical encounters occur in primary care, and to emphasize practitioner errors, rather than patients' own understandings of safety. To explore patients' understandings of safety in primary care. Qualitative interviews were conducted with patients recruited from general practices in northwest England. Participants were asked basic socio-demographic information; thereafter, topics were largely introduced by interviewees themselves. Transcripts were coded and analysed using NVivo10 (qualitative data software), following a process of constant comparison. Thirty-eight people (14 men, 24 women) from 19 general practices in rural, small town and city locations were interviewed. Many of their concerns (about access, length of consultation, relationship continuity) have been discussed in terms of quality, but, in the interviews, were raised as matters of safety. Three broad themes were identified: (i) trust and psycho-social aspects of professional-patient relationships; (ii) choice, continuity, access, and the temporal underpinnings of safety; and (iii) organizational and systems-level tensions constraining safety. Conceptualizations of safety included common reliance on a bureaucratic framework of accreditation, accountability, procedural rules and regulation, but were also individual and context-dependent. For patients, safety is not just a property of systems, but personal and contingent and is realized in the interaction between doctor and patient. However, it is the systems approach that has dominated safety thinking, and patients' individualistic and relational conceptualizations are poorly accommodated within current service organization. © 2015 The Authors Health Expectations Published by John Wiley & Sons Ltd.
Herzig, Lilli; Mühlemann, Nicole; Bischoff, Thomas
Mental disorders (depression, anxiety and somatization) are frequent in Primary care and are often associated to physical complaints and to psychosocial stressors. Mental disorders have in this way a specific presentation and in addition patients may present different associations of them. Sometimes it is difficult to recognize them, but it is important to do so and to take rapidly care of these patients. Specific screening questions exist and have been used in a research of the Institute of General Medicine and the Department of Ambulatory Care and Community Medicine (PMU), University of Lausanne, Switzerland.
Østerås, Nina; van Bodegom-Vos, Leti; Dziedzic, Krysia; Moseng, Tuva; Aas, Eline; Andreassen, Øyvor; Mdala, Ibrahim; Natvig, Bård; Røtterud, Jan Harald; Schjervheim, Unni-Berit; Vlieland, Thea Vliet; Hagen, Kåre Birger
Previous research indicates that people with osteoarthritis (OA) are not receiving the recommended and optimal treatment. Based on international treatment recommendations for hip and knee OA and previous research, the SAMBA model for integrated OA care in Norwegian primary health care has been developed. The model includes physiotherapist (PT) led patient OA education sessions and an exercise programme lasting 8-12 weeks. This study aims to assess the effectiveness, feasibility, and costs of a tailored strategy to implement the SAMBA model. A cluster randomized controlled trial with stepped wedge design including an effect, process, and cost evaluation will be conducted in six municipalities (clusters) in Norway. The municipalities will be randomized for time of crossover from current usual care to the implementation of the SAMBA model by a tailored strategy. The tailored strategy includes interactive workshops for general practitioners (GPs) and PTs in primary care covering the SAMBA model for integrated OA care, educational material, educational outreach visits, feedback, and reminder material. Outcomes will be measured at the patient, GP, and PT levels using self-report, semi-structured interviews, and register based data. The primary outcome measure is patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire) at 6-month follow-up. Secondary outcomes include referrals to PT, imaging, and referrals to the orthopaedic surgeon as well as participants' treatment satisfaction, symptoms, physical activity level, body weight, and self-reported and measured lower limb function. The actual exposure to the tailor made implementation strategy and user experiences will be measured in a process evaluation. In the economic evaluation, the difference in costs of usual OA care and the SAMBA model for integrated OA care will be compared with the difference in health outcomes and reported by the incremental cost-effectiveness ratio (ICER). The results
Blackburn, Steven; McLachlan, Sarah; Jowett, Sue; Kinghorn, Philip; Gill, Paramjit; Higginbottom, Adele; Rhodes, Carol; Stevenson, Fiona; Jinks, Clare
In the UK, more patients go to primary care than other parts of the health service. Therefore it is important for research into primary care to include the insights and views of people who receive these services. To explore the extent, quality and impact of patient and public involvement (PPI) in primary care research, we examined documents of 200 projects and surveyed 191 researchers.We found that about half of studies included PPI to develop research ideas and during the study itself. Common activities included designing study materials, advising on methods, and managing the research. Some studies did not undertake the PPI activities initially planned and funded for. PPI varied by study design, health condition and study population. We found pockets of good practice: having a PPI budget, supporting PPI contributors, and PPI informing recruitment issues. However, good practice was lacking in other areas. Few projects offered PPI contributors training, used PPI to develop information for participants about study progress and included PPI to advise on publishing findings.Researchers reported beneficial impacts of PPI. Most impact was reported when the approach to PPI included more indicators of good practice. The main cost of PPI for researchers was their time. Many reported difficulties providing information about PPI.In partnership with PPI contributors, we have used these findings to develop:a new Cost and Consequences Framework for PPI highlighting financial and non-financial costs, benefits and harms of PPIFifteen co-produced recommendations to improve the practice and delivery of PPI. Background: To improve the lives of patients in primary care requires the involvement of service users in primary care research. We aimed to explore the extent, quality and impact of patient and public involvement (PPI) in primary care research. Methods: We extracted information about PPI from grant applications, reports and an electronic survey of researchers of studies funded
Full Text Available Introduction: Early detection of Chronic Obstructive Pulmonary Diseases (COPD is the key for its control and management in Primary Health Care. Nurses could significantly contribute to the early detection of COPD if they receive appropriate training and develop skills such as performing spirometry tests and assess early COPD’s signs and symptoms. Aim: To assess the ability of nursing students to detect undiagnosed cases of COPD through a designed spirometry program. Methods: Participants were approached following an open invitation by the local municipal authorities during January-June 2015 in 4 primary health care centres of the island of Crete, Greece. A screening program was conducted using two different diagnostic methods of COPD. All participants completed the ‘International Primary Care Airways Guidelines’ (IPAG questionnaire, a validated instrument for COPD cases identification and performed a spirometry, a gold standard method for the diagnosis of COPD. Nursing students were trained for one month.Two different diagnoses of COPD were given using the interpretations of the spirometry tests and IPAG results for each individual participant (IPAG & GOLD standards. Diagnosis of COPD was based on the spirometry values using the GOLD recommendations (fixed ratio FEV1/FVC<70%. The capacity of nursing students in detecting COPD was based on the degree of agreement (Kappa test and ROC curve between the two diagnoses of COPD (IPAG & GOLD. P-values <0.05 were considered statistically significant. Results: The mean age of the 390 participants was 55.6 (12.7 years old and 46.9% were male. The prevalence of COPD was 20% (78 cases according to IPAG questionnaire and 12.1% (47 cases according to spirometry. However, 31 cases of COPD that were detected using the IPAG, were classified as normal in spirometry, showing middle level of agreement (Kappa=0.71, p<0.001, 47/78 cases. Consequently, a sensitivity and specificity analysis was performed reported
Escobar, JI; Gara, M; Waitzkin, H; Silver, RC; Holman, A; Compton, W
The object of this study was to assess the prevalence and correlates of the DSM-IV diagnosis of hypochondriasis in a primary care setting. A large sample (N = 1456) of primary care users was given a structured interview to make diagnoses of mood, anxiety, and somatoform disorders and estimate levels of disability. The prevalence of hypochondriasis (DSM-IV) was about 3%. Patients with this disorder had higher levels of medically unexplained symptoms (abridged somatization) and were more impair...
O'Brien, Doireann; Harvey, Kate; Young, Bridget; Reardon, Tessa; Creswell, Cathy
Anxiety disorders have a median age of onset of 11 years and are the most common emotional disorders in childhood; however, a significant proportion of those affected do not access professional support. In the UK, GPs are often the first medical professional that families see so are in a prime position to support children with anxiety disorders; however, currently there is little research available on GPs' perspectives on and experiences of supporting children with these disorders. To explore the experiences of GPs in relation to identification, management, and access to specialist services for children (<12 years) with anxiety disorders. Twenty semi-structured interviews were conducted with GPs in primary care throughout England. GPs reflected a diverse group in relation to the ethnic and socioeconomic profile of registered patients, GP age, sex, professional status, previous engagement with research, and practice size and location. Purposive sampling was used to recruit GPs until theoretical saturation was reached. Data were analysed using a constant comparative method of thematic analysis. Data from 20 semi-structured interviews were organised into three themes: decision making, responsibility, and emotional response, with an overarching theme of GPs feeling ill equipped. These themes were retrospectively analysed to illustrate their role at different stages in the primary care process (identification, management, and access to specialist services). GPs feel ill equipped to manage and support childhood anxiety disorders, demonstrating a need for medical training to include greater emphasis on children's mental health, as well as potential for greater collaboration between primary and specialist services. © British Journal of General Practice 2017.
Full Text Available Abstract Background Care management programmes are an effective approach to care for high risk patients with complex care needs resulting from multiple co-occurring medical and non-medical conditions. These patients are likely to be hospitalized for a potentially "avoidable" cause. Nurse-led care management programmes for high risk elderly patients showed promising results. Care management programmes based on health care assistants (HCAs targeting adult patients with a high risk of hospitalisation may be an innovative approach to deliver cost-efficient intensified care to patients most in need. Methods/Design PraCMan is a cluster randomized controlled trial with primary care practices as unit of randomisation. The study evaluates a complex primary care practice-based care management of patients at high risk for future hospitalizations. Eligible patients either suffer from type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic heart failure or any combination. Patients with a high likelihood of hospitalization within the following 12 months (based on insurance data will be included in the trial. During 12 months of intervention patients of the care management group receive comprehensive assessment of medical and non-medical needs and resources as well as regular structured monitoring of symptoms. Assessment and monitoring will be performed by trained HCAs from the participating practices. Additionally, patients will receive written information, symptom diaries, action plans and a medication plan to improve self-management capabilities. This intervention is addition to usual care. Patients from the control group receive usual care. Primary outcome is the number of all-cause hospitalizations at 12 months follow-up, assessed by insurance claims data. Secondary outcomes are health-related quality of life (SF12, EQ5D, quality of chronic illness care (PACIC, health care utilisation and costs, medication adherence (MARS, depression
Pons-Vigués, Mariona; Berenguera, Anna; Coma-Auli, Núria; Pombo-Ramos, Haizea; March, Sebastià; Asensio-Martínez, Angela; Moreno-Peral, Patricia; Mora-Simón, Sara; Martínez-Andrés, Maria; Pujol-Ribera, Enriqueta
Although some articles have analysed the definitions of health and health promotion from the perspective of health-care users and health care professionals, no published studies include the simultaneous participation of health-care users, primary health care professionals and key community informants. Understanding the perception of health and health promotion amongst these different stakeholders is crucial for the design and implementation of successful, equitable and sustainable measures that improve the health and wellbeing of populations. Furthermore, the identification of different health assets and deficits by the different informants will generate new evidence to promote healthy behaviours, improve community health and wellbeing and reduce preventable inequalities. The objective of this study is to explore the concept of health and health promotion and to compare health assets and deficits as identified by health-care users, key community informants and primary health care workers with the ultimate purpose to collect the necessary data for the design and implementation of a successful health promotion intervention. A descriptive-interpretive qualitative research was conducted with 276 participants from 14 primary care centres of 7 Spanish regions. Theoretical sampling was used for selection. We organized 11 discussion groups and 2 triangular groups with health-care users; 30 semi-structured interviews with key community informants; and 14 discussion groups with primary health care workers. A thematic content analysis was carried out. Health-care users and key community informants agree that health is a complex, broad, multifactorial concept that encompasses several interrelated dimensions (physical, psychological-emotional, social, occupational, intellectual, spiritual and environmental). The three participants' profiles consider health promotion indispensable despite defining it as complex and vague. In fact, most health-care users admit to having
VPDs, this represents 17% of global total. 1 ... Knowledge, Attitude and Practice of Childhood Immunization ... Department of Community Health & Primary Care, College of Medicine, University of Lagos, Idi-Araba, P.M.B. 12003, ... include access to services, parental (maternal) ... Calmette Guerin (BCG) vaccine Oral Polio.
Prins Marijn A
Full Text Available Abstract Background There is little evidence as to whether or not guideline concordant care in general practice results in better clinical outcomes for people with anxiety and depression. This study aims to determine possible associations between guideline concordant care and clinical outcomes in general practice patients with depression and anxiety, and identify patient and treatment characteristics associated with clinical improvement. Methods This study forms part of the Netherlands Study of Depression and Anxiety (NESDA. Adult patients, recruited in general practice (67 GPs, were interviewed to assess DSM-IV diagnoses during baseline assessment of NESDA, and also completed questionnaires measuring symptom severity, received care, socio-demographic variables and social support both at baseline and 12 months later. The definition of guideline adherence was based on an algorithm on care received. Information on guideline adherence was obtained from GP medical records. Results 721 patients with a current (6-month recency anxiety or depressive disorder participated. While patients who received guideline concordant care (N = 281 suffered from more severe symptoms than patients who received non-guideline concordant care (N = 440, both groups showed equal improvement in their depressive or anxiety symptoms after 12 months. Patients who (still had moderate or severe symptoms at follow-up, were more often unemployed, had smaller personal networks and more severe depressive symptoms at baseline than patients with mild symptoms at follow-up. The particular type of treatment followed made no difference to clinical outcomes. Conclusion The added value of guideline concordant care could not be demonstrated in this study. Symptom severity, employment status, social support and comorbidity of anxiety and depression all play a role in poor clinical outcomes.
Full Text Available Background The National Health Service in England has given increasing priority to improving inter-professional communication, enabling better management of patients with chronic conditions and reducing medical errors through effective use of information. Despite considerable efforts to reduce patient harm through better information usage, medical errors continue to occur, posing a serious threat to patient safety.Objectives This study explores the range, quality and sophistication of existing information systems in primary care with the aim to capture what information practitioners need to provide a safe service and identify barriers to its effective use in care pathways.Method Data were collected through semi-structured interviews with general practitioners from surgeries in North West London and a survey evaluating their experience with information systems in care pathways.Results Important information is still missing, specifically discharge summaries detailing medication changes and changes in the diagnosis and management of patients, blood results ordered by hospital specialists and findings from clinical investigations. Participants identified numerous barriers, including the communication gap between primary and secondary care, the variable quality and consistency of clinical correspondence and the inadequate technological integration.Conclusion Despite attempts to improve integration and information flow in care pathways, existing systems provide practitioners with only partial access to information, hindering their ability to take informed decisions. This study offers a framework for understanding what tools should be in place to enable effective use of information in primary care.
Boadu, Nana Yaa; Amuasi, John; Ansong, Daniel; Einsiedel, Edna; Menon, Devidas; Yanow, Stephanie K
Rapid diagnostic Tests (RDTs) for malaria enable diagnostic testing at primary care facilities in resource-limited settings, where weak infrastructure limits the use of microscopy. In 2010, Ghana adopted a test-before-treat guideline for malaria, with RDT use promoted to facilitate diagnosis. Yet healthcare practitioners still treat febrile patients without testing, or despite negative malaria test results. Few studies have explored RDT implementation beyond the notions of provider or patient acceptability. The aim of this study was to identify the factors directly influencing malaria RDT implementation at primary care facilities in a Ghanaian district. Qualitative interviews, focus groups and direct observations were conducted with 50 providers at six purposively selected primary care facilities in the Atwima-Nwabiagya district. Data were analysed thematically. RDT implementation was hampered by: (1) healthcare delivery constraints (weak supply chain, limited quality assurance and control, inadequate guideline emphasis, staffing limitations); (2) provider perceptions (entrenched case-management paradigms, limited preparedness for change); (3) social dynamics of care delivery (expected norms of provider-patient interaction, test affordability); and (4) limited provider engagement in policy processes leading to fragmented implementation of health sector reform. Limited health system capacity, socio-economic, political, and historical factors hampered malaria RDT implementation at primary care facilities in the study district. For effective RDT implementation providers must be: (1) adequately enabled through efficient allocation and management of essential healthcare commodities; (2) appropriately empowered with the requisite knowledge and skill through ongoing, effective professional development; and (3) actively engaged in policy dialogue to demystify socio-political misconceptions that hinder health sector reform policies from improving care delivery. Clear
López Varela, Maria Victorina; Montes de Oca, Maria; Rey, Alejandra; Casas, Alejandro; Stirbulov, Roberto; Di Boscio, Valentina
Opportunistic chronic obstructive pulmonary disease (COPD) case finding approaches for high-risk individuals with or without symptoms is a feasible option for disease identification. PUMA is an opportunistic case finding study conducted in primary care setting of Argentina, Colombia, Venezuela and Uruguay. The objectives were to measure COPD prevalence in an at-risk population visiting primary care for any reason, to assess the yield of this opportunistic approach and the accuracy of a score developed to detect COPD. Subjects attending routine primary care visits, ≥40 years of age, current or former smokers or exposed to biomass smoke, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator (post-BD) forced expiratory volume in 1 s (FEV1 )/forced vital capacity (FVC) 50 years, heavy smokers (>30 pack-years), with dyspnoea, and having prior spirometry. A simple score and a weighted score constructed using the following predictive factors: gender, age, pack-years smoking, dyspnoea, sputum, cough and spirometry, had a mean accuracy for detecting COPD (post-BD FEV1 /FVC tool to select subjects for spirometry in primary care. © 2016 Asian Pacific Society of Respirology.
Full Text Available Abstract Background Emigrants are often a selected sample and in good health, but migration can have deleterious effects on health. Many immigrant groups report poor health and increased use of health services, and it is often claimed that they tend to use emergency primary health care (EPHC services for non-urgent purposes. The aim of the present study was to analyse immigrants’ use of EPHC, and to analyse variations according to country of origin, reason for immigration, and length of stay in Norway. Methods We conducted a registry based study of all immigrants to Norway, and a subsample of immigrants from Poland, Germany, Iraq and Somalia, and compared them with native Norwegians. The material comprised all electronic compensation claims for EPHC in Norway during 2008. We calculated total contact rates, contact rates for selected diagnostic groups and for services given during consultations. Adjustments for a series of socio-demographic and socio-economic variables were done by multiple logistic regression analyses. Results Immigrants as a whole had a lower contact rate than native Norwegians (23.7% versus 27.4%. Total contact rates for Polish and German immigrants (mostly work immigrants were 11.9% and 7.0%, but for Somalis and Iraqis (mostly asylum seekers 31.8% and 33.6%. Half of all contacts for Somalis and Iraqis were for non-specific pain, and they had relatively more of their contacts during night than other groups. Immigrants’ rates of psychiatric diagnoses were low, but increased with length of stay in Norway. Work immigrants suffered less from respiratory and gastrointestinal infections, but had more injuries and higher need for sickness certification. All immigrant groups, except Germans, were more often given a sickness certificate than native Norwegians. Use of interpreter was reduced with increasing length of stay. All immigrant groups had an increased need for long consultations, while laboratory tests were most often used
Martín Martín, R; Sánchez Bayle, M; Gancedo García, C; Teruel de Francisco, M C; Coullaut López, A
To study the impact of the economic crisis on the families of the children who attend Primary Health Care and its relationship with their socioeconomic status. Observational descriptive study was conducted by analysing the results of 453 questionnaires, given to the parents of children between 1 and 7 years old who attended 4 paediatric clinics in Madrid. The raw data was analysed, and comparisons between groups and multivariate analysis were performed. In the multivariate analysis, the variables related to the non-acquisition of prescribed medication are: lower income level OR=0.118, p<.0001 and lower educational level OR=0.464, p<.001; the variables related to the reduction of food expenditure are: lower income level OR=0.100, p<.0001 and a higher number of family members OR=1.308, p=.045; the variables related to anti-pneumococcal vaccination without public funding are: higher income level OR=2.170, p=.0001, higher educational level OR=1.835, p=.013, and not being an immigrant OR=0.532, p=.037. The presence of health problems from the beginning of the economic crisis is related to unemployment OR=4.079, p=.032, lower educational level R=0.678, p=.042, and income level OR=0.342, p<.0001. In all cases, the models achieved a statistical significance of p<.0001. The economic crisis has greater impact on the group with the lowest income level in all analysed variables. The lower educational level and higher number of family members has an impact on the reduction in food expenditure. The fact of being an immigrant has an impact on not receiving the anti-pneumococcal and rotavirus vaccination. Unemployment leads to an increase in health problems in the family. To sum up, the economic crisis has increased inequalities according to socioeconomic status. Copyright © 2015 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.
Background Emigrants are often a selected sample and in good health, but migration can have deleterious effects on health. Many immigrant groups report poor health and increased use of health services, and it is often claimed that they tend to use emergency primary health care (EPHC) services for non-urgent purposes. The aim of the present study was to analyse immigrants’ use of EPHC, and to analyse variations according to country of origin, reason for immigration, and length of stay in Norway. Methods We conducted a registry based study of all immigrants to Norway, and a subsample of immigrants from Poland, Germany, Iraq and Somalia, and compared them with native Norwegians. The material comprised all electronic compensation claims for EPHC in Norway during 2008. We calculated total contact rates, contact rates for selected diagnostic groups and for services given during consultations. Adjustments for a series of socio-demographic and socio-economic variables were done by multiple logistic regression analyses. Results Immigrants as a whole had a lower contact rate than native Norwegians (23.7% versus 27.4%). Total contact rates for Polish and German immigrants (mostly work immigrants) were 11.9% and 7.0%, but for Somalis and Iraqis (mostly asylum seekers) 31.8% and 33.6%. Half of all contacts for Somalis and Iraqis were for non-specific pain, and they had relatively more of their contacts during night than other groups. Immigrants’ rates of psychiatric diagnoses were low, but increased with length of stay in Norway. Work immigrants suffered less from respiratory and gastrointestinal infections, but had more injuries and higher need for sickness certification. All immigrant groups, except Germans, were more often given a sickness certificate than native Norwegians. Use of interpreter was reduced with increasing length of stay. All immigrant groups had an increased need for long consultations, while laboratory tests were most often used for Somalis and Iraqis
Apps, Lindsay D; Harrison, Samantha L; Williams, Johanna E A; Hudson, Nicky; Steiner, Michael; Morgan, Mike D; Singh, Sally J
There is much description in the literature of how patients with chronic obstructive pulmonary disease (COPD) manage their breathlessness and engage in self-care activities; however, little of this is from the perspective of those with less severe disease, who are primarily managed in primary care. This study aimed to understand the self-care experiences of patients with COPD who are primarily managed in primary care, and to examine the challenges of engaging in such behaviors. Semistructured interviews were carried out with 15 patients with COPD as part of a larger project evaluating a self-management intervention. Thematic analysis was supported by NVivo software (version 8, QSR International, Melbourne, Australia). Three main themes are described, ie, experiencing and understanding symptoms of COPD, current self-care activities, and the importance of family perceptions in managing COPD. Self-care activities evolved spontaneously as participants experienced symptoms of COPD. However, there was a lack of awareness about whether these strategies would impact upon symptoms. Perceptions of COPD by family members posed a challenge to self-care for some participants. Health care professionals should elicit patients' prior disease experiences and utilize spontaneous attempts at disease management in future self-management. These findings have implications for promoting self-management and enhancing quality of life.
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.
Fortney, Luke; Luchterhand, Charlene; Zakletskaia, Larissa; Zgierska, Aleksandra; Rakel, David
Burnout, attrition, and low work satisfaction of primary care physicians are growing concerns and can have a negative influence on health care. Interventions for clinicians that improve work-life balance are few and poorly understood. We undertook this study as a first step in investigating whether an abbreviated mindfulness intervention could increase job satisfaction, quality of life, and compassion among primary care clinicians. A total of 30 primary care clinicians participated in an abbreviated mindfulness course. We used a single-sample, pre-post design. At 4 points in time (baseline, and 1 day, 8 weeks, and 9 months postintervention), participants completed a set of online measures assessing burnout, anxiety, stress, resilience, and compassion. We used a linear mixed-effects model analysis to assess changes in outcome measures. Participants had improvements compared with baseline at all 3 follow-up time points. At 9 months postintervention, they had significantly better scores (1) on all Maslach Burnout Inventory burnout subscales-Emotional Exhaustion (P =.009), Depersonalization (P = .005), and Personal Accomplishment (P job burnout, depression, anxiety, and stress. Modified mindfulness training may be a time-efficient tool to help support clinician health and well-being, which may have implications for patient care.
Alexopoulos, George S.; Reynolds, Charles F.; Bruce, Martha L.; Katz, Ira R.; Raue, Patrick J.; Mulsant, Benoit H.; Oslin, David; Have, Thomas Ten
Objective The PROSPECT Study evaluated the impact of a care management intervention on suicidal ideation and depression in older primary care patients. This is the first report of outcomes over a 2-year period. Method The subjects (N=599) were older (>=60 years) patients with major or minor depression selected after screening 9,072 randomly identified patients of 20 primary care practices randomly assigned to the PROSPECT intervention or usual care. The intervention consisted of services of 15 trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 24 months. Results Intervention patients had a higher likelihood to receive antidepressants and or psychotherapy (84.9–89% vs. 49–59%) and a 2.2 times greater decline in suicidal ideation than usual care patients over 24 months. Treatment response occurred earlier in intervention patients and continued to increase from the 18th to the 24th month, while there was no appreciable increase in usual care patients during the same period. Among patients with major depression, a greater number achieved remission in the intervention than the usual care group at 4 (26.6 vs. 15.2%), 8 (36% vs. 22.5%), and 24 (45.4% vs. 31.5%) months. Patients with minor depression had favorable outcomes regardless of treatment assignment. Conclusions Sustained collaborative care maintains high utilization of antidepressant treatment, reduces suicidal ideation, and improves the outcomes of major depression over two years. These observations suggest that sustained collaborative care increases depression-free days. PMID:19528195
Manniën, J.; Klomp, T.; Wiegers, T.; Pereboom, M.T.R.; Brug, J.; de Jonge, J.; van der Meijde, M.; Hutton, E.K.; Schellevis, F.; Spelten, E.
Background: In the Netherlands, midwives are autonomous medical practitioners and 78% of pregnant women start their maternity care with a primary care midwife. Scientific research to support evidence-based practice in primary care midwifery in the Netherlands has been sparse. This paper describes
Manniën, J.; Klomp, T.; Wiegers, T.; Pereboom, M.; Brug, J.; Jonge, A. de; Meijde, M. van der; Hutton, E.; Schellevis, F.; Spelten, E.
Background: In the Netherlands, midwives are autonomous medical practitioners and 78% of pregnant women start their maternity care with a primary care midwife. Scientific research to support evidence-based practice in primary care midwifery in the Netherlands has been sparse. This paper describes
Rasmussen-Barr, Eva; Savage, Mairi; Von Knorring, Mia
Health care is undergoing changes and this requires the participation and leadership of all health-care professions. While numerous studies have explored leadership competence among physicians and nurses, the physiotherapy profession has received but limited attention. The aim of this study was to explore how leadership manifests in the patient-therapist interaction among physiotherapists in primary health care and how the physiotherapists themselves relate their perception of leadership to their clinical practice. A qualitative study with semi-structured interviews was conducted with a purposive sample of 10 physiotherapists working in primary health care. The interviews were analyzed using inductive qualitative content analysis. Five themes were identified related to how leadership manifests in the patient-therapist interaction: (1) establishing resonant relationships; (2) engaging patients to build ownership; (3) drawing on authority; (4) building on professionalism; and (5) relating physiotherapists clinical practice to leadership. This study describes how leadership manifests in the patient-physiotherapist interaction. The findings can be used to empower physiotherapists in their clinical leadership and to give them confidence in taking on formal leadership roles, thus becoming active participants in improving health care. Future studies are needed to explore other aspects of leadership used in physiotherapy clinical practice.
Zhang, Mingji; Wang, Wei; Millar, Ross; Li, Guohong; Yan, Fei
Health reform in China since 2009 has emphasized basic public health services to enhance the function of Community Health Services as a primary health care facility. A variety of studies have documented these efforts, and the challenges these have faced, yet up to now the experience of primary health care (PHC) providers in terms of how they have coped with these changes remains underdeveloped. Despite the abundant literature on psychological coping processes and mechanisms, the application of coping research within the context of human resources for health remains yet to be explored. This research aims to understand how PHC providers coped with the new primary health care model and the job characteristics brought about by these changes. Semi-structured interviews with primary health care workers were conducted in Jinan city of Shandong province in China. A maximum variation sampling method selected 30 PHC providers from different specialties. Thematic analysis was used drawing on a synthesis of theories related to the Job Demands-Resources model, work adjustment, and the model of exit, voice, loyalty and neglect to understand PHC providers' coping strategies. Our interviews identified that the new model of primary health care significantly affected the nature of primary health work and triggered a range of PHC providers' coping processes. The results found that health workers perceived their job as less intensive than hospital medical work but often more trivial, characterized by heavy workload, blurred job description, unsatisfactory income, and a lack of professional development. However, close relationship with community and low work pressure were satisfactory. PHC providers' processing of job demands and resources displayed two ways of interaction: aggravation and alleviation. Processing of job demands and resources led to three coping strategies: exit, passive loyalty, and compromise with new roles and functions. Primary health care providers employed coping
Bakken, Inger J; Tveito, Kari; Aaberg, Kari M; Ghaderi, Sara; Gunnes, Nina; Trogstad, Lill; Magnus, Per; Stoltenberg, Camilla; Håberg, Siri E
Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a complex condition. Causal factors are not established, although underlying psychological or immunological susceptibility has been proposed. We studied primary care diagnoses for children with CFS/ME, with children with another hospital diagnosis (type 1 diabetes mellitus [T1DM]) and the general child population as comparison groups. All Norwegian children born 1992-2012 constituted the study sample. Children with CFS/ME (n = 1670) or T1DM (n = 4937) were identified in the Norwegian Patient Register (NPR) (2008-2014). Children without either diagnosis constituted the general child population comparison group (n = 1337508). We obtained information on primary care diagnoses from the Norwegian Directorate of Health. For each primary care diagnosis, the proportion and 99 % confidence interval (CI) within the three groups was calculated, adjusted for sex and age by direct standardization. Children with CFS/ME were more often registered with a primary care diagnosis of weakness/general tiredness (89.9 % [99 % CI 88.0 to 91.8 %]) than children in either comparison group (T1DM: 14.5 % [99 % CI: 13.1 to 16.0 %], general child population: 11.1 % [99 % CI: 11.0 to 11.2 %]). Also, depressive disorder and anxiety disorder were more common in the CFS/ME group, as were migraine, muscle pain, and infections. In the 2 year period prior to the diagnoses, infectious mononucleosis was registered for 11.1 % (99 % CI 9.1 to 13.1 %) of children with CFS/ME and for 0.5 % (99 % CI (0.2 to 0.8 %) of children with T1DM. Of children with CFS/ME, 74.6 % (1292/1670) were registered with a prior primary care diagnosis of weakness / general tiredness. The time span from the first primary care diagnosis of weakness / general tiredness to the specialist health care diagnosis of CFS/ME was 1 year or longer for 47.8 %. This large nationwide registry linkage study confirms that the clinical picture in CFS
Haastrup, Peter; Hansen, Jane Møller; Jarbøl, Dorte Ejg
Background: Antisecretory drugs (ADs) are often prescribed in primary care for upper gastrointestinal symptoms. Reimbursement modifications have been made in Denmark to minimize costs related to use of ADs. However knowledge about development in use of ADs over the past decade and the impacts...... of the reimbursement modifications is sparse. Research questions: How has use of ADs developed in Denmark 2001-2011? Which impacts have the reimbursement modifications had on the use of ADs? Methods: The Register of Medicinal Product Statistics includes all sales and redeemed prescriptions nationwide covering...... through the years 2001-2011 were used. Data from prescriptions redeemed by persons younger than 20 years were excluded. Prescriptions for ulcerogenic drugs (acetylsalicylic acid and non-steroidal anti-inflammatory drugs) redeemed by persons aged 65 years and older were included since ulcer prophylaxis...
Leysen, Bert; Van den Eynden, Bart; Gielen, Birgit; Bastiaens, Hilde; Wens, Johan
Starting with early identification of palliative care patients by general practitioners (GPs), the Care Pathway for Primary Palliative Care (CPPPC) is believed to help primary health care workers to deliver patient- and family-centered care in the last year of life. The care pathway has been pilot-tested, and will now be implemented in 5 Belgian regions: 2 Dutch-speaking regions, 2 French-speaking regions and the bilingual capital region of Brussels. The overall aim of the CPPPC is to provide better quality of primary palliative care, and in the end to reduce the hospital death rate. The aim of this article is to describe the quantitative design and innovative data collection strategy used in the evaluation of this complex intervention. A quasi-experimental stepped wedge cluster design is set up with the 5 regions being 5 non-randomized clusters. The primary outcome is reduced hospital death rate per GPs' patient population. Secondary outcomes are increased death at home and health care consumption patterns suggesting high quality palliative care. Per research cluster, GPs will be recruited via convenience sampling. These GPs -volunteering to be involved will recruit people with reduced life expectancy and their informal care givers. Health care consumption data in the last year of life, available for all deceased people having lived in the research clusters in the study period, will be used for comparison between patient populations of participating GPs and patient populations of non-participating GPs. Description of baseline characteristics of participating GPs and patients and monitoring of the level of involvement by GPs, patients and informal care givers will happen through regular, privacy-secured web-surveys. Web-survey data and health consumption data are linked in a secure way, respecting Belgian privacy laws. To evaluate this complex intervention, a quasi-experimental stepped wedge cluster design has been set up. Context characteristics and involvement
Chukwudozie, Ifeanyi Beverly; Fitzgibbon, Marian L; Schiffer, Linda; Berbaum, Michael; Gilmartin, Cheryl; David, Pyone; Ekpo, Eson; Fischer, Michael J; Porter, Anna C; Aziz-Bradley, Alana; Hynes, Denise M
Patients with chronic kidney disease have a high disease burand may benefit from primary care services and care coord A medical home model with direct access to primary care services is one approach that may address this need, yet has not been examined. As a substudy of the Patient-Centered Outcomes Research Institute (PCORI) patient-centered medical home for kidney disease (PCMH-KD) health system intervention study, we examined the uptake of free primary care physician (PCP) services. The PCORI PCMH-KD study was an initial step toward integrating PCPs, a nurse coordinator, a pharmacist, and community health workers (CHWs) within the health care delivery team. Adult chronic hemodialysis (CHD) at two urban dialysis centers were enrolled in the intervention. We examined trends and factors associated with the use of the PCMH-KD PCP among two groups of patients based on their report of having a regular physician for at least six months (established-PCP) or not (no-PCP). Of the 173 enrolled patients, 91 (53%) patients had at least one visit with the PCMH-KD PCP. The rate of visits was higher in those in the no-PCP group compared with those in the established-PCP group (62% vs. 41%, respectively). Having more visits with the CHW was positively associated with having a visit with the PCMH-KD PCPs for both groups. Embedded CHWs within the care team played a role in facilithe uptake of PCMH-KD PCP. Lessons from this health system intervention can inform future approaches on the integration of PCPs and care coordination for CHD patients.
Montes de Oca, Maria; Zabert, Gustavo; Moreno, Dolores; Laucho-Contreras, Maria E; Lopez Varela, Maria Victorina; Surmont, Filip
The evidence indicates that risk factors other than smoking are important in the development of COPD. It has been postulated that less traditional risk factors (eg, exposure to coal and/or biomass smoke) may interact with smoking to further increase COPD risk. This analysis evaluated the effect of exposure to biomass and smoking on COPD risk in a primary care setting in Latin America. Subjects attending routine primary care visits, ≥40 y old, who were current or former smokers or were exposed to biomass smoke, completed a questionnaire and performed spirometry. COPD was defined as post-bronchodilator FEV 1 /FVC 30), and biomass exposure was defined as an exposure to coal or wood (for heating, cooking, or both) for ≥ 10 y. One thousand seven hundred forty-three individuals completed the questionnaire, and 1,540 performed spirometry. Irrespective of COPD definition, approximately 40% of COPD subjects reported exposure to biomass versus 30% of those without COPD. A higher proportion of COPD subjects (post-bronchodilator FEV 1 /FVC 30 pack-years (66% vs 39%); similar results were found with the lower limit of normal definition. Analysis of exposure to biomass > 10 y plus smoking > 20 pack-years (reference was no exposure) found that tobacco smoking (crude odds ratio [OR] 4.50, 95% CI 2.73-7.41; adjusted OR 3.30, 95% CI 1.93-5.63) and biomass exposure (crude OR 3.66, 95% CI 2.00-6.73; adjusted OR 2.28, 95% CI 1.18-4.41) were risk factors for COPD, with smoking a possible confounder for the association between biomass and COPD (post-bronchodilator FEV 1 /FVC biomass and smoking compared with non-COPD subjects. Smoking and biomass are both risk factors for COPD, but they do not appear to have an additive effect. Copyright © 2017 by Daedalus Enterprises.
Neergaard, Mette Asbjørn; Jensen, Anders Bonde; Olesen, Frede
BACKGROUND. Palliative care for cancer patients is an important part of a GP's work. Although every GP is frequently involved in care for terminally ill cancer patients, only little is known about how these palliative efforts are perceived by the patients and their families, a knowledge...... that is vital to further improve palliative care in the primary sector.AIM. The aim of the study was to analyse the quality of palliative home care with focus on the GP's role based on evaluations by relatives of recently deceased cancer patients and professionals from both the primary and secondary health care...... approach.RESULTS. The analyses revealed several key areas, e.g.: 1) How to take, give and maintain professional responsibility for palliative home care. 2) A need for transparent communication both among primary care professionals and among professionals across the primary/secondary interface. 3...
O’Brien, Doireann; Harvey, Kate; Young, Bridget; Reardon, Tessa; Creswell, Cathy
Background Anxiety disorders have a median age of onset of 11 years and are the most common emotional disorders in childhood; however, a significant proportion of those affected do not access professional support. In the UK, GPs are often the first medical professional that families see so are in a prime position to support children with anxiety disorders; however, currently there is little research available on GPs’ perspectives on and experiences of supporting children with these disorders. Aim To explore the experiences of GPs in relation to identification, management, and access to specialist services for children (research, and practice size and location. Purposive sampling was used to recruit GPs until theoretical saturation was reached. Data were analysed using a constant comparative method of thematic analysis. Results Data from 20 semi-structured interviews were organised into three themes: decision making, responsibility, and emotional response, with an overarching theme of GPs feeling ill equipped. These themes were retrospectively analysed to illustrate their role at different stages in the primary care process (identification, management, and access to specialist services). Conclusion GPs feel ill equipped to manage and support childhood anxiety disorders, demonstrating a need for medical training to include greater emphasis on children’s mental health, as well as potential for greater collaboration between primary and specialist services. PMID:29061716
Rashidian, Arash; Eccles, Martin P; Russell, Ian
We aimed to explore key themes for the implementation of guidelines' prescribing recommendations. We interviewed a purposeful sample of 25 participants in British primary care in late 2000 and early 2001. Thirteen were academics in primary care and 12 were non-academic GPs. We asked about implementation of guidelines for five conditions (asthma, coronary heart disease prevention, depression, epilepsy, menorrhagia) ensuring variation in complexity, role of prescribing in patient management, GP role in prescribing and GP awareness of guidelines. We used the Theory of Planned Behaviour to design the study and the framework method for the analysis. Seven themes explain implementation of prescribing recommendations in primary care: credibility of content, credibility of source, presentation, influential people, organisational factors, disease characteristics, and dissemination strategy. Change in recommendations may hinder implementation. This is important since the development of evidence-based guidelines requires change in recommendations. Practitioners do not have a universal view or a common understanding of valid 'evidence'. Credibility is improved if national bodies develop primary care guidelines with less input from secondary care and industry, and with simple and systematic presentation. Dissemination should target GPs' perceived needs, improve ownership and get things right in the first implementation attempt. Enforcement strategies should not be used routinely. GPs were critical of guidelines' development, relevance and implementation. Guidelines should be clear about changes they propose. Future studies should quantify the relationship between evidence base of recommendations and implementation, and between change in recommendations and implementation. Small but important costs and side effects of implementing guidelines should be measured in evaluative studies.
Perkins, Neil; Coleman, Anna; Wright, Michael; Gadsby, Erica; McDermott, Imelda; Petsoulas, Christina; Checkland, Kath
The 2012 Health and Social Care Act in England replaced primary care trusts with clinical commissioning groups (CCGs) as the main purchasing organisations. These new organisations are GP-led, and it was claimed that this increased clinical input would significantly improve commissioning practice. To explore some of the key assumptions underpinning CCGs, and to examine the claim that GPs bring 'added value' to commissioning. In-depth interviews with clinicians and managers across seven CCGs in England between April and September 2013. A total of 40 clinicians and managers were interviewed. Interviews focused on the perceived 'added value' that GPs bring to commissioning. Claims to GP 'added value' centred on their intimate knowledge of their patients. It was argued that this detailed and concrete knowledge improves service design and that a close working relationship between GPs and managers strengthens the ability of managers to negotiate. However, responders also expressed concerns about the large workload that they face and about the difficulty in engaging with the wider body of GPs. GPs have been involved in commissioning in many ways since fundholding in the 1990s, and claims such as these are not new. The key question is whether these new organisations better support and enable the effective use of this knowledge. Furthermore, emphasis on experiential knowledge brings with it concerns about representativeness and the extent to which other voices are heard. Finally, the implicit privileging of GPs' personal knowledge ahead of systematic public health intelligence also requires exploration. © British Journal of General Practice 2014.
Sicsic, Jonathan; Le Vaillant, Marc; Franc, Carine
Like many other OECD nations, France has implemented a pay-for-performance (P4P) model in primary care. However, the benefits have been debated, particularly regarding the possibly undesirable effects of extrinsic motivation (EM) on intrinsic motivation (IM). To examine the relationship between French GPs' IM and EM based on an intrinsic motivation composite score (IMCS) developed for this purpose. If a negative relationship is found, P4P schemes could have side effects on GPs' IM that is a key determinant of quality of care. From data on 423 GPs practicing in a region of France, IM indicators are selected using a multiple correspondence analysis and aggregated from a multilevel model. Several doctors' characteristics have significant impacts on IMCS variability, especially group practice and salaried practice. Qualitative EM variables are negatively correlated with the IMCS: GPs who report not being satisfied with their income or feeling "often" constrained by patients' requests in terms of consultations length and office appointments obtain a lower mean IMCS than other GPs. Our results provide a cautionary message to regulators who should take into account the potential side effects of increasing EM through policies such as P4P. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Hofmeister, Mark; Memedovich, Ally; Dowsett, Laura E; Sevick, Laura; McCarron, Tamara; Spackman, Eldon; Stafinski, Tania; Menon, Devidas; Noseworthy, Tom; Clement, Fiona
The aim of palliative care is to improve the quality of life of patients and families through the prevention and relief of suffering. Frequently, patients may choose to receive palliative care in the home. The objective of this paper is to summarize the quality and primary outcomes measured within the palliative care in the home literature. This will synthesize the current state of the literature and inform future work. A scoping review was completed using PRISMA guidelines. PubMed, Embase, CINAHL, Web of Science, Cochrane Library, EconLit, PsycINFO, Centre for Reviews and Dissemination, Database of Abstracts of Reviews of Effects, and National Health Service Economic Evaluation Database were searched from inception to August 2016. Inclusion criteria included: 1) care was provided in the "home of the patient" as defined by the study, 2) outcomes were reported, and 3) reported original data. Thematic component analysis was completed to categorize interventions. Fifty-three studies formed the final data set. The literature varied extensively. Five themes were identified: accessibility of healthcare, caregiver support, individualized patient centered care, multidisciplinary care provision, and quality improvement. Primary outcomes were resource use, symptom burden, quality of life, satisfaction, caregiver distress, place of death, cost analysis, or described experiences. The majority of studies were of moderate or unclear quality. There is robust literature of varying quality, assessing different components of palliative care in the home interventions, and measuring different outcomes. To be meaningful to patients, these interventions need to be consistently evaluated with outcomes that matter to patients. Future research could focus on reaching a consensus for outcomes to evaluate palliative care in the home interventions.
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.
Plas, A.G.M. van der; Francke, A.L.; Deliens, L.; Jansen, W.J.J.; Vissers, K.C.; Onwuteaka-Philipsen, B.D.
Introduction: Case managers have been introduced in primary palliative care in the Netherlands; these are nurses with expertise in palliative care who offer support to patients and informal care givers. The case manager provides support in addition to the care provided by the home care nurse and
Dekker Janny H
Full Text Available Abstract Background Coordination between care providers of different disciplines is essential to improve the quality of care, in particular for patients with chronic diseases. The way in which general practitioners (GP's and medical specialists interact has important implications for any healthcare system in which the GP plays the role of gatekeeper to specialist care. Patient experiences and preferences have proven to be increasingly important in discussing healthcare policy. The Dutch government initiated the development of a special website with information for patients on performance indicators of hospitals as well as information on illness or treatment. In the present study we focus on the transition of care at the primary – secondary interface with reference to the impact of patients' ability to make choices about their secondary care providers. The purpose of this study is to (a explore experiences and preferences of patients regarding the transition between primary and secondary care, (b study informational resources on illness/treatment desired by patients and (c determine how information supplied could make it easier for the patient to choose between different options for care (hospital or specialist. Methods We conducted a qualitative study using semi-structured focus group interviews among 71 patients referred for various indications in the north and west of The Netherlands. Results Patients find it important that they do not have to wait, that they are taken seriously, and receive adequate and individually relevant information. A lack of continuity from secondary to primary care was experienced. The patient's desire for free choice of type of care did not arise in any of the focus groups. Conclusion Hospital discharge information needs to be improved. The interval between discharge from specialist care and the report of the specialist to the GP might be a suitable performance indicator in healthcare. Patients want to receive
Ab Rahman, Norazida; Teng, Cheong Lieng; Sivasampu, Sheamini
Antibiotic overuse is driving the emergence of antibiotic resistance worldwide. Good data on prescribing behaviours of healthcare providers are needed to support antimicrobial stewardship initiatives. This study examined the differences in antibiotic prescribing rates of public and private primary care clinics in Malaysia. We used data from the National Medical Care Survey (NMCS), a nationwide cluster sample of Malaysian public and private primary care clinics in 2014. NMCS contained demographic, diagnoses and prescribing from 129 public clinics and 416 private clinics. We identified all encounters who were prescribed antibiotic and analyse the prescribing rate, types of antibiotics, and diagnoses that resulted in antibiotic. Five thousand eight hundred ten encounters were prescribed antibiotics; antibiotic prescribing rate was 21.1 % (public clinics 6.8 %, private clinics 30.8 %). Antibiotic prescribing was higher in private clinics where they contributed almost 87 % of antibiotics prescribed in primary care. Upper respiratory tract infection (URTI) was the most frequent diagnosis in patients receiving antibiotic therapy and accounted for 49.2 % of prescriptions. Of the patients diagnosed with URTI, 46.2 % received antibiotic treatment (public 16.8 %, private 57.7 %). Penicillins, cephalosporins and macrolides were the most commonly prescribed antibiotics and accounted for 30.7, 23.6 and 16.0 % of all antibiotics, respectively. More recently available broad-spectrum antibiotics such as azithromycin and quinolones were more frequently prescribed in private clinics. Antibiotic prescribing rates are high in both public and private primary care settings in Malaysia, especially in the latter. This study provides evidence of excessive and inappropriate antibiotic prescribing for self-limiting conditions. These data highlights the needs for more concerted interventions targeting both prescribers and public. Improvement strategies should focus on reducing
Correlation between patients' reasons for encounters/health problems and population density in Japan: a systematic review of observational studies coded by the International Classification of Health Problems in Primary Care (ICHPPC) and the International Classification of Primary care (ICPC).
Kaneko, Makoto; Ohta, Ryuichi; Nago, Naoki; Fukushi, Motoharu; Matsushima, Masato
The Japanese health care system has yet to establish structured training for primary care physicians; therefore, physicians who received an internal medicine based training program continue to play a principal role in the primary care setting. To promote the development of a more efficient primary health care system, the assessment of its current status in regard to the spectrum of patients' reasons for encounters (RFEs) and health problems is an important step. Recognizing the proportions of patients' RFEs and health problems, which are not generally covered by an internist, can provide valuable information to promote the development of a primary care physician-centered system. We conducted a systematic review in which we searched six databases (PubMed, the Cochrane Library, Google Scholar, Ichushi-Web, JDreamIII and CiNii) for observational studies in Japan coded by International Classification of Health Problems in Primary Care (ICHPPC) and International Classification of Primary Care (ICPC) up to March 2015. We employed population density as index of accessibility. We calculated Spearman's rank correlation coefficient to examine the correlation between the proportion of "non-internal medicine-related" RFEs and health problems in each study area in consideration of the population density. We found 17 studies with diverse designs and settings. Among these studies, "non-internal medicine-related" RFEs, which was not thought to be covered by internists, ranged from about 4% to 40%. In addition, "non-internal medicine-related" health problems ranged from about 10% to 40%. However, no significant correlation was found between population density and the proportion of "non-internal medicine-related" RFEs and health problems. This is the first systematic review on RFEs and health problems coded by ICHPPC and ICPC undertaken to reveal the diversity of health problems in Japanese primary care. These results suggest that primary care physicians in some rural areas of Japan
Javanparast, Sara; Coveney, John; Saikia, Udoy
Due to the multifaceted aspect of child malnutrition, a comprehensive approach, taking social factors into account, has been frequently recommended in health literature. The Alma-Ata declaration explicitly outlined comprehensive primary health care as an approach that addresses the social, economic and political causes of poor health and nutrition. Iran as a signatory country to the Alma Ata Declaration has established primary health care since 1979 with significant progress on many health indicators during the last three decades. However, the primary health care system is still challenged to reduce inequity in conditions such as child malnutrition which trace back to social factors. This study aimed to explore the perceptions of the Iranian health stakeholders with respect to the Iranian primary health care performance and actions to move towards a comprehensive approach in addressing childhood malnutrition. Health stakeholders are defined as those who affect or can be affected by health system, for example health policy-makers, health providers or health service recipients. Stakeholder analysis approach was undertaken using a qualitative research method. Different levels of stakeholders, including health policy-makers, health providers and community members were interviewed as either individuals or focus groups. Qualitative content analysis was used to interpret and compare/contrast the viewpoints of the study participants. The results demonstrated that fundamental differences exist in the perceptions of different health stakeholders in the understanding of comprehensive notion and action. Health policy-makers mainly believed in the need for a secure health management environment and the necessity for a whole of the government approach to enhance collaborative action. Community health workers, on the other hand, indicated that staff motivation, advocacy and involvement are the main challenges need to be addressed. Turning to community stakeholders, greater
Liddy, Clare; Singh, Jatinderpreet; Kelly, Ryan; Dahrouge, Simone; Taljaard, Monica; Younger, Jamie
Several new primary care models have been implemented in Ontario, Canada over the past two decades. These practice models differ in team structure, physician remuneration, and group size. Few studies have examined the impact of these models on specialist referrals. We compared specialist referral rates amongst three primary care models: 1) Enhanced Fee-for-service, 2) Capitation- Non-Interdisciplinary (CAP-NI), 3) Capitation - Interdisciplinary (CAP-I). We conducted a cross-sectional study using health administrative data from primary care practices in Ontario from April 1st, 2008 to March 31st, 2010. The analysis included all family physicians providing comprehensive care in one of the three models, had at least 100 patients, and did not have a prolonged absence (eight consecutive weeks). The primary outcome was referral rate (# of referrals to all medical specialties/1000 patients/year). A multivariable clustered Poisson regression analysis was used to compare referral rates between models while adjusting for provider (sex, years since graduation, foreign trained, time in current model) and patient (age, sex, income, rurality, health status) characteristics. Fee-for-service had a significantly lower adjusted referral rate (676, 95% CI: 666-687) than the CAP-NI (719, 95% confidence interval (CI): 705-734) and CAP-I (694, 95% CI: 681-707) models and the interdisciplinary CAP-I group had a 3.5% lower referral rate than the CAP-NI group (RR = 0.965, 95% CI: 0.943-0.987, p = 0.002). Female and Canadian-trained physicians referred more often, while female, older, sicker and urban patients were more likely to be referred. Primary care model is significantly associated with referral rate. On a study population level, these differences equate to 111,059 and 37,391 fewer referrals by fee-for-service versus CAP-NI and CAP-I, respectively - a difference of $22.3 million in initial referral appointment costs. Whether a lower rate of referral is more appropriate or not is not
Full Text Available Abstract Background Due to the multifaceted aspect of child malnutrition, a comprehensive approach, taking social factors into account, has been frequently recommended in health literature. The Alma-Ata declaration explicitly outlined comprehensive primary health care as an approach that addresses the social, economic and political causes of poor health and nutrition. Iran as a signatory country to the Alma Ata Declaration has established primary health care since 1979 with significant progress on many health indicators during the last three decades. However, the primary health care system is still challenged to reduce inequity in conditions such as child malnutrition which trace back to social factors. This study aimed to explore the perceptions of the Iranian health stakeholders with respect to the Iranian primary health care performance and actions to move towards a comprehensive approach in addressing childhood malnutrition. Health stakeholders are defined as those who affect or can be affected by health system, for example health policy-makers, health providers or health service recipients. Methods Stakeholder analysis approach was undertaken using a qualitative research method. Different levels of stakeholders, including health policy-makers, health providers and community members were interviewed as either individuals or focus groups. Qualitative content analysis was used to interpret and compare/contrast the viewpoints of the study participants. Results The results demonstrated that fundamental differences exist in the perceptions of different health stakeholders in the understanding of comprehensive notion and action. Health policy-makers mainly believed in the need for a secure health management environment and the necessity for a whole of the government approach to enhance collaborative action. Community health workers, on the other hand, indicated that staff motivation, advocacy and involvement are the main challenges need to be
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.
Bullington, Jennifer; Cronqvist, Agneta
In primary health care, efficacious treatment strategies are lacking for these patients, although the most prominent symptoms accounting for consultation in primary care often cannot be related to any biological causes. The aim was to explore whether group supervision from a specific phenomenological theory of psychosomatics could provide healthcare professionals treating patients with psychosomatic health issues within primary care a deeper understanding of these conditions and stimulate profession-specific treatment strategies. Our research questions were as follows: (i) What is the healthcare professionals' understanding of psychosomatics before and after the intervention? (ii) What are the treatment strategies for this group of patients before and after the intervention? The study was an explorative qualitative intervention pilot study. The six participants from a primary healthcare setting in a medium-sized city in Sweden participated in the study. A supervision group was formed, based on a mix of professions, age, gender and years of clinical experience. Supervision consisted of one 75-minutes meeting every month during the course of 6 months. Participants were interviewed before and after the supervision intervention. The study showed two distinct categories emerged from the data. One category of healthcare professionals espoused a psycho-educative approach, while the other lacked a cohesive approach. The supervision improved the second category of healthcare professionals' understanding of psychosomatics. The psycho-educative group did not change their understanding of psychosomatics, although they felt strengthened in their approach by the supervision. Profession-specific strategies were not developed. This pilot study indicates that a relatively short supervision intervention can aid clinicians in their clinical encounters with these patients; however, further research is necessary to ascertain the value of the specific phenomenologically based
Malakouti, Seyed Kazem; Nojomi, Marzieh; Poshtmashadi, Marjan; Hakim Shooshtari, Mitra; Mansouri Moghadam, Fariba; Rahimi-Movaghar, Afarin; Afghah, Susan; Bolhari, Jafar; Bazargan-Hejazi, Shahrzad
To describe and evaluate the feasibility of integrating a suicide prevention program with Primary Health Care services and evaluate if such system can improve screening and identification of depressive disorder, reduce number of suicide attempters, and lower rate of suicide completion. This was a quasi-experimental trial in which one community was exposed to the intervention versus the control community with no such exposure. The study sites were two counties in Western Iran. The intervention protocol called for primary care and suicide prevention collaboration at different levels of care. The outcome variables were the number of suicides committed, the number of documented suicide attempts, and the number of identified depressed cases. We identified a higher prevalence of depressive disorders in the intervention site versus the control site (χ (2) = 14.8, P suicide completion in the intervention region compared to the control, but a higher prevalence of suicide attempts in both the intervention and the control sites. Integrating a suicide prevention program with the Primary Health Care network enhanced depression and suicide surveillance capacity and subsequently reduced the number of suicides, especially in rural areas.
Seyed Kazem Malakouti
Full Text Available Objective. To describe and evaluate the feasibility of integrating a suicide prevention program with Primary Health Care services and evaluate if such system can improve screening and identification of depressive disorder, reduce number of suicide attempters, and lower rate of suicide completion. Methodology. This was a quasi-experimental trial in which one community was exposed to the intervention versus the control community with no such exposure. The study sites were two counties in Western Iran. The intervention protocol called for primary care and suicide prevention collaboration at different levels of care. The outcome variables were the number of suicides committed, the number of documented suicide attempts, and the number of identified depressed cases. Results. We identified a higher prevalence of depressive disorders in the intervention site versus the control site (χ2=14.8, P<0.001. We also found a reduction in the rate of suicide completion in the intervention region compared to the control, but a higher prevalence of suicide attempts in both the intervention and the control sites. Conclusion. Integrating a suicide prevention program with the Primary Health Care network enhanced depression and suicide surveillance capacity and subsequently reduced the number of suicides, especially in rural areas.
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.
Frostholm, Lisbeth; Ørnbøl, Eva; Christensen, Kaj Aage Sparle
OBJECTIVE: Little is known about whether illness perceptions affect health outcomes in primary care patients. The aim of this study was to examine if patients' illness perceptions were associated with their self-rated health in a 2-year follow-up period. METHODS: One thousand seven hundred eighty...... at follow-up for the whole group of patients. Patients presenting with MUS had more negative illness perceptions and lower mental and physical components subscale of the SF-36 scores at all time points. CONCLUSIONS: Patients' perception of a new or recurrent health problem predicts self-reported physical......-five primary care patients presenting a new or recurrent health problem completed an adapted version of the illness perception questionnaire and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) at baseline and 3, 12, and 24 months' follow-up. Linear regressions were performed for (1) all...
Coleman, Nathan; Halas, Gayle; Peeler, William; Casaclang, Natalie; Williamson, Tyler; Katz, Alan
Electronic Medical Records (EMRs) are increasingly used in the provision of primary care and have been compiled into databases which can be utilized for surveillance, research and informing practice. The primary purpose of these records is for the provision of individual patient care; validation and examination of underlying limitations is crucial for use for research and data quality improvement. This study examines and describes the validity of chronic disease case definition algorithms and factors affecting data quality in a primary care EMR database. A retrospective chart audit of an age stratified random sample was used to validate and examine diagnostic algorithms applied to EMR data from the Manitoba Primary Care Research Network (MaPCReN), part of the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). The presence of diabetes, hypertension, depression, osteoarthritis and chronic obstructive pulmonary disease (COPD) was determined by review of the medical record and compared to algorithm identified cases to identify discrepancies and describe the underlying contributing factors. The algorithm for diabetes had high sensitivity, specificity and positive predictive value (PPV) with all scores being over 90%. Specificities of the algorithms were greater than 90% for all conditions except for hypertension at 79.2%. The largest deficits in algorithm performance included poor PPV for COPD at 36.7% and limited sensitivity for COPD, depression and osteoarthritis at 72.0%, 73.3% and 63.2% respectively. Main sources of discrepancy included missing coding, alternative coding, inappropriate diagnosis detection based on medications used for alternate indications, inappropriate exclusion due to comorbidity and loss of data. Comparison to medical chart review shows that at MaPCReN the CPCSSN case finding algorithms are valid with a few limitations. This study provides the basis for the validated data to be utilized for research and informs users of its
Hoffmann, Kathryn; George, Aaron; Dorner, Thomas E; Süß, Katharina; Schäfer, Willemijn L A; Maier, Manfred
Multidisciplinary Primary Health Care Teams (PHCT) provide a comprehensive approach to address the social and health needs of communities. It was the aim of this analysis to assess the number of PHCT in Austria, a country with a weak PHC system, and to compare preventive activities, psychosocial care, and work satisfaction between GPs who work and those who do not work in PHCT. Within the QUALICOPC study, data collection was performed between November 2011 and May 2012, utilizing a standardized questionnaire for GPs. A stratified sample of GPs from across Austria was invited. Statistical analyses included descriptive statistics and tests. Data from 171 GPs questionnaires were used for this analysis. Of these, 61.1 % (n = 113) had a mono-disciplinary office, 26.3 % (n = 45) worked in an office consisting of GP, receptionist and one additional primary care profession, and 7.6 % (n = 13) worked in a larger PHCT. GPs that worked in larger PHCT were younger and more involved in psychosocial and preventive care. No differences were found with regard to work satisfaction or workload. This study gives insight into the structures of PHC in Austria. The results indicate a low number of PHCT; however, the overall return rate in our sample was low with more male GPs, more GPs from urban areas and more GPs working in offices together with other physicians than the national average. Younger GPs demonstrate a greater tendency to implement this primary care practice model in their practices, which seems to be associated with an emphasis in psychosocial and preventive care. If Austria is to increase the number of PHC teams, the country should embrace the work of young GPs and should offer relevant support for PHCT. Future developments could be guided by considering effective models of good practice and governmental support as in other countries.
Sansom, Anna; Calitri, Raff; Carter, Mary; Campbell, John
To investigate the reasons behind intentions to quit direct patient care among experienced general practitioners (GPs) aged 50-60 years. Qualitative study based on semistructured interviews with GPs in the South West region of England. Transcribed interviews were analysed thematically. 23 GPs aged 50-60 years: 3 who had retired from direct patient care before age 60, and 20 who intended to quit direct patient care within the next 5 years. The analysis identified four key themes: early retirement is a viable option for many GPs; GPs have employment options other than undertaking direct patient care; GPs report feeling they are doing an (almost) undoable job; and GPs may have other aspirations that pull them away from practice. Findings from this study confirmed those from earlier research, with high workload, ageing and health, family and domestic life, and organisational change all influencing GPs' decisions about when to retire/quit direct patient care. However, in addition, GPs expressed feelings of insecurity and uncertainty regarding the future of general practice, low morale, and issues regarding accountability (appraisal and revalidation) and governance. Suggestions about how to help retain GPs within the active clinical workforce were offered, covering individual, practice and organisational levels. This research highlights aspects of the current professional climate for GPs that are having an impact on retirement decisions. Any future changes to policy or practice to help retain experienced GPs will benefit from this informed understanding of GPs' views. Key factors to take into account include: making the GP workload more manageable; managing change sympathetically; paying attention to GPs' own health; improving confidence in the future of general practice; and improving GP morale. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
dearth of information on patient satisfaction with HIV/AIDS care. This study sought ... with the doctor. Satisfaction rates were: 94.9% technical quality, ... of the delivery of care into several dimensions of contributed by studies carried out in Western. 14 ... efficiency of services as an index of patient needs of its clients. Secondly ...
Full Text Available Although most people with Type 2 diabetes receive their diabetes care in primary care, only a limited amount is known about the quality of diabetes care in this setting. We investigated the provision and receipt of diabetes care delivered in UK primary care.Postal surveys with all healthcare professionals and a random sample of 100 patients with Type 2 diabetes from 99 UK primary care practices.326/361 (90.3% doctors, 163/186 (87.6% nurses and 3591 patients (41.8% returned a questionnaire. Clinicians reported giving advice about lifestyle behaviours (e.g. 88% would routinely advise about calorie restriction; 99.6% about increasing exercise more often than patients reported having received it (43% and 42% and correlations between clinician and patient report were low. Patients' reported levels of confidence about managing their diabetes were moderately high; a median (range of 21% (3% to 39% of patients reporting being not confident about various areas of diabetes self-management.Primary care practices have organisational structures in place and are, as judged by routine quality indicators, delivering high quality care. There remain evidence-practice gaps in the care provided and in the self confidence that patients have for key aspects of self management and further research is needed to address these issues. Future research should use robust designs and appropriately designed studies to investigate how best to improve this situation.
Crabtree, Benjamin F.
I will focus my comments on uncertainty and surprise in primary care practices. I am a medical anthropologist by training, and have been a full-time researcher in family medicine for close to twenty years. In this talk I want to look at primary care practices as complex systems, particularly taking the perspective of translating evidence into practice. I am going to discuss briefly the challenges we have in primary care, and in medicine in general, of translating new evidence into the everyday care of patients. To do this, I will look at two studies that we have conducted on family practices, then think about how practices can be best characterized as complex adaptive systems. Finally, I will focus on the implications of this portrayal for disseminating new knowledge into practice.
Bracco, Mario Maia; Mafra, Ana Carolina Cintra Nunes; Abdo, Alexandre Hannud; Colugnati, Fernando Antonio Basile; Dalla, Marcello Dala Bernardina; Demarzo, Marcelo Marcos Piva; Abrahamsohn, Ises; Rodrigues, Aline Pacífico; Delgado, Ana Violeta Ferreira de Almeida; Dos Prazeres, Glauber Alves; Teixeira, José Carlos; Possa, Silvio
Better communication among field health care teams and points of care, together with investments focused on improving teamwork, individual management, and clinical skills, are strategies for achieving better outcomes in patient-oriented care. This research aims to implement and evaluate interventions focused on improving communication and knowledge among health teams based on points of care in a regional public health outreach network, assessing the following hypotheses: 1) A better-working communication process between hospitals and primary health care providers can improve the sharing of information on patients as well as patients' outcomes. 2) A skill-upgrading education tool offered to health providers at their work sites can improve patients' care and outcomes. A quasi-experimental study protocol with a mixed-methods approach (quantitative and qualitative) was developed to evaluate communication tools for health care professionals based in primary care units and in a general hospital in the southern region of São Paulo City, Brazil. The usefulness and implementation processes of the integration strategies will be evaluated, considering: 1) An Internet-based communication platform that facilitates continuity and integrality of care to patients, and 2) A tailored updating distance-learning course on ambulatory care sensitive conditions for clinical skills improvements. The observational study will evaluate a non-randomized cohort of adult patients, with historical controls. Hospitalized patients diagnosed with an ambulatory care sensitive condition will be selected and followed for 1 year after hospital discharge. Data will be collected using validated questionnaires and from patients' medical records. Health care professionals will be evaluated related to their use of education and communication tools and their demographic and psychological profiles. The primary outcome measured will be the patients' 30-day hospital readmission rates. A sample size of 560
Full Text Available Primary care is regarded as a setting that potentially mitigate patient health literacy (HL related inequalities. However, there is a lack of evidence about influence of patient HL on the patients' perception of quality of primary care. We aimed to examine the association between HL and patient experience of primary care attributes. We conducted a cross-sectional survey, and sent questionnaires to adult residents who were randomly selected from a basic resident register in Yugawara Town, Kanagawa, Japan. We assessed HL using a 14-item Health Literacy Scale (HLS-14 and patient experience of primary care attributes using a Japanese version of Primary Care Assessment Tool (JPCAT, which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available, comprehensiveness (services provided, and community orientation. We used a multivariable linear regression analyses to adjust individual covariates. Data were analyzed for 381 residents who had a usual source of care. After adjustment for patients' sociodemographic and health characteristics, patient HL was positively associated with the JPCAT total score (B = 4.49, 95% confidence interval: 0.27 to 8.65 for HLS-14 total score highest quartile, compared with the lowest quartile. Among primary care attributes, HL had significant associations with longitudinality and comprehensiveness (service provided. We found that HL was positively associated with patient experience of primary care attributes in Japanese people. Our findings indicated that greater efforts might be needed to improve patient-centered and tailored primary care to those with low HL.
Magnil, Maria; Janmarker, Lena; Gunnarsson, Ronny; Björkelund, Cecilia
The aim of this study was to observe course, risk factors, and prognostic factors in a primary care cohort aged > 60 with mild to moderate depression during two-year follow-up. Observational study. Primary care. During an 11-month period all (n = 302) consecutive patients aged 60 and above attending a primary care centre in Gothenburg, Sweden were screened by a nurse for depressive symptoms with the Primary Care Evaluation of Mental Disorders, Patient Questionnaire (PRIME-MD PQ) and the Montgomery-Åsberg Depression Rating Scale, self-rated version (MADRS-S) and by a GP with a patient-centred consultation model. In the second step, the GPs diagnosed depression in screen-positives by use of the PRIME-MD Clinical Evaluation Guide (PRIME-MD CEG). All patients with mild to moderate depression were followed up for two years to assess course with several MADRS-S score assessments. Main outcome measures. Risk factors, prognostic factors, and symptoms at baseline and after two years were tested with logistic regression, using the DSM-IV and MADRS-S (cut-off > 13) respectively. Course patterns were observed and described. A total of 54 patients were diagnosed with depression. Follow-up revealed declining median MADRS-S scores and three course patterns: remitting, stable, and fluctuating. History of depression, significant life events, lacking leisure activities, and use of sedatives were risk factors for depression, all previously known. An important finding was that lacking leisure activities also increased the risk of depressive symptoms after two years (odds ratio 12, confidence interval 1.1-136). It is desirable to identify elderly individuals with less severe depression. Three course patterns were observed; this finding requires further study of the clinical characteristics related to the different patterns. Awareness of risk factors may facilitate identification of those at highest risk of poor prognosis.
Perkins, Neil; Coleman, Anna; Wright, Michael; Gadsby, Erica; McDermott, Imelda; Petsoulas, Christina; Checkland, Kath
Background The 2012 Health and Social Care Act in England replaced primary care trusts with clinical commissioning groups (CCGs) as the main purchasing organisations. These new organisations are GP-led, and it was claimed that this increased clinical input would significantly improve commissioning practice. Aim To explore some of the key assumptions underpinning CCGs, and to examine the claim that GPs bring ‘added value’ to commissioning. Design and setting In-depth interviews with clinicians and managers across seven CCGs in England between April and September 2013. Method A total of 40 clinicians and managers were interviewed. Interviews focused on the perceived ‘added value’ that GPs bring to commissioning. Results Claims to GP ‘added value’ centred on their intimate knowledge of their patients. It was argued that this detailed and concrete knowledge improves service design and that a close working relationship between GPs and managers strengthens the ability of managers to negotiate. However, responders also expressed concerns about the large workload that they face and about the difficulty in engaging with the wider body of GPs. Conclusion GPs have been involved in commissioning in many ways since fundholding in the 1990s, and claims such as these are not new. The key question is whether these new organisations better support and enable the effective use of this knowledge. Furthermore, emphasis on experiential knowledge brings with it concerns about representativeness and the extent to which other voices are heard. Finally, the implicit privileging of GPs’ personal knowledge ahead of systematic public health intelligence also requires exploration. PMID:25348997
McCleskey, Patrick E
Dermatology instruction for primary care learners is limited, and the American Academy of Dermatology (AAD) has developed a new core curriculum for dermatology. This study sought to prospectively evaluate short-term knowledge acquisition and long-term knowledge retention after using the AAD core curriculum during a clinical dermatology clerkship. Resident physicians and physician assistant students performing clerkships at military dermatology clinics were given access to the AAD core curriculum teaching modules before their public availability. Knowledge acquisition was measured with pretests and posttests, and a follow-up quiz was given up to a year after the dermatology rotation to assess knowledge retention. In all, 82 primary care learners met inclusion criteria. Knowledge improved significantly from pretest to posttest (60.1 vs 77.4, P dermatology clerkship. Copyright © 2012 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.
Full Text Available OBJECTIVES: To study potentially traumatic events (PTE, post-traumatic stress disorder (PTSD, anxiety, depression, somatization and post-migration living difficulties (PMLD in primary care immigrants. DESIGN: Patients self-rated transculturally validated questionnaires. Those with and without PTSD were compared on all variables. The influence of the number of PTE and of PMLD on PTSD was measured. RESULTS: 391 patients completed the questionnaires. Prevalence of PTSD was 10.2%. PTE and PMLD were frequent in the whole sample but more common in PTSD subjects. Either the number of PTE and of PMLD significantly increased the likelihood to have a PTSD. CONCLUSIONS: PTE, PMLD, PTSD and related conditions (anxiety, depression and somatization are frequent among immigrants in primary care, and either PTE and PMLD significantly influence resulting psychopathology. The implications in clinical practice are discussed.
Casey, Monica; Hayes, Patrick S; Glynn, Fergus; OLaighin, Gearóid; Heaney, David; Murphy, Andrew W; Glynn, Liam G
Regular physical activity is known to help prevent and treat numerous non-communicable diseases. Smartphone applications (apps) have been shown to increase physical activity in primary care but little is known regarding the views of patients using such technology or how such technology may change behaviour. To explore patients' views and experiences of using smartphones to promote physical activity in primary care. This qualitative study was embedded within the SMART MOVE randomised controlled trial, which used an app (Accupedo-Pro Pedometer) to promote physical activity in three primary care centres in the west of Ireland. Taped and transcribed semi-structured interviews with a purposeful sample of 12 participants formed the basis of the investigation. Framework analysis was used to analyse the data. Four themes emerged from the analysis: transforming relationships with exercise; persuasive technology tools; usability; and the cascade effect. The app appeared to facilitate a sequential and synergistic process of positive change, which occurred in the relationship between the participants and their exercise behaviour; the study has termed this the 'Know-Check-Move' effect. Usability challenges included increased battery consumption and adjusting to carrying the smartphone on their person. There was also evidence of a cascade effect involving the families and communities of participants. Notwithstanding technological challenges, an app has the potential to positively transform, in a unique way, participants' relationships with exercise. Such interventions can also have an associated cascade effect within their wider families and communities. © British Journal of General Practice 2014.
Elley, C Raina; Kerse, Ngaire M; Arroll, Bruce
The question of whether the public health issue of physical inactivity should be addressed in primary health care is a controversial matter. Baseline cross-sectional analysis of a physician-based physical activity intervention trial involving sedentary adults was undertaken within 42 rural and urban family practices in New Zealand to examine self-reported levels of physical activity and cardiovascular risk factors. A self-administered single question about physical activity was used to screen 40- to 79-year-old patients from waiting rooms for physical inactivity. The positive predictive value of the screening question was 81%. Participation rates for the study were high, including 74% of family physicians (n = 117) in the region. Eighty-eight percent of consecutive patients in the age group agreed to be screened and 46% were identified as sedentary. Of those eligible, 66% (n = 878) agreed to participate in a study involving a lifestyle intervention from their family physician. Blood pressure and BMI were significantly greater than that in the general population. There were high rates of hypertension (52%), diabetes (10.5%), obesity (43%), previous cardiovascular disease (19%), and risk factors for cardiovascular disease (93%). Decreasing total energy expenditure was associated with increasing cardiovascular risk (P = 0.001). Sedentary adults in primary care represent a high cardiovascular risk population. Screening for inactivity in primary care is effective and efficient. Two-thirds of sedentary adults agreed to receive a lifestyle intervention from their family physician.
Melin, Eva O; Svensson, Ralph; Thulesius, Hans O
Feasibility testing of a psychoeducational method -The Affect School and Script Analyses (ASSA) - in a Swedish primary care setting. Exploring associations between psychological, and medically unexplained physical symptoms (MUPS). Pilot study. Three Swedish primary care centers serving 20,000 people. 8 weekly 2-hour sessions with a 5-7 participant group led by two instructors - followed by 10 individual hour-long sessions. Thirty-six patients, 29 women (81%), on sick-leave due to depression, anxiety, or fibromyalgia. Feasibility in terms of participation rates and expected improvements of psychological symptoms and MUPS, assessed by self-report instruments pre-, one-week post-, and 18 months post-intervention. Regression coefficients between psychological symptoms and MUPS. The entire 26-hour psychoeducational intervention was completed by 30 patients (83%), and 33 patients (92%) completed the 16-hour Affect School. One-week post-intervention median test score changes were significantly favorable for 27 respondents, with p 80% participation rates, and clear improvements of self-assessed psychological symptoms and MUPS. The ASSA intervention thus showed adequate feasibility in a Swedish primary care setting. Key Points A pilot study of a psychoeducational intervention - The Affect School and Script Analyses (ASSA) - was performed in primary care • The intervention showed feasibility for patients on sick-leave due to depression, anxiety, or fibromyalgia • 92% completed the 8 weeks/16 hours Affect School and 83% completed the entire 26-hour ASSA intervention • 9 of 11 self-reported measures improved significantly one-week post intervention • 7 of 11 self-reported measures improved significantly 18 months post-intervention.
Riihimäki, K; Vuorilehto, M; Isometsä, E
Most practice guidelines recommend maintenance antidepressant treatment for recurrent major depressive disorder. However, the degree to which such guidance is actually followed in primary health care has remained obscure. We investigated the provision of maintenance antidepressant treatment within a representative primary care five-year cohort study. In the Vantaa Primary Care Depression Study, a stratified random sample of 1119 adult patients was screened for depression using the Prime-MD. Depressive and comorbid psychiatric disorders were diagnosed using SCID-I/P and SCID-II interviews. Of the 137 patients with depressive disorders, 82% completed the prospective five-year follow-up. A graphic life chart enabling evaluation of the longitudinal course of episodes plus duration of pharmacotherapies was used. In accordance with national guidelines, an indication for maintenance treatment was defined to exist after three or more lifetime major depressive episodes (MDEs); maintenance treatment was to commence four months after onset of full remission. Of the cohort patients, 34% (46/137) had three or more lifetime MDEs, thus indicating the requirement for maintenance pharmacotherapy. Of these, half (54%, 25/46) received maintenance treatment, for only 29% (489/1670) of the months indicated. In this cohort of depressed primary care patients, half of patients with indications for maintenance treatment actually received it, and only for a fraction of the time indicated. Antidepressant maintenance treatment for the prevention of recurrences is unlikely to be subject to large-scale actualization as recommended, which may significantly undermine the potential public health benefits of treatment. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Flyckt, Lena; Hassler, Ejda; Lotfi, Louise; Krakau, Ingvar; Nilsson, Gunnar H
To identify clinical cues indicative of depression in medical records of cases in primary care with undetected depression. Depressive disorders are common; the lifetime risk for men and women is 27% and 45%, respectively. Despite effective treatment methods such as antidepressants and cognitive behavioural therapy, depression often remains undiscovered in primary care, with great implications both on the individual and societal level. Clinical cues indicating depression were sought in medical records the year before an opportunistic screening for depression in primary care. In a previous study of 221 patients in the waiting room of a primary care centre during 10 randomly selected days, 45 (20%) showed signs of depression (MADRS-S ⩾ 12) and 60% of these were verified as having depressive disorders (Prime-MD). These 45 patients constitute the cases in the present study. Age- and gender-matched controls were selected among those who scored below the chosen cut-off level. Seventeen (38%) of the 45 cases compared with eight (18%) of the 45 controls had one or more cues [odds ratio (OR) 2.81; 95% confidence interval (CI): 1.06-7.43]. Sleep disturbance showed the greatest difference between cases and controls (OR 4.53; 95% CI: 1.17-17.55). A significant relationship was found between severity of depression, frequency of cues and lower functional level. Cues were twice as common in patients with undetected depression and their functional level was lower. A two-stage procedure, screening and a structured diagnostic interview, is recommended when sleep disturbances and lowered function are present.
Javanparast, Sara; Maddern, Janny; Baum, Fran; Freeman, Toby; Lawless, Angela; Labonté, Ronald; Sanders, David
Globally, health reforms continue to be high on the health policy agenda to respond to the increasing health care costs and managing the emerging complex health conditions. Many countries have emphasised PHC to prevent high cost of hospital care and improve population health and equity. The existing tension in PHC philosophies and complexity of PHC setting make the implementation and management of these changes more difficult. This paper presents an Australian case study of PHC restructuring and how these changes have been managed from the viewpoint of practitioners and middle managers. As part of a 5-year project, we interviewed PHC practitioners and managers of services in 7 Australian PHC services. Our findings revealed a policy shift away from the principles of comprehensive PHC including health promotion and action on social determinants of health to one-to-one disease management during the course of study. Analysis of the process of change shows that overall, rapid, and top-down radical reforms of policies and directions were the main characteristic of changes with minimal communication with practitioners and service managers. The study showed that services with community-controlled model of governance had more autonomy to use an emergent model of change and to maintain their comprehensive PHC services. Change is an inevitable feature of PHC systems continually trying to respond to health care demand and cost pressures. The implementation of change in complex settings such as PHC requires appropriate change management strategies to ensure that the proposed reforms are understood, accepted, and implemented successfully. Copyright © 2017 John Wiley & Sons, Ltd.
Full Text Available Antiepileptic drugs (AEDs are commonly prescribed for epilepsy and bipolar disorder but little is known about their use in pregnancy. We examined secular trends in AED prescribing in pregnancy and pregnancy as a determinant for stopping AED prescribing.We identified 174,055 pregnancies from The Health Improvement Network UK primary care database. Secular trends in AED prescribing during pregnancy were examined between 1994 and 2009. We used Cox's regression analyses to compare time to discontinuation of AED prescriptions between pregnant and non-pregnant women and to identify predictors of discontinuation of AEDs in pregnancy.Prescribing of carbamazepine and sodium valproate have declined since 1994 despite being the most commonly prescribed AEDs in pregnancy up to 2004. Prescribing of lamotrigine in pregnancy has steadily increased and has been the most popular AED prescribed in pregnancy since 2004. Pregnant women with epilepsy were twice as likely to stop receiving AEDs (Hazard Ratio (HR 2.00, 95% Confidence Interval (CI 1.62-2.47 when compared to non-pregnant women and for women with bipolar disorder this was even higher (HR 3.07, 95% CI 2.04-4.62. For pregnant women with epilepsy, those receiving AEDs less regularly before pregnancy were more likely to stop receiving AEDs in pregnancy.Lamotrigine has been increasingly prescribed in pregnancy over older AEDs namely carbamazepine and sodium valproate. Pregnancy is a strong determinant for the discontinuation of AED prescribing particularly for women with bipolar disorder.
Zuithoff, Nicolaas P A; Vergouwe, Yvonne; King, Michael; Nazareth, Irwin; Hak, Eelko; Moons, Karel G M; Geerlings, Mirjam I
BACKGROUND: Major depressive disorder often remains unrecognized in primary care. OBJECTIVE: Development of a clinical prediction rule using easily obtainable predictors for major depressive disorder in primary care patients. METHODS: A total of 1046 subjects, aged 18-65 years, were included from
S. Prasanna Lakshmi
Full Text Available BACKGROUND The caesarean section epidemic is a reason for immediate concern and deserves serious National and International attention. Rates of caesarean section are of concern to both developed and developing countries. The indications for caesarean section have been undergoing a gradual change over the last few decades. Besides the obstetric causes, several other medical, social, ethical, economical and medicolegal factors play a role in the rising trend of caesarean section. The aim of the study was undertaken to determine the rate, indications, intraoperative and postoperative complications of primary caesarean section in primi and multipara and maternal and foetal morbidities in these patients. MATERIALS AND METHODS This is a retrospective study carried out on primary caesarean section in the Department of O and G at Mahatma Gandhi Memorial Government Hospital attached to K.A.P.Viswanatham Government Medical College, Trichy, during 1 year period from January 2015-December 2015. Inclusion Criteria- Patients (booked/unbooked attending the labour room undergoing primary caesarean section in the department. Their intraoperative and postoperative complications were noted and also maternal and foetal morbidities and complications. Exclusion Criteria- Gestational age <28 wks., previous LSCS, previous uterine surgery or hysterotomy, multiple gestation. RESULTS There has been a steady increase in total deliveries (increase by 5.2% in the last 2 yrs. at Mahathma Gandhi Memorial Government Hospital attached to K.A.P. Viswanatham Government Medical College, Trichy, and total caesarean section rate (increased by 19.3% and primary caesarean section rate (increased by 12.3% in the past 2 years with concomitant reduction in neonatal mortality rate by 28%. However, this doesn’t justify the increase in primary caesarean section rate. CONCLUSION Potentially modifiable factors such as patient preferences, practice variations among hospitals, systems and
Cragg, Liza; Williams, Siân; van der Molen, Thys; Thomas, Mike; Correia de Sousa, Jaime; Chavannes, Niels H
There is growing awareness amongst healthcare planners, providers and researchers of the need to make better use of routinely collected health data by translating it into actionable information that improves efficiency of healthcare and patient outcomes. There is also increased acceptance of the importance of real world research that recruits patients representative of primary care populations and evaluates interventions realistically delivered by primary care professionals. The UNLOCK Group is an international collaboration of primary care researchers and practitioners from 15 countries. It has coordinated and shared datasets of diagnostic and prognostic variables for COPD and asthma to answer research questions meaningful to professionals working in primary care over a 6-year period. Over this time the UNLOCK Group has undertaken several studies using data from unselected primary care populations from diverse contexts to evaluate the burden of disease, multiple morbidities, treatment and follow-up. However, practical and structural constraints have hampered the UNLOCK Group's ability to translate research ideas into studies. This study explored the constraints, challenges and successes experienced by the UNLOCK Group and its participants' learning as researchers and primary care practitioners collaborating to answer primary care research questions. The study identified lessons for future studies and collaborations that require data sharing across borders. It also explored specific challenges to fostering the exchange of primary care data in comparison to other datasets such as public health, prescribing or hospital data and mechanisms that may be used to overcome these.
Full Text Available Abstract Background The performance of Primary Care Trusts in England is assessed and published using a number of different performance indicators. Our study has two broad purposes. Firstly, to find out whether pairs of indicators that purport to measure similar aspects of quality are correlated (as would be expected if they are both valid measures of the same construct. Secondly, we wanted to find out whether broad (global indicators correlated with any particular features of Primary Care Trusts, such as expenditure per capita. Methods Cross sectional quantitative analysis using data from six 2004/05 PCT performance indicators for 303 English Primary Care Trusts from four sources in the public domain: Star Rating, aggregated Quality and Outcomes Framework scores, Dr Foster mortality index, Dr Foster equity index (heart by-pass and hip replacements, NHS Litigation Authority Risk Management standards and Patient Satisfaction scores from the Star Ratings. Forward stepwise multiple regression analysis to determine the effect of Primary Care Trust characteristics on performance. Results Star Rating and Quality and Outcomes Framework total, both summary measures of global quality, were not correlated with each other (F = 0.66, p = 0.57. There were however positive correlations between Quality and Outcomes Framework total and patient satisfaction (r = 0.61, p Conclusion Performance assessment in healthcare remains on the Government's agenda, with new core and developmental standards set to replace the Star Ratings in 2006. Yet the results of this analysis provide little evidence that the current indicators have sufficient construct validity to measure the underlying concept of quality, except when the specific area of screening is considered.
da Silva, Andréa Tenório Correia; Peres, Maria Fernanda Tourinho; Lopes, Claudia de Souza; Schraiber, Lilia Blima; Susser, Ezra; Menezes, Paulo Rossi
Implementation of primary care has long been a priority in low- and middle-income countries. Violence at work may hamper progress in this field. Hence, we examined the associations between violence at work and depressive symptoms/major depression in primary care teams (physicians, nurses, nursing assistants, and community health workers). A cross-sectional study was undertaken in the city of Sao Paulo, Brazil. We assessed a random sample of Family Health Program teams. We investigated depressive symptoms and major depression using the nine-item Patient Health Questionnaire (PHQ-9), and exposure to violence at work in the previous 12 months using a standardized questionnaire. Associations between exposure to violence and depressive symptoms/major depression were analyzed using multinomial logistic regression. Of 3141 eligible workers, 2940 (93 %) completed the interview. Of these, 36.3 % (95 % CI 34.6-38.1) presented intermediate depressive symptoms, and 16 % (95 % CI 14.6-17.2), probable major depression. The frequencies of exposure to the different types of violence at work were: insults (44.9 %), threats (24.8 %), physical aggression (2.3 %), and witnessing violence (29.5 %). These exposures were strongly and progressively associated with depressive symptoms (adjusted odds ratio 1.67 for exposure to one type of violence; and 5.10 for all four types), and probable major depression (adjusted odds ratio 1.84 for one type; and 14.34 for all four types). Primary care workers presenting depressive symptoms and those who have experienced violence at work should be assisted. Policy makers should prioritize strategies to prevent these problems, since they can threaten primary care sustainability.
Björk Brämberg, Elisabeth; Torgerson, Jarl; Norman Kjellström, Anna; Welin, Peder; Rusner, Marie
Persons with severe mental illness (e.g. schizophrenia, bipolar disorder) have a high prevalence of somatic conditions compared to the general population. Mortality data in the Nordic countries reveal that these persons die 15-20 years earlier than the general population. Some factors explaining this high prevalence may be related to the individuals in question; others arise from the health care