Schmidt, Karen L; Lingler, Jennifer H; Schulz, Richard
Primary care visits of patients with Alzheimer's disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual's verbal participation in these triadic interactions. To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty-three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed. PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver's own verbal participation. Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less. Encouraging verbal participation by AD patients and their caregivers may increase the AD patient's active role and caregiver satisfaction with primary care visits.
especially, District Management Teams, as these are thought to be critical for the development of the service. Across all ... respect as a basis for teamwork, and ensuring networking and co-ordination. (SA Fam ..... success of the doctor s visit is.
Goyal, Neera K; Hall, Eric S; Kahn, Robert S; Wexelblatt, Scott L; Greenberg, James M; Samaan, Zeina M; Brown, Courtney M
Objective Despite practice recommendations that all newborns be examined within 3-5 days after discharge, many are not seen within this timeframe. Our objective was to determine the association between care coordination and timing of newborn follow-up. Methods This retrospective study evaluated 6251 newborns from eight maternity hospitals who scheduled a primary care appointment at one of two academic pediatric practices over 3.5 years. Two programs were sequentially implemented: (1) newborn discharge coordination, and (2) primary care intake coordination. Primary outcome was days between discharge and follow-up, dichotomized as ≤ or >5 days. Number of rescheduled appointments and loss to follow-up were also assessed. Adjusted relative risks (RR) and odds ratios (OR) were determined by piecewise generalized linear and logistic regression. Results Among 5943 newborns with a completed visit, 52.9 % were seen within 5 days of discharge (mean 6.7 days). After multivariable adjustment, the pre-exposure period (8 months) demonstrated a downward monthly trend in completing early follow-up (RR 0.93, p coordinator implementation and roughly 33 % after primary care coordinator implementation. The latter was also associated with a 13 % monthly decrease in odds of loss to follow-up (OR 0.87, p Care coordination increases adherence among low income families to recommended newborn follow-up after birth hospitalization.
Full Text Available The Institute of Medicine Report called for a greater role for nurses within the context of oral health in two recent publications, Advancing Oral Health in America (2011 and Improving Access to Oral Health Care for Vulnerable and Underserved Populations (2011. Nurses provide care for many vulnerable persons, including frail and functionally dependent older adults, persons with disabilities, and persons with intellectual and developmental disabilities. These persons are the least likely to receive necessary, health-sustaining dental care (which is distinct from mouth care. The mouth, or more accurately, plaque, serves as a reservoir for bacteria and pathogens. The link between mouth care, oral health, and systemic health is well-documented; infections such as pneumonia have been linked to poor oral health. Nurses, therefore, need to reframe mouth care as oral infection control and infection control more broadly. The can provide the preventive measure that are crucial to minimizing systemic infections. Nurses in all settings can potentially provide mouth care, conduct oral health assessments, educate patients about best mouth care practices, and make dental referrals. Yet, nurses are often hesitant to do anything beyond basic oral hygiene—and even in this area, often fail to provide mouth care based on best practices.
Müller Christiane A
Full Text Available Abstract Background Home visits are claimed to be a central element of primary care. However, the frequency with which home visits are made is declining both internationally and in Germany despite the increase in the number of chronically ill elderly patients. Given this, the question arises as to how to ensure sufficient primary health care for this vulnerable patient group. The aim of this study was to explore German general practitioners' (GPs attitudes with regard to the feasibility, burden and outlook of continued home visits in German primary care. Methods Qualitative semi-structured interviews were carried out with 24 GPs from the city of Hannover, Germany, and its rural surroundings. Data was analysed using qualitative content analysis. Results The GPs indicated that they frequently conduct home visits, but not all of them were convinced of their benefit. Most were not really motivated to undertake home visits but some felt obliged to. The basic conditions covering home visits were described as unsatisfactory, in particular with respect to reimbursement and time constraints. House calls for vulnerable, elderly people remained undisputed, whereas visits of a social nature were mostly deleted. Urgent house calls were increasingly delegated to the emergency services. Visits to nursing homes were portrayed as being emotionally distressing. GPs considered good cooperation with nursing staff the key factor to ensure a successful nursing home visit. The GPs wanted to ease their work load while still ensuring quality home care but were unable to suggest how this might be achieved. Better financial compensation was proposed most often. The involvement of specially trained nurses was considered possible, but viewed with resentment. Conclusions Home visits are still an integral aspect of primary care in Germany and impose a considerable workload on many practices. Though the existing situation was generally perceived as unsatisfactory, German GPs
Brown, Jonathan D; Wissow, Lawrence S
Youth have concerns about sensitive health topics, such as drugs, sex, and mental health, and many wish to discuss those concerns with a primary care provider. Research has not determined whether the discussion of sensitive health topics during primary care visits is independently associated with youth perceptions of care. This study examined whether the discussion of sensitive health topics during primary care visits was associated with youth's perceptions of the provider and of participation in treatment. Directly after visits to 54 primary care providers in 13 geographically diverse offices and clinics, youth age 11-16 years old (N = 358) reported whether the visit included the discussion of mood, behavior, getting along with others, drugs, tobacco, alcohol, sexuality, birth control, parent mood, or family problems. Youth also reported whether the provider understood their problems, eased their worries, allowed them to make decisions about treatment, gave them some control over treatment, and asked them to take some responsibility for treatment. Providers reported confidence in their ability to offer counseling for nonmedical concerns and their beliefs and attitudes toward treating nonmedical concerns. Youth had more positive perceptions of the provider and were more likely to report taking an active role in treatment when the visit included the discussion of a sensitive health topic. Results from multivariate random effects logistic regression suggested that youth were more likely to report that the provider understood their problems (OR = 3.62, CI = 1.57-8.31), eased their worries (OR = 2.13, CI = 1.06-3.92), allowed them to make decisions about treatment (OR = 2.71, CI = 1.44-5.10), gave them some control over treatment (OR = 2.51, CI = 1.32-4.71), and asked them to take some responsibility for treatment (OR = 2.00, CI = 1.04-3.86) when the visit included the discussion of one or more sensitive health topics. The odds of each of these outcomes were also
Grove, A L; Meredith, J O; Macintyre, M; Angelis, J; Neailey, K
This paper presents the findings of a 13-month lean implementation in National Health Service (NHS) primary care health visiting services from May 2008 to June 2009. Lean was chosen for this study because of its reported success in other healthcare organisations. Value-stream mapping was utilised to map out essential tasks for the participating health visiting service. Stakeholder mapping was conducted to determine the links between all relevant stakeholders. Waste processes were then identified through discussions with these stakeholders, and a redesigned future state process map was produced. Quantitative data were provided through a 10-day time-and-motion study of a selected number of staff within the service. This was analysed to provide an indication of waste activity that could be removed from the system following planned improvements. The value-stream map demonstrated that there were 67 processes in the original health visiting service studied. Analysis revealed that 65% of these processes were waste and could be removed in the redesigned process map. The baseline time-and-motion data demonstrate that clinical staff performed on average 15% waste activities, and the administrative support staff performed 46% waste activities. Opportunities for significant waste reduction have been identified during the study using the lean tools of value-stream mapping and a time-and-motion study. These opportunities include simplification of standard tasks, reduction in paperwork and standardisation of processes. Successful implementation of these improvements will free up resources within the organisation which can be redirected towards providing better direct care to patients.
Izquierdo, Adriana; Sarkisian, Catherine; Ryan, Gery; Wells, Kenneth B; Miranda, Jeanne
To describe salient experiences with a primary care visit (eg, the context leading up to the visit, the experience and/or outcomes of that visit) for emotional, personal and/or mental health problems older Latinos with a history of depression and recent depressive symptoms and/or antidepressant medication use reported 10 years after enrollment into a randomized controlled trial of quality-improvement for depression in primary care. Secondary analysis of existing qualitative data from the second stage of the continuation study of Partners in Care (PIC). Latino ethnicity, aged > or =50 years, recent depressive symptoms and/or antidepressant medication use, and a recent primary care visit for mental health problems. Of 280 second-stage participants, 47 were eligible. Both stages of the continuation study included participants from the PIC parent study control and 2 intervention groups, and all had a history of depression. Data analyzed by a multidisciplinary team using grounded theory methodology. Five themes were identified: beliefs about the nature of depression; prior experiences with mental health disorders/treatments; sociocultural context (eg, social relationships, caregiving, the media); clinic-related features (eg, accessibility of providers, staff continuity, amount of visit time); and provider attributes (eg, interpersonal skills, holistic care approach). Findings emphasize the importance of key features for shaping the context leading up to primary care visits for help-seeking for mental health problems, and the experience and/or outcomes of those visits, among older depressed Latinos at long-term follow-up, and may help tailor chronic depression care for the clinical management of this vulnerable population.
Full Text Available Abstract Background Many Finnish emergency departments (ED serve both primary and secondary health care patients and are therefore referred to as combined emergency departments. Primary care doctors are responsible for the initial assessment and treatment. They, thereby, also regulate referral and access to secondary care. Primary health care EDs are easy for the public to access, leading to non-acute patient visits to the emergency department. This has caused increased queues and unnecessary difficulties in providing immediate treatment for urgent patients. The primary aim of this study was to assess whether the flow of patients was changed by implementing the ABCDE-triage system in the EDs of Espoo City, Finland. Methods The numbers of monthly visits to doctors were recorded before and after intervention in Espoo primary care EDs. To study if the implementation of the triage system redirects patients to other health services, the numbers of monthly visits to doctors were also scored in the private health care, the public sector health services of Espoo primary care during office hours and local secondary health care ED (Jorvi hospital. A face-to-face triage system was applied in the primary care EDs as an attempt to provide immediate treatment for the most acute patients. It is based on the letters A (patient sent directly to secondary care, B (to be examined within 10 min, C (to be examined within 1 h, D (to be examined within 2 h and E (no need for immediate treatment for assessing the urgency of patients' treatment needs. The first step was an initial patient assessment by a health care professional (triage nurse. The introduction of this triage system was combined with information to the public on the "correct" use of emergency services. Results After implementation of the ABCDE-triage system the number of patient visits to a primary care doctor decreased by up to 24% (962 visits/month as compared to the three previous years in the EDs
Thomas E Cowling
Full Text Available BACKGROUND: The number of visits to hospital emergency departments (EDs in England has increased by 20% since 2007-08, placing unsustainable pressure on the National Health Service (NHS. Some patients attend EDs because they are unable to access primary care services. This study examined the association between access to primary care and ED visits in England. METHODS: A cross-sectional, population-based analysis of patients registered with 7,856 general practices in England was conducted, for the time period April 2010 to March 2011. The outcome measure was the number of self-referred discharged ED visits by the registered population of a general practice. The predictor variables were measures of patient-reported access to general practice services; these were entered into a negative binomial regression model with variables to control for the characteristics of patient populations, supply of general practitioners and travel times to health services. MAIN RESULT AND CONCLUSION: General practices providing more timely access to primary care had fewer self-referred discharged ED visits per registered patient (for the most accessible quintile of practices, RR = 0.898; P<0.001. Policy makers should consider improving timely access to primary care when developing plans to reduce ED utilisation.
Cowling, Thomas E.; Cecil, Elizabeth V.; Soljak, Michael A.; Lee, John Tayu; Millett, Christopher; Majeed, Azeem; Wachter, Robert M.; Harris, Matthew J.
Background The number of visits to hospital emergency departments (EDs) in England has increased by 20% since 2007-08, placing unsustainable pressure on the National Health Service (NHS). Some patients attend EDs because they are unable to access primary care services. This study examined the association between access to primary care and ED visits in England. Methods A cross-sectional, population-based analysis of patients registered with 7,856 general practices in England was conducted, for the time period April 2010 to March 2011. The outcome measure was the number of self-referred discharged ED visits by the registered population of a general practice. The predictor variables were measures of patient-reported access to general practice services; these were entered into a negative binomial regression model with variables to control for the characteristics of patient populations, supply of general practitioners and travel times to health services. Main Result and Conclusion General practices providing more timely access to primary care had fewer self-referred discharged ED visits per registered patient (for the most accessible quintile of practices, RR = 0.898; P<0.001). Policy makers should consider improving timely access to primary care when developing plans to reduce ED utilisation. PMID:23776694
Ikeoluwapo O. Ajayi
Full Text Available A cross sectional study was conducted in Primary Health Centers among pregnant women to elucidate adequacy of antenatal care across different socio demographic variables. Four hundred respondents were proportionately selected from 18 primary health centers using simple random sampling. Exit interviews were conducted using the adapted antenatal care exit interview form of the Safe Motherhood Needs Assessment package. Data was analyzed using descriptive statistics and Chi square test. Adequacy of antenatal care in this study was measured by the single adequacy indicators which are duration of pregnancy at entry into antenatal care and number of antenatal visits; which are particularly suitable for developing countries. Age of respondents, means of transportation to the PHCs, occupation, location and level of education of the respondents were found to be determinants of whether the pregnant women attended their first antenatal visit in the first trimester, similarly, age of the respondents was a predictor of whether the women made up to four antenatal visits by their third trimester. Occupation and level of education were determinants of whether or not the pregnant women made their first antenatal visits at the first trimester. More respondents who were not working and those who were unskilled workers made their first antenatal visit at the first trimester compared to those who were skilled workers; work place policies and the fact that antenatal booking are made on weekdays and at work hours may hinder or be discouraging to the working class mothers.
Vogler, Carrie N; Sattovia, Stacy; Salazar, Laura Y; Leung, Tiffany I; Botchway, Albert
This study evaluates the impact of pain education group visits on patients with chronic non-cancer pain (CNCP). The primary outcome of the study was to evaluate patients' functional status and secondary outcomes included knowledge, behavior, and satisfaction, before and after participation in the pain education group visits. Locally produced patient educational videos on chronic non-cancer pain were delivered during patient group visits led by a healthcare provider. Study participants included patients with CNCP pain in an academic general medicine practice. The primary outcome was functional status, measured by the Pain Intensity, Enjoyment of life, and General Activity (PEG) score and the Oswestry Disability Index. Secondary outcomes were evaluated through a pre- and post-intervention knowledge assessment and chart review of opioid use and utilization of emergency and urgent care services. A satisfaction survey was administered after each group visit. Thirty-five patient-group visits were analyzed and 14 patient charts reviewed. A moderately positive correlation was observed between PEG and Oswestry Disability Index (r = 0.47, p high. Group visits providing patient education about CNCP may benefit patients' knowledge about this clinical condition, and was received with high patient satisfaction. Further investigation is needed to evaluate longer-term knowledge retention, sustainability of improvements resulting from the intervention, and longer-term effects of the intervention on functional status.
Whittaker, William; Anselmi, Laura; Lau, Yiu-Shing; Bower, Peter; Checkland, Katherine; Elvey, Rebecca; Stokes, Jonathan
Background Health services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators. Methods and Findings Throughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in “minor” patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for “minor” problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184). There was an insignificant
Celia Maria Sivalli Campos
Full Text Available Objective Identify nurses’ emancipatory practices in primary care, to contribute to the improvement of health care. Method A case study type social research of qualitative nature, in which nurses of a primary health care service unit in São Paulo were interviewed. Results The home visit was identified as a nursing practice possible to be expanded in order to identify social determinants of health, triggering emancipatory practices in the service. This expansion occurred because the design of health care labour intended by the service team changed its focus from the traditional object of health services, the disease. Conclusion First, it is advocated that social policies lead projects with the purpose of improving health needs. On the other hand, the daily labour needs to provide opportunities for reflection and discussion of healthcare projects, leading workers to propose labour-processes targeted to both the social determinants of health and people’s illness.
Ensing, Hendrik T; Koster, Ellen S; Stuijt, Clementine C M; van Dooren, Ad A; Bouvy, Marcel L
Bridging the gap between hospital and primary care is important as transition from one healthcare setting to another increases the risk on drug-related problems and consequent readmissions. To reduce those risks, pharmacist interventions during and after hospitalization have been frequently studied,
Ensing, Hendrik T; Koster, Ellen S; Stuijt, Clementine C M; van Dooren, Ad A; Bouvy, Marcel L
Bridging the gap between hospital and primary care is important as transition from one healthcare setting to another increases the risk on drug-related problems and consequent readmissions. To reduce those risks, pharmacist interventions during and after hospitalization have been frequently studied, albeit with variable effects. Therefore, in this manuscript we propose a three phase approach to structurally address post-discharge drug-related problems. First, hospitals need to transfer up-todate medication information to community pharmacists. Second, the key phase of this approach consists of adequate follow-up at the patients' home. Pharmacists need to apply their clinical and communication skills to identify and analyze drug-related problems. Finally, to prevent and solve identified drug related problems a close collaboration within the primary care setting between pharmacists and general practitioners is of utmost importance. It is expected that such an approach results in improved quality of care and improved patient safety.
Speed, Shaun; Luker, Karen A
This paper examines the ways in which district nurses and general practitioners interacted and influenced each other's work within primary care services. The data presented here examine how the developments in the organisation of primary care affected the work of district nurses during a time of turbulent change. Qualitative data from 300 hours of participant observation and 40 semi-structured interviews with 33 district nurses were analysed using grounded theory, after which a literature review was undertaken. The findings from this study were interpreted using a Foucauldian notion of power and Fox's (1995) analysis of 'organisation'. The shift in power to general practitioners (GPs) has meant that they can exercise ever-increasing authority over nurses in their employ. Strict rules governed the process of inter-professional work and nurses and doctors used creative strategies to overcome the problems that existed between them. The data show that nurses could and did resist the power of GPs but this resistance generally elicited other more punishing forms of authority. Direct and indirect threats were commonplace. The data suggest that district nurses were moving into a closer, more business-like and tightly-controlled working relationship with general practitioners, through which competing discourses interplayed and circulated between GPs and district nurses in the organisation of primary care services.
Sokol, Randi; Albanese, Chiara; Chaponis, Deviney; Early, Jessica; Maxted, George; Morrill, Diana; Poirier, Grace; Puopolo, Fran; Schuman-Olivier, Zev
Primary care providers are well positioned to respond to the opioid crisis by providing buprenorphine/naloxone (B/N) through shared medical appointments (SMAs). Although quantitative research has been previously conducted on SMAs with B/N, the authors conducted a qualitative assessment from the patients' point of view, considering whether and how group visits provide value for patients. Twenty-five participants with opioid use disorder (OUD) who were enrolled in a weekly B/N group visit at a family medicine clinic participated in either of two 1-hour-long focus groups, which were conducted as actual group visits. Participants were prompted with the question "How has this group changed you as a person?" Data were audio-recorded and professionally transcribed and analyzed using a qualitative thematic approach, identifying common communication behaviors and resulting attitudes about the value of the group visit model. Participants demonstrated several communication behaviors that support group members in their recovery, including offering direct emotional support to others struggling with difficult experiences, making an intentional effort to probe about others' lives, venting about heavy situations, joking to lighten the mood, and expressing feelings of gratitude to the entire group. These communication behaviors appear to act as mechanisms to foster a sense of accountability, a shared identity, and a supportive community. Other demonstrated group behaviors may detract from the value of the group experience, including side conversations, tangential comments, and individual participants disproportionately dominating group time. The group visit format for delivering B/N promotes group-specific communication behaviors that may add unique value in supporting patients in their recovery. Future research should elucidate whether these benefits can be isolated from those achieved solely through medication treatment with B/N and if similar benefits could be achieved in non-primary
Bohnert, Kipling M; Pfeiffer, Paul N; Szymanski, Benjamin R; McCarthy, John F
For patients with an initial primary care (PC) encounter in the Veterans Health Administration (VHA) that included a mental health diagnosis, we evaluate whether same-day receipt of Primary Care-Mental Health Integration (PC-MHI) services is associated with the likelihood of receiving a subsequent mental-health-related encounter in the following 90 days. Using VHA administrative data, we identified 9046 patients who received VHA care for the first time in fiscal year 2009, received a PC encounter that included a mental health diagnosis on the first day of their VHA services and initiated care at a VHA facility that provided PC-MHI services. Using multivariable generalized estimating equations logistic regression, we examined whether receipt of same-day PC-MHI was associated with receipt of a subsequent encounter with a mental health diagnosis within 90 days. Analyses adjusted for Operation Enduring Freedom/Operation Iraqi Freedom Veteran status, demographic characteristics, service-connected disability, psychiatric and non-psychiatric diagnoses, and psychotropic medication initiation on the index day of service use. Receipt of same-day PC-MHI services was positively associated with having a mental-health-related encounter in the following 90 days (adjusted odds ratio=2.05; 95% confidence interval=1.66-2.54). PC-MHI services may enhance mental health continuation of care among PC patients with mental health conditions who initiate VHA services. Published by Elsevier Inc.
Bartels, S.J.; Aschbrenner, K.A.; Rolin, S.A.; Hendrick, D.C.; Naslund, J.A.; Faber, M.J.
Objective: Persons with serious mental illness frequently receive inadequate medical care and are more likely to experience difficulty navigating the health care system compared with the general population. To address this gap in quality, we developed a program of peer co-led collaborative activatio
McGill, M; Molyneaux, L M; Yue, D K; Turtle, J R
Modern diabetes management emphasizes the early detection and prompt treatment of diabetic complications. However it is difficult to organize comprehensive screening at the primary care level. To address this problem we established a complication assessment service whereby all the major diabetes-specific complications were assessed in a single 3 h visit. A report with results and recommendations was sent to the general practitioner (GP). Being philosophically a complication-specific service, no attempt was made to intervene with metabolic management. This paper describes our experience with the first 743 patients of whom 92% had been referred from GPs. Of the diabetes-specific complications, 22% of patients had one, 5% had two, and 1% had three major complications. Many of the patients were unaware of the presence of these complications. One hundred and three people had attended the service on more than one occasion with an average time between visits of 1.7 years. The results demonstrated that GPs were very good at following a recommendation to refer a patient for ophthalmic assessment (85% of cases) and improving hypertension but were less successful in treating hyperlipidaemia. This service has proven to be an excellent forum for the collection of data and the teaching of health professionals. It is a move away from the traditional format of hospital-based clinics providing comprehensive diabetes management.
Introduction Elevated blood pressure in childhood may predict increased cardiovascular risk in young adulthood. The Task Force on the Diagnosis, Evaluation and Treatment of High Blood pressure in Children and Adolescents recommends that blood pressure be measured in children aged 3 years or older at all health care visits. Guidelines from both Bright Futures and the Expert Panel of Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents recommend annual ...
Altschuler, Andrea; Chawla, Neetu; Kowalski, Christine; McQuillan, Deanna; Bayliss, Elizabeth; Heisler, Michele; Grant, Richard W
Background Complex patients with multiple chronic conditions often face significant challenges communicating and coordinating with their primary care physicians. These challenges are exacerbated by the limited time allotted to primary care visits. Objective Our aim was to employ a user-centered design process to create a tablet tool for use by patients for visit discussion prioritization. Methods We employed user-centered design methods to create a tablet-based waiting room tool that enables complex patients to identify and set discussion topic priorities for their primary care visit. In an iterative design process, we completed one-on-one interviews with 40 patients and their 17 primary care providers, followed by three design sessions with a 12-patient group. We audiorecorded and transcribed all discussions and categorized major themes. In addition, we met with 15 key health communication, education, and technology leaders within our health system to further review the design and plan for broader implementation of the tool. In this paper, we present the significant changes made to the tablet tool at each phase of this design work. Results Patient feedback emphasized the need to make the tablet tool accessible for patients who lacked technical proficiency and to reduce the quantity and complexity of text presentation. Both patients and their providers identified specific content choices based on their personal experiences (eg, the ability to raise private or sensitive concerns) and recommended targeting new patients. Stakeholder groups provided essential input on the need to augment text with video and to create different versions of the videos to match sex and race/ethnicity of the actors with patients. Conclusions User-centered design in collaboration with patients, providers, and key health stakeholders led to marked evolution in the initial content, layout, and target audience for a tablet waiting room tool intended to assist complex patients with setting
Atkins, Salla; Ojajärvi, Ulla; Talola, Nina; Viljamaa, Mervi; Nevalainen, Jaakko; Uitti, Jukka
Employment protects and fosters health. Occupational health services, particularly in Finland, have a central role in protecting employee health and preventing work ability problems. However, primary care within occupational health services is currently underused in informing preventive activities. This study was designed to assess whether the recording of work ability problems and improvement of follow-up of work-related primary care visits can reduce sickness absences and work disability pensions after 1 year. A pragmatic trial will be conducted using patient electronic registers and registers of the central pensions agency in Finland. Twenty-two occupational health centres will be randomised to intervention and control groups. Intervention units will receive training to improve recording of work ability illnesses in the primary care setting and improved follow-up procedures. The intervention impact will be assessed through examining rates of sickness absence across intervention and control clinics as well as before and after the intervention. The trial will develop knowledge of the intervention potential of primary care for preventing work disability pensions and sickness absence. The use of routine patient registers and pensions registers to assess the outcomes of a randomised controlled trial will bring forward trial methodology, particularly when using register-based data. If successful, the intervention will improve the quality of occupational health care primary care and contribute to reducing work disability. ISRCTN Registry reference number ISRCTN45728263 . Registered on 18 April 2016.
Full Text Available The aim of this study was to examine whether there are social disparities in who receives questions and advice on smoking habits when visiting primary care and whether these disparities can be explained by differences in smoking habits. The study is based on 30,188 individuals aged 16–84 years who responded to a population survey questionnaire in 2012 in four counties in mid-Sweden (response rate 51%. Multivariate logistic regression models were used in statistical analyses. A total of 32% of those who visited a health care centre during the last three months reported that they were asked about their smoking habits during their latest visit, 6% received advice. In general, daily smokers received more often questions, and especially advice, than non-smokers. Persons with low education received more advice than persons with high education due to higher smoking prevalence. However, persons on disability pension and the unemployed were less frequently asked about their smoking habits than employees even though they smoke more. Women received less often questions and advice than men. Persons born outside the Nordic countries received advice twice as often as native Swedes regardless of whether they were daily smokers or not. In Sweden, those who are asked and, in particular, receive advice about changing their smoking habits while visiting primary care are mainly those who need it most. But the findings also imply that measures to reduce smoking should be intensified for women and are perhaps too intense for persons born outside the Nordic countries.
Full Text Available The role of post-migration living difficulties (PMLD on somatization was studied in 101 first generation immigrants visited in primary care. Premigratory traumas and post-traumatic stress disorder (PTSD were also assessed. About one third of patients somatized. Sociodemographic variables were similar in somatizers and non-somatizers. Premigratory traumas, PTSD and the likelihood to report at least one serious or very serious PMLD were higher in somatizers. Four kinds of PMLD were more frequent in somatizers: worries about unavailability of health assistance, working problems, discrimination and poor social help. Traumas and PTSD influenced the effect of PMLD on somatization. Findings suggest that in specific samples of primary care immigrants severe premigratory traumas increase the sensitivity to PMLD and in turn distress due to PMLD amplifies the tendency to somatize.
Martín-Fernández, Jesús; Pérez-Rivas, Francisco Javier; Gómez-Gascón, Tomás; del Cura-González, Isabel; Tello Bernabé, Eugenia; Rodríguez-Martínez, Gemma; Polentinos-Castro, Elena; Domínguez-Bidagor, Julia; Ariza-Cardiel, Gloria; Conde-López, Juan Francisco; Beamud-Lagos, Milagros; Aguado-Arroyo, Oscar; Sanz-Bayona, Teresa; Gil-Lacruz, Ana Isabel
The identification of the attribution of economic value that users of a health system assign to a health service could be useful in planning these services. The method of contingent valuation can provide information about the user's perception of value in monetary terms, and therefore comparable between services of a very different nature. This study attempts to extract the economic value that the subject, user of primary care nursing services in a public health system, attributes to this service by the method of contingent valuation, based on the perspectives of Willingness to Pay (WTP) and Willingness to Accept [Compensation] (WTA). This is an economic study with a transversal design. The contingent valuation method will be used to estimate the user's willingness to pay (WTP) for the care received from the primary care nurse and the willingness to accept [compensation] (WTA), were this service eliminated. A survey that meets the requisites of the contingent valuation method will be constructed and pilot-tested. Subsequently, 600 interviews will be performed with subjects chosen by systematic randomized sampling from among those who visit nursing at twenty health centers with different socioeconomic characteristics in the Community of Madrid. The characteristics of the subject and of the care received that can explain the variations in WTP, WTA and in the WTP/WTA ratio expressed will be studied. A theoretical validation of contingent valuation will be performed constructing two explanatory multivariate mixed models in which the dependent variable will be WTP, and the WTP/WTA relationship, respectively. The identification of the attribution of economic value to a health service that does not have a direct price at the time of use, such as a visit to primary care nursing, and the definition of a profile of "loss aversion" in reference to the service evaluated, can be relevant elements in planning, enabling incorporating patient preferences to health policy decision-making.
Full Text Available Abstract Background The identification of the attribution of economic value that users of a health system assign to a health service could be useful in planning these services. The method of contingent valuation can provide information about the user's perception of value in monetary terms, and therefore comparable between services of a very different nature. This study attempts to extract the economic value that the subject, user of primary care nursing services in a public health system, attributes to this service by the method of contingent valuation, based on the perspectives of Willingness to Pay (WTP and Willingness to Accept [Compensation] (WTA. Methods/Design This is an economic study with a transversal design. The contingent valuation method will be used to estimate the user's willingness to pay (WTP for the care received from the primary care nurse and the willingness to accept [compensation] (WTA, were this service eliminated. A survey that meets the requisites of the contingent valuation method will be constructed and pilot-tested. Subsequently, 600 interviews will be performed with subjects chosen by systematic randomized sampling from among those who visit nursing at twenty health centers with different socioeconomic characteristics in the Community of Madrid. The characteristics of the subject and of the care received that can explain the variations in WTP, WTA and in the WTP/WTA ratio expressed will be studied. A theoretical validation of contingent valuation will be performed constructing two explanatory multivariate mixed models in which the dependent variable will be WTP, and the WTP/WTA relationship, respectively. Discussion The identification of the attribution of economic value to a health service that does not have a direct price at the time of use, such as a visit to primary care nursing, and the definition of a profile of "loss aversion" in reference to the service evaluated, can be relevant elements in planning
Thomas G Land
Full Text Available BACKGROUND: The United States Public Health Service (USPHS Guideline for Treating Tobacco Use and Dependence includes ten key recommendations regarding the identification and the treatment of tobacco users seen in all health care settings. To our knowledge, the impact of system-wide brief interventions with cigarette smokers on smoking prevalence and health care utilization has not been examined using patient population-based data. METHODS AND FINDINGS: Data on clinical interventions with cigarette smokers were examined for primary care office visits of 104,639 patients at 17 Harvard Vanguard Medical Associates (HVMA sites. An operational definition of "systems change" was developed. It included thresholds for intervention frequency and sustainability. Twelve sites met the criteria. Five did not. Decreases in self-reported smoking prevalence were 40% greater at sites that achieved systems change (13.6% vs. 9.7%, p<.01. On average, the likelihood of quitting increased by 2.6% (p<0.05, 95% CI: 0.1%-4.6% per occurrence of brief intervention. For patients with a recent history of current smoking whose home site experienced systems change, the likelihood of an office visit for smoking-related diagnoses decreased by 4.3% on an annualized basis after systems change occurred (p<0.05, 95% CI: 0.5%-8.1%. There was no change in the likelihood of an office visit for smoking-related diagnoses following systems change among non-smokers. CONCLUSIONS: The clinical practice data from HVMA suggest that a systems approach can lead to significant reductions in smoking prevalence and the rate of office visits for smoking-related diseases. Most comprehensive tobacco intervention strategies focus on the provider or the tobacco user, but these results argue that health systems should be included as an integral component of a comprehensive tobacco intervention strategy. The HVMA results also give us an indication of the potential health impacts when meaningful use core
Oliva, Francesco; Versino, Elisabetta; Gammino, Lorenzo; Colombi, Nicoletta; Ostacoli, Luca; Carletto, Sara; Furlan, Pier Maria; Picci, Rocco Luigi
To estimate the relationship between type D personality and essential hypertension among patients visiting their GPs for any health problem, 101 hypertensive and 138 nonhypertensive patients were consecutively recruited and assessed using the Type D Personality Scale (DS14). The predictive value of type D personality was determined using a logistic regression model, taking into account the differences in recognized confounders between groups. Type D personality in the hypertension group was twice as frequent as in the no hypertension group and hypertension was more frequent among type D than non-type D patients. Logistic regression showed a significant predictive value of type D personality for hypertension, adjusting for sex, age, body mass index, family history of hypertension, living condition, education, and employment. Therefore, type D personality was strongly related to hypertension and it was a noteworthy predictor of hypertension in a real-world cohort of primary care patients.
Full Text Available Effective promotion of exercise could result in substantial savings in healthcare cost expenses in terms of direct medical costs, such as the number of medical appointments. However, this is hampered by our limited knowledge of how to achieve sustained increases in physical activity.To assess the effectiveness of a Primary Health Care (PHC based physical activity program in reducing the total number of visits to the healthcare center among inactive patients, over a 15-month period.Randomized controlled trial.Three hundred and sixty-two (n = 362 inactive patients suffering from at least one chronic condition were included. One hundred and eighty-three patients (n = 183; mean (SD; 68.3 (8.8 years; 118 women were randomly allocated to the physical activity program (IG. One hundred and seventy-nine patients (n = 179; 67.2 (9.1 years; 106 women were allocated to the control group (CG. The IG went through a three-month standardized physical activity program led by physical activity specialists and linked to community resources.The total number of medical appointments to the PHC, during twelve months before and after the program, was registered. Self-reported health status (SF-12 version 2 was assessed at baseline (month 0, at the end of the intervention (month 3, and at 12 months follow-up after the end of the intervention (month 15.The IG had a significantly reduced number of visits during the 12 months after the intervention: 14.8 (8.5. The CG remained about the same: 18.2 (11.1 (P = .002.Our findings indicate that a 3-month physical activity program linked to community resources is a short-duration, effective and sustainable intervention in inactive patients to decrease rates of PHC visits.ClinicalTrials.gov NCT00714831.
Land, Thomas G; Rigotti, Nancy A; Levy, Douglas E; Schilling, Thad; Warner, Donna; Li, Wenjun
The United States Public Health Service (USPHS) Guideline for Treating Tobacco Use and Dependence includes ten key recommendations regarding the identification and the treatment of tobacco users seen in all health care settings. To our knowledge, the impact of system-wide brief interventions with cigarette smokers on smoking prevalence and health care utilization has not been examined using patient population-based data. Data on clinical interventions with cigarette smokers were examined for primary care office visits of 104,639 patients at 17 Harvard Vanguard Medical Associates (HVMA) sites. An operational definition of "systems change" was developed. It included thresholds for intervention frequency and sustainability. Twelve sites met the criteria. Five did not. Decreases in self-reported smoking prevalence were 40% greater at sites that achieved systems change (13.6% vs. 9.7%, pstrategies focus on the provider or the tobacco user, but these results argue that health systems should be included as an integral component of a comprehensive tobacco intervention strategy. The HVMA results also give us an indication of the potential health impacts when meaningful use core tobacco measures are widely adopted.
The China National Committee on Ageing recently announced the revision of the law which protects the rights of elderly people was completed. Among the revised sections,a provision that grown-up children will have to visit society’s elderly seniors more often was included in the draft law.
Healthy Lifestyle Pregnancy week by week During the third trimester, prenatal care might include vaginal exams to check the baby's ... 2015 Original article: http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/prenatal-care/art- ...
Healthy Lifestyle Pregnancy week by week During the second trimester, prenatal care includes routine lab tests and measurements of your ... 2015 Original article: http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/prenatal-care/art- ...
... mention even sensitive issues, such as domestic abuse, abortion or past drug use. Remember, the information you ... Your health care provider will use a fetal ultrasound to help confirm the date. Physical exam Your ...
Characteristics of primary care office visits to nurse practitioners, physician assistants and physicians in United States Veterans Health Administration facilities, 2005 to 2010: a retrospective cross-sectional analysis
Morgan Perri A
Full Text Available Abstract Background Primary care, an essential determinant of health system equity, efficiency, and effectiveness, is threatened by inadequate supply and distribution of the provider workforce. The Veterans Health Administration (VHA has been a frontrunner in the use of nurse practitioners (NPs and physician assistants (PAs. Evaluation of the roles and impact of NPs and PAs in the VHA is critical to ensuring optimal care for veterans and may inform best practices for use of PAs and NPs in other settings around the world. The purpose of this study was to characterize the use of NPs and PAs in VHA primary care and to examine whether their patients and patient care activities were, on average, less medically complex than those of physicians. Methods This is a retrospective cross-sectional analysis of administrative data from VHA primary care encounters between 2005 and 2010. Patient and patient encounter characteristics were compared across provider types (PA, NP, and physician. Results NPs and PAs attend about 30% of all VHA primary care encounters. NPs, PAs, and physicians fill similar roles in VHA primary care, but patients of PAs and NPs are slightly less complex than those of physicians, and PAs attend a higher proportion of visits for the purpose of determining eligibility for benefits. Conclusions This study demonstrates that a highly successful nationwide primary care system relies on NPs and PAs to provide over one quarter of primary care visits, and that these visits are similar to those of physicians with regard to patient and encounter characteristics. These findings can inform health workforce solutions to physician shortages in the USA and around the world. Future research should compare the quality and costs associated with various combinations of providers and allocations of patient care work, and should elucidate the approaches that maximize quality and efficiency.
Hout, van H.P.J.; Nijpels, M.G.A.A.M.; Marwijk, van H.W.J.; Jansen, A.P.D.; Veer, van 't P.J.; Tybout, W.; Stalman, W.A.B.
BACKGROUND: The objective of this article is to describe the design of an evaluation of the cost-effectiveness of systematic home visits by nurses to frail elderly primary care patients. Pilot objectives were: 1. To determine the feasibility of postal multidimensional frailty screening instruments;
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.
Tai-Seale, Ming; Foo, Patricia; Stults, Cheryl
Background/Aims Encouraging patients to ask questions in clinical visits is seen as a key to engaging patients. Multiple interventions have focused on activating patients to ask questions when visiting physicians. We know little about whether patients with mental illness ask questions in primary care visits, how their question-asking behavior is associated with physicians’ relational communication and the length of visit. Methods We conducted in-depth mixed method analyses of 322 audio-recordings of periodic health exams (PHE) made by patients 50–80 years of age. Patients included those with mental health (MH) needs, based on 2-item Personal Health Questionnaire (PHQ2) scores (2 or greater), on having filled or been prescribed a psychotropic medication, on having a MH diagnosis or visited a MH provider in prior 12 months, or on having a MH discussion in the visit. Using transcribed recordings, each conversation was categorized into “topics,” which were grouped into three categories: biomedical, MH, or other. Multivariate models were estimated using generalized estimating equations. Results About 99% of patients (319 of 322) asked at least one question. Patients asked questions throughout the visit, averaging 18 per visit. Half of them asked their first question within the first 1.4 minutes. Patients were more likely to ask a question if a topic discussed a medication (OR = 1.57, P <.01) and less likely if the topic was about MH issues compared to biomedical issues (OR = .51, P <.01). PHQ2 score was not a significant factor. The number of patient questions was negatively correlated with ratings of their physicians’ relational communication. Each additional question was associated with a 12-second increase in visit length (P <.01). Conclusions Patients ask many questions, and they ask them early and often. The number of patient questions was associated with unfavorable views of physician relational communication and with slightly longer visits. Patient
Full Text Available Abstract Background The objective of this article is to describe the design of an evaluation of the cost-effectiveness of systematic home visits by nurses to frail elderly primary care patients. Pilot objectives were: 1. To determine the feasibility of postal multidimensional frailty screening instruments; 2. to identify the need for home visits to elderly. Methods Main study: The main study concerns a randomized controlled in primary care practices (PCP with 18 months follow-up and blinded PCPs. Frail persons aged 75 years or older and living at home but neither terminally ill nor demented from 33 PCPs were eligible. Trained community nurses (1 visit patients at home and assess the care needs with the Resident Assessment Instrument-Home Care, a multidimensional computerized geriatric assessment instrument, enabling direct identification of problem areas; (2 determine the care priorities together with the patient; (3 design and execute interventions according to protocols; (4 and visit patients at least five times during a year in order to execute and monitor the care-plan. Controls receive usual care. Outcome measures are Quality of life, and Quality Adjusted Life Years; time to nursing home admission; mortality; hospital admissions; health care utilization. Pilot 1: Three brief postal multidimensional screening measures to identify frail health among elderly persons were tested on percentage complete item response (selected after a literature search: 1 Vulnerable Elders Screen, 2 Strawbridge's frailty screen, and 3 COOP-WONCA charts. Pilot 2: Three nurses visited elderly frail patients as identified by PCPs in a health center of 5400 patients and used an assessment protocol to identify psychosocial and medical problems. The needs and experiences of all participants were gathered by semi-structured interviews. Discussion The design holds several unique elements such as early identification of frail persons combined with case-management by
McGrail, Kimberlyn Marie; Ahuja, Megan Alyssa; Leaver, Chad Andrew
Virtual visits are clinical interactions in health care that do not involve the patient and provider being in the same room at the same time. The use of virtual visits is growing rapidly in health care. Some health systems are integrating virtual visits into primary care as a complement to existing modes of care, in part reflecting a growing focus on patient-centered care. There is, however, limited empirical evidence about how patients view this new form of care and how it affects overall health system use. Descriptive objectives were to assess users and providers of virtual visits, including the reasons patients give for use. The analytic objective was to assess empirically the influence of virtual visits on overall primary care use and costs, including whether virtual care is with a known or a new primary care physician. The study took place in British Columbia, Canada, where virtual visits have been publicly funded since October 2012. A survey of patients who used virtual visits and an observational study of users and nonusers of virtual visits were conducted. Comparison groups included two groups: (1) all other BC residents, and (2) a group matched (3:1) to the cohort. The first virtual visit was used as the intervention and the main outcome measures were total primary care visits and costs. During 2013-2014, there were 7286 virtual visit encounters, involving 5441 patients and 144 physicians. Younger patients and physicians were more likely to use and provide virtual visits (Pvirtual visit patients indicated that virtual visits were liked by patients, with 372 (93.2%) of respondents saying their virtual visit was of high quality and 364 (91.2%) reporting their virtual visit was "very" or "somewhat" helpful to resolve their health issue. Segmented regression analysis and the corresponding regression parameter estimates suggested virtual visits appear to have the potential to decrease primary care costs by approximately Can $4 per quarter (Can -$3.79, P=.12
Gordon, Aliza S; Adamson, Wallace C; DeVries, Andrea R
Expansion of virtual health care-real-time video consultation with a physician via the Internet-will continue as use of mobile devices and patient demand for immediate, convenient access to care grow. The objective of the study is to analyze the care provided and the cost of virtual visits over a 3-week episode compared with in-person visits to retail health clinics (RHC), urgent care centers (UCC), emergency departments (ED), or primary care physicians (PCP) for acute, nonurgent conditions. A cross-sectional, retrospective analysis of claims from a large commercial health insurer was performed to compare care and cost of patients receiving care via virtual visits for a condition of interest (sinusitis, upper respiratory infection, urinary tract infection, conjunctivitis, bronchitis, pharyngitis, influenza, cough, dermatitis, digestive symptom, or ear pain) matched to those receiving care for similar conditions in other settings. An episode was defined as the index visit plus 3 weeks following. Patients were children and adults younger than 65 years of age without serious chronic conditions. Visits were classified according to the setting where the visit occurred. Care provided was assessed by follow-up outpatient visits, ED visits, or hospitalizations; laboratory tests or imaging performed; and antibiotic use after the initial visit. Episode costs included the cost of the initial visit, subsequent medical care, and pharmacy. A total of 59,945 visits were included in the analysis (4635 virtual visits and 55,310 nonvirtual visits). Virtual visit episodes had similar follow-up outpatient visit rates (28.09%) as PCP (28.10%, P=.99) and RHC visits (28.59%, P=.51). During the episode, lab rates for virtual visits (12.56%) were lower than in-person locations (RHC: 36.79%, Pvirtual visits (6.62%) were typically lower than in-person locations (RHC: 5.97%, P=.11; UCC: 8.77%, Pvirtual visit episodes, respectively, including medical and pharmacy costs. Virtual care appears to
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 assesse
Nápoles, Anna M; Santoyo-Olsson, Jasmine; Karliner, Leah S; O'Brien, Helen; Gregorich, Steven E; Pérez-Stable, Eliseo J
Linguistic interpretation ameliorates health disparities disfavoring underserved limited English-proficient patients, yet few studies have compared clinician satisfaction with these services. Self-administered clinician post-visit surveys compared the quality of interpretation and communication, visit satisfaction, degree of patient engagement, and cultural competence of visits using untrained people acting as interpreters (ad hoc), in-person professional, or video conferencing professional interpretation for 283 visits. Adjusting for clinician and patient characteristics, the quality of interpretation of in-person and video conferencing modes were rated similarly (OR 1.79, 95% CI 0.74, 4.33). The quality of in-person (OR 5.55, 95% CI 1.50, 20.51) and video conferencing (OR 3.10, 95% CI 1.16, 8.31) were rated higher than ad hoc interpretation. Self-assessed cultural competence was better for in-person versus video conferencing interpretation (OR 2.32, 95% CI 1.11, 4.86). Video conferencing interpretation increases access without compromising quality, but cultural nuances may be better addressed by in-person interpreters. Professional interpretation is superior to ad hoc (OR 4.15, 95% CI 1.43, 12.09).
Use of patient flow analysis to improve patient visit efficiency by decreasing wait time in a primary care-based disease management programs for anticoagulation and chronic pain: a quality improvement study.
Potisek, Nicholas M; Malone, Robb M; Shilliday, Betsy Bryant; Ives, Timothy J; Chelminski, Paul R; DeWalt, Darren A; Pignone, Michael P
Patients with chronic conditions require frequent care visits. Problems can arise during several parts of the patient visit that decrease efficiency, making it difficult to effectively care for high volumes of patients. The purpose of the study is to test a method to improve patient visit efficiency. We used Patient Flow Analysis to identify inefficiencies in the patient visit, suggest areas for improvement, and test the effectiveness of clinic interventions. At baseline, the mean visit time for 93 anticoagulation clinic patient visits was 84 minutes (+/- 50 minutes) and the mean visit time for 25 chronic pain clinic patient visits was 65 minutes (+/- 21 minutes). Based on these data, we identified specific areas of inefficiency and developed interventions to decrease the mean time of the patient visit. After interventions, follow-up data found the mean visit time was reduced to 59 minutes (+/-25 minutes) for the anticoagulation clinic, a time decrease of 25 minutes (t-test 39%; p pain clinic was reduced to 43 minutes (+/- 14 minutes) a time decrease of 22 minutes (t-test 34 %; p effective technique to identify inefficiencies in the patient visit and efficiently collect patient flow data. Once inefficiencies are identified they can be improved through brief interventions.
Alper, Philip R.
Given the chorus of approval for primary care emanating from every party to the health reform debate, one might suppose that the future for primary physicians is bright. Yet this is far from certain. And when one looks to history and recognizes that primary care medicine has failed virtually every conceivable market test in recent years, its…
Development of primary care in Japan in still relatively unorganized and unstructured. As mentioned above, the author describes some strengths and weaknesses of the Japanese primary care system. In addressing the weaknesses the following suggestions are offered for the Japanese primary care delivery system: Increase the number of emergency rooms for all day, especially on holidays and at night. Introduce an appointment system. Introduce an open system of hospitals. Coordinate with public hospitals and primary care clinics. Organize the referral system between private practitioners and community hospitals. Increase the number of paramedical staff. Strengthen group practice among primary care physicians. Increase the establishment of departments of primary care practice with government financial incentives to medical schools and teaching hospitals. Develop a more active and direct teaching role for primary care practice or family practice at undergraduate, graduate, and postgraduate levels. Improve and maintain present health insurance payment method, shifting from quantity of care to quality and continuity of care. Introduce formal continuing education. Introduce formal training programs of primary care and strengthen ambulatory care teaching programs.
Carter, Amy J; Deselms, JoAnn; Ruyle, Shelley; Morrissey-Lucas, Marcella; Kollar, Suzie; Cannon, Shelly; Schick, Lois
Despite advocacy by professional nursing organizations, no randomized controlled trials (RCTs) have evaluated the response of family members to a visit with an adult patient during a postanesthesia care unit (PACU) stay. Therefore, the purpose of this RCT was to evaluate the impact of a brief PACU visitation on the anxiety of family members. The study was conducted in a phase I PACU of a large community-based hospital. Subjects were designated adult family members or significant others of an adult PACU patient who had undergone general anesthesia. A pretest-posttest RCT design was used. The dependent variable was the change in anxiety scores of the visitor after seeing his or her family member in the PACU. Student t test (unpaired, two tailed) was used to determine if changes in anxiety scores (posttest score-pretest score) were different for the PACU visit and no visit groups. A total of 45 participants were studied over a 3-month period, with N=24 randomly assigned to a PACU visit and N=21 assigned to usual care (no PACU visit). Participants in the PACU visit group had a statistically significant (P=.0001) decrease in anxiety after the visitation period (-4.11±6.4); participants in the usual care group (no PACU visit) had an increase in anxiety (+4.47±6.6). The results from this study support the value and importance of PACU visitation for family members.
Horney, Carolyn; Schmader, Kenneth; Sanders, Linda L; Heflin, Mitchell; Ragsdale, Luna; McConnell, Eleanor; Hocker, Michael; Hastings, S Nicole
Older adults in the United States receive a significant amount of care in the emergency department (ED), yet the associations between ED and other types of health care utilization have not been adequately studied in this population. The goals of this study were to examine the relationships between health care use before and after an ED visit among older adults. This retrospective cohort study examined health care use among 308 patients 65 years or older discharged from a university-affiliated ED. Proportional-hazards models were used to assess the relationship between pre-ED health care use (primary care physician [PCP], specialist, ED, and hospital) and risk of return ED visits. Older ED patients in this study had visited other types of providers frequently in the previous year (median number of PCP and specialist visits, 4). Patients who used the ED on 2 or more occasions in the previous year were found to have visited their PCP more often than those without frequent ED use (median number of visits, 7.0 vs 4.0; P < .001). Despite more PCP use in this population, frequent ED use was associated with increased risk of a repeat ED visit (hazard ratio, 2.20; 95% confidence interval, 1.15-4.21), in models adjusted for demographics and health status. Older adults who use the ED are also receiving significant amounts of care from other sources; simply providing additional access to care may not improve outcomes for these vulnerable individuals. Published by Elsevier Inc.
Holtrop, Jodi Summers; Luo, Zhehui; Alexanders, Lynn
Care management in primary care can be effective in helping patients with chronic disease improve their health; however, primary care practices are often challenged to identify revenue to pay for it. This study explored the impact of direct reimbursement on the provision of care management in a primary care physician organization. Using data on expenses and health plan reimbursement during the initial 16 months of care management implementation at 5 practices, we calculated the percentage of related costs that were covered by payments. Qualitative data from interviews with practice members were used to identify their perceived barriers to care management reimbursement and the impact of current reimbursement strategies on service delivery. Direct reimbursement for care management covered only 21% of the costs. Reimbursement varied by care manager background, patient diagnoses, insurer, and indication for the visit. Barriers to gaining reimbursement included patient resistance to copay, clinician hesitation to bill for care management visits (for fear the patient may receive a bill), differential reimbursement policies of insurers, and general lack of reimbursement for care management in many cases. Although practice-level quality improvement incentives were an alternative means of supporting care management, because these incentives were not directly tied to the service of care management, they were used for other activities ultimately supporting patient care. This study highlights the need for sufficient reimbursement to initiate and maintain care management for patients in primary care as proposed for service reforms under the Affordable Care Act. © Copyright 2015 by the American Board of Family Medicine.
Strader, Kathleen; Counts, Jacqueline; Filene, Jill
The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program is part of The Patient Protection and Affordable Care Act and provides $1.5 billion over 5 years to states, territories, and tribes with the goal of delivering evidence-based home visiting services as part of a high-quality, comprehensive early childhood system that promotes…
Koppula, Sudha; Brown, Judith B.; Jordan, John M.
Abstract Objective To explore the experiences and recommendations for recruitment of family physicians who practise and teach primary care obstetrics. Design Qualitative study using in-depth interviews. Setting Six primary care obstetrics groups in Edmonton, Alta, that were involved in teaching family medicine residents in the Department of Family Medicine at the University of Alberta. Participants Twelve family physicians who practised obstetrics in groups. All participants were women, which was reasonably representative of primary care obstetrics providers in Edmonton. Methods Each participant underwent an in-depth interview. The interviews were audiotaped and transcribed verbatim. The investigators independently reviewed the transcripts and then analyzed the transcripts together in an iterative and interpretive manner. Main findings Themes identified in this study include lack of confidence in teaching, challenges of having learners, benefits of having learners, and recommendations for recruiting learners to primary care obstetrics. While participants described insecurity and challenges related to teaching, they also identified positive aspects, and offered suggestions for recruiting learners to primary care obstetrics. Conclusion Despite describing poor confidence as teachers and having challenges with learners, the participants identified positive experiences that sustained their interest in teaching. Supporting these teachers and recruiting more such role models is important to encourage family medicine learners to enter careers such as primary care obstetrics. PMID:24627402
Conclusion: There were inequalities in risks of ambulatory care use among Taiwan's dentists. Further studies should be conducted to investigate the causes responsible for the observed geographic and institutional variations in the risk of morbidity among dentists in Taiwan.
This video is an extract of a reportage broadcasted by SKAI TV in Greece about the visit of Prof. Dimitri Nanopoulos to Hill Primary School, the oldest operating school in Greece. The video describes a breakthrough education programme aimed at introducing big ideas in physics, particle physics and cosmology to K-6 students through a pedagogical approach that promotes inquiry, creativity and hands-on experimentation with the use everyday materials.
Horney, Carolyn; Schmader, Kenneth; Sanders, Linda L.; Heflin, Mitchell; Ragsdale, Luna; McConnell, Eleanor; Hocker, Michael; Hastings, S. Nicole
Background Older adults in the U.S. receive a significant amount of care in the emergency department (ED), yet the associations between ED and other types of health care utilization has not been adequately studied in this population. Objectives The goal of this study were to examine the relationships between health care use before and after an ED visit among older adults. Methods This retrospective cohort study examined health care use among 308 patients ≥ 65 years old discharged from a university-affiliated ED. Proportional-hazards models were used to assess the relationship between pre-ED health care use (primary care physician (PCP), specialist, ED and hospital) and risk of return ED visits. Results Older ED patients in this study had visited other types of providers frequently in the previous year (median number of primary care physician (PCP) and specialist visits = 4). Patients who used the ED on 2 or more occasions in the previous year were found to have visited their PCP more often than those without frequent ED use (median number of visits 7.0 vs 4.0, p<.001). Despite more PCP use in this population, frequent ED use was associated with increased risk of a repeat ED visit (HR 2.20, 95% CI 1.15–4.21), in models adjusted for demographics and health status. Conclusion Older adults who use the ED are also receiving significant amounts of care from other sources; simply providing additional access to care may not improve outcomes for these vulnerable individuals. PMID:21216555
Over the past decade, at least 600,000 refugees from more than 60 different countries have been resettled in the United States. The personal history of a refugee is often marked by physical and emotional trauma. Although refugees come from many different countries and cultures, their shared pattern of experiences allows for some generalizations to be made about their health care needs and challenges. Before being accepted for resettlement in the United States, all refugees must pass an overseas medical screening examination, the purpose of which is to identify conditions that could result in ineligibility for admission to the United States. Primary care physicians have the opportunity to care for members of this unique population once they resettle. Refugees present to primary care physicians with a variety of health problems, including musculoskeletal and pain issues, mental and social health problems, infectious diseases, and longstanding undiagnosed chronic illnesses. Important infectious diseases to consider in the symptomatic patient include tuberculosis, parasites, and malaria. Health maintenance and immunizations should also be addressed. Language barriers, cross-cultural medicine issues, and low levels of health literacy provide additional challenges to caring for this population. The purpose of this article is to provide primary care physicians with a guide to some of the common issues that arise when caring for refugee patients.
María del Mar Alfaya Góngora
Full Text Available Objectives:To describe the clinical encounters that occur when a palliative care team provides patient care and the features that influence these encounters and indicate whether they are favorable or unfavorable depending on the expectations and feelings of the various participants.Methods:A qualitative case study conducted via participant observation. A total of 12 observations of the meetings of palliative care teams with patients and families in different settings (home, hospital and consultation room were performed. The visits were follow-up or first visits, either scheduled or on demand. Content analysis of the observation was performed.Results:The analysis showed the normal follow-up activity of the palliative care unit that was focused on controlling symptoms, sharing information and providing advice on therapeutic regimens and care. The environment appeared to condition the patients' expressions and the type of patient relationship. Favorable clinical encounter conditions included kindness and gratitude. Unfavorable conditions were deterioration caused by approaching death, unrealistic family objectives and limited resources.Conclusion:Home visits from basic palliative care teams play an important role in patient and family well-being. The visits seem to focus on controlling symptoms and are conditioned by available resources.
Macek, Mark D; Wagner, Mark L; Goodman, Harold S; Manz, Michael C; Marrazzo, Ilise D
Regular dental visits afford an opportunity for dentists to provide preventive services and to diagnose and treat disease. Not all children, however, have equal access to these services. The authors conducted this study to describe access to and utilization of oral health care services for Maryland schoolchildren in kindergarten and third grade. They obtained data from a questionnaire filled out by parents or guardians participating in the Survey of the Oral Health Status of Maryland School Children, 2000-2001 (N = 2,642). Outcome variables included having a dental visit in the last year, prophylaxis in the last year, usual source of medical care and usual source of dental care. Descriptor variables included region, grade, race/ethnicity, eligibility for free or reduced-fee meals, parents' or guardians' education and dental insurance status. Overall, general dental visit and dental prophylaxis visit rates were similar (74.1 and 71.3 percent, respectively). Schoolchildren, however, were more likely to have had a usual source of medical care than of dental care (96.0 and 82.9 percent, respectively). Third graders, those ineligible for free or reduced-fee meals and those with some dental insurance coverage were more likely to have received a prophylaxis in the last year and were more likely to have a usual source of dental care. Non-Hispanic white and non-Hispanic black schoolchildren also were more likely to have had a usual source of dental care than were Hispanics. Schoolchildren most likely to have received regular preventive dental care were those who had parents or guardians with financial resources. Medicaid and State Children's Health Insurance Program (SCHIP) provide safety nets, but these programs could be improved. Dentistry's challenge is to determine which characteristics are unique to those who visit the dentist regularly and use this information to help meet the needs of the underserved.
Mao, Jun J; Kapur, Rahul
Acupuncture, an ancient traditional Chinese medical therapy, is used widely around the world. When practiced by a certified provider, it is safe and patients often find it calming and relaxing. Animal and human studies have found a physiologic basis for acupuncture needling in that it affects the complex central and peripheral neurohormonal network. Although it is unclear whether acupuncture is beneficial over sham/placebo acupuncture, acupuncture care yields clinically relevant short- and long-term benefits for low back pain, knee osteoarthritis, chronic neck pain, and headache. The integration of acupuncture into a primary care setting also appears to be cost-effective. The practice of acupuncture in primary care requires rigorous training, financial discipline, and good communication skills. When done correctly, acupuncture is beneficial for both patients and providers.
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.
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.
Full Text Available There is increasing interest in models that integrate behavioral health services into primary care. For patients with severe mental illness (SMI, a population with disproportionate morbidity and mortality, little is known about the impact of such models on primary care clinic utilization, and provider panels. We performed a retrospective cohort pilot study examining visit patterns for 1,105 patients with SMI overall, by provider, before, and after the implementation of a primary care behavioral health model which had a ramp up period from May 2006-August 2007. We used 2003-2012 electronic health record data from two clinics of a Federally Qualified Health Center and conducted interrupted time series and chi-square analyses. During the intervention period there was a significant increase in the proportion of visits per month to the clinic for patient with SMI relative to overall visits (0.27; 95% CI 0.22-0.32. After the intervention period, this rate declined (-0.23; -0.19-0.28 but remained above the pre-intervention period. After integration of behavioral health into our primary care clinics, there was a sharp increase in the number of patients with SMI, suggesting patient willingness to explore receiving care under this model. Clinics looking to adopt the model should be mindful of potential changes in patient subpopulations and proactively manage this transition.
Escudero, D; Martín, L; Viña, L; Quindós, B; Espina, M J; Forcelledo, L; López-Amor, L; García-Arias, B; del Busto, C; de Cima, S; Fernández-Rey, E
To determine the design and comfort in the Intensive Care Units (ICUs), by analysing visiting hours, information, and family participation in patient care. Descriptive, multicentre study. Spanish ICUs. A questionnaire e-mailed to members of the Spanish Society of Intensive Care Medicine, Critical and Coronary Units (SEMICYUC), subscribers of the Electronic Journal Intensive Care Medicine, and disseminated through the blog Proyecto HU-CI. A total of 135 questionnaires from 131 hospitals were analysed. Visiting hours: 3.8% open 24h, 9.8% open daytime, and 67.7% have 2 visits a day. Information: given only by the doctor in 75.2% of the cases, doctor and nurse together in 4.5%, with a frequency of once a day in 79.7%. During weekends, information is given in 95.5% of the cases. Information given over the phone 74.4%. Family participation in patient care: hygiene 11%, feeding 80.5%, physiotherapy 17%. Personal objects allowed: mobile phone 41%, computer 55%, sound system 77%, and television 30%. Architecture and comfort: all individual cubicles 60.2%, natural light 54.9%, television 7.5%, ambient music 12%, clock in the cubicle 15.8%, environmental noise meter 3.8%, and a waiting room near the ICU 68.4%. Visiting policy is restrictive, with a closed ICU being the predominating culture. On average, technological communication devices are not allowed. Family participation in patient care is low. The ICU design does not guarantee privacy or provide a desirable level of comfort. Copyright © 2015 SECA. Published by Elsevier Espana. All rights reserved.
Gorman, Rosemary D
Improved quality of life, care consistent with patient goals of care, and decreased health care spending are benefits of palliative care. Palliative care is appropriate for anyone with a serious illness. Advances in technology and pharmaceuticals have resulted in increasing numbers of seriously ill individuals, many with a high symptom burden. The numbers of individuals who could benefit from palliative care far outweighs the number of palliative care specialists. To integrate palliative care into primary care it is essential that resources are available to improve generalist palliative care skills, identify appropriate patients and refer complex patients to specialist palliative care providers.
Wright, Robert; Saul, Robert A
Epigenetics, the study of functionally relevant chemical modifications to DNA that do not involve a change in the DNA nucleotide sequence, is at the interface between research and clinical medicine. Research on epigenetic marks, which regulate gene expression independently of the underlying genetic code, has dramatically changed our understanding of the interplay between genes and the environment. This interplay alters human biology and developmental trajectories, and can lead to programmed human disease years after the environmental exposure. In addition, epigenetic marks are potentially heritable. In this article, we discuss the underlying concepts of epigenetics and address its current and potential applicability for primary care providers.
Hoedeman, Rob; Blankenstein, Annette H.; van der Feltz-Cornelis, Christina M.; Krol, Boudien; Stewart, Roy; Groothoff, Johan W.; van der Feltz-Cornelis, CM
Background In primary care between 10% and 35% of all visits concern patients with medically unexplained physical symptoms (MUPS). MUPS are associated with high medical consumption, significant disabilities and psychiatricmorbidity. Objectives To assess the effectiveness of consultation letters (CLs
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 i...
The Abbreviated Pandemic Influenza Plan Template for Primary Care Provider Offices is intended to assist primary care providers and office managers with preparing their offices for quickly putting a plan in place to handle an increase in patient calls and visits, whether during the 2009-2010 influenza season or future influenza seasons.
Ijäs, Jarja; Alanen, Seija; Kaila, Minna
-sectional telephone survey. SETTING: All municipal health centres in Finland. SUBJECTS: Health centres where both the head physician and the senior nursing officer responded. MAIN OUTCOME MEASURES: Agreement in views of the senior executives on the adoption of clinical practices as recommended in the Hypertension......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
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...
availability and affordability of ACTs in Secondary Health Care (SHC) facilities in Lagos State and ... percent (37.5%) of the hospitals did not have the drug in stock at the time of visit and drugs had been out of .... Only one in the community pharmacies as single dose .... funding and international competitive bidding for.
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...
Selma Aparecida Lagrosa Garcia
Full Text Available Objective: To investigate, with a qualitative approach, the role of Obstetric Nurses at the primary level of care given to women’s health as a vital component of the multidisciplinary team, which today is fundamental for providing care, prevention as well as health education and promotion, especially in programs whose activities are geared towards primary care of pregnant, parturient, and puerpera women. Methods: Brazilian laws and the determinations of Nursing Councils in reference to the activities of the obstetric nurse were researched, including the nurse’s responsibilities and limits. The bibliographic search was conducted in health-related journals, lay publications, and the Internet. Results: The conflicts between professional physicians and nurses were discussed. Conclusions: It was concluded that the activities of the nurse, conducting low-risk prenatal clinical visits in the basic healthcare network, has legal and ethical support and provides true benefit to the clients.
Decker, Sandra L; Burt, Catharine W; Sisk, Jane E
Using data from the National Ambulatory Medical Care Survey, logit models tested for trends in the probability that visits by adult diabetes patients to their primary care providers included recommended treatment measures, such as a prescription for an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-II receptor blocker (ARB), blood pressure measurement, and diet/nutrition or exercise counseling. Results indicated that the probability that visits included prescription of an ACE or ARB and blood pressure measurement increased significantly over the 1997-2005 period, while the probability that visits documented provision of exercise counseling rose since 2001.
Department of Community Health & Primary Care, College of Medicine, University of Lagos, Idi-Araba, P.M.B. ... the child's health, culturally based beliefs and ..... immunization safety as this was a rural ... Charles SW, Olalekan AU, Peter MN,.
Journal of Community Medicine and Primary Health Care. ... This is one of the factors that determine whether or ..... Expired vaccines found in fridge / cold box .... date vaccine temperature monitoring charts. were stored on refrigerator door ...
Rodriguez, Hector P; Rogers, William H; Marshall, Richard E; Safran, Dana Gelb
Multidisciplinary teams may hold promise for improving primary care quality. This study examined the influence of multidisciplinary teams on patients' assessments of primary care, including access, integration, and clinician-patient interaction quality. From January 2004 through March 2005, a large multispecialty practice in Massachusetts obtained data monthly from patients of 145 primary care physicians using a well-validated patient questionnaire. The analytic sample included respondents with at least 2 primary care visits over the study period (n=14,835). For each respondent, administrative data were used to compute visit continuity over the study period and to classify each primary care visit as PCP, on-team, or off-team. Multivariate regression modeled the relationship of visit continuity to each primary care measure. Approximately one-third of patients (35%) saw only their PCP; 15% had only PCP and "on-team" visits; 9% had a mix of PCP, on-, and off-team visits; and 41% had only "off-team" visits when not seeing their PCP. Greater PCP continuity was associated with more favorable scores on nearly all measures (P<0.001). An exception was patients' assessments of teams, which were better when on- versus off-team visits occurred (P<0.01). For other measures, the decrements associated with discontinuity were the same irrespective of whether discontinuities involved on- or off-team visits. The finding that PCP visit discontinuities are associated with more negative care experiences, irrespective of whether discontinuities involve on- or off-team visits, highlights the challenges of incorporating teams into primary care in ways that patients experience as value-added rather than disruptive to primary care relationships.
Handler, Joel; Mohan, Yasmina; Kanter, Michael H; Reynolds, Kristi; Li, Xia; Nguyen, Miki; Young, Deborah R; Koebnick, Corinna
Visits with nonprimary care providers such as optometrists may be missed opportunities for the detection of high blood pressure (BP). For this study, normotensive adults with at least 12 months of health plan membership on January 1, 2009 (n=1,075,522) were followed-up for high BP through March 14, 2011. Of 111,996 patients with a BP measurement ≥140/90 mm Hg, 82.7% were measured during primary care visits and 17.3% during nonprimary care visits. Individuals with a BP ≥140/90 mm Hg measured during nonprimary care visits were older and more likely to be male and non-Hispanic white. The proportion of patients with follow-up and false-positives were comparable between primary and nonprimary care. The main nonprimary care specialty to identify a first BP ≥140/90 mm Hg was ophthalmology/optometry with 24.5% of all patients. Results suggest that expanding screening for hypertension to nonprimary care settings may improve the detection of hypertension.
Hanley, Julie Boyer; Piazza, Julie
To guide family adjustment, an effort was made to facilitate pediatric visitation in an adult intensive care unit (ICU). Goals were to improve customer satisfaction and to raise staff comfort level with child visitation. After implementing an open visitation policy, concerns around pediatric visitation in the ICU remained. Fears centered on risks to both patient and child. Literature was reviewed before a book was written entitled A Visit to the ICU. It contained information about what a child visiting the ICU would see, hear, and feel when visiting a loved one. The book provided reassurance for caregivers and children, informing them about what to expect when visiting. The goal of the book was to provide caregivers with a framework for age-appropriate education. Staff education was provided on developmental stages, including a child's understandings of illness and death. Nursing interventions were reviewed and resources provided. A survey demonstrated that the book increased staff comfort level with children visiting the unit, was a positive tool for patients and families, and eased fears among children while helping to facilitate coping mechanisms. The article will describe the practice change of pediatric visitation in an ICU and how it could be applied to other critical care settings.
Acupuncture is an ancient traditional Chinese medical therapy that is used widely around the world. When practiced by a certified provider, it is safe and often perceived as calming and relaxing for patients. Animal and human studies have found a physiological basis for acupuncture needling in that it affects the complex central and peripheral neuro-hormonal network. Although it is unclear whether acupuncture is beneficial over sham/placebo acupuncture, acupuncture care yields clinically rele...
Alpert, J J
Primary care is about the intimate contact that takes place when a patient comes to the physician because that individual is concerned that he or she, son or daughter, parent or grandparent is sick, or is well and wants to stay well. Our history has been that we have paid attention to important problems but we have missed so far on primary care as a megatrend. As noted, one of our most important societal megatrends is proverty and how poverty places children at risk. Poverty and primary care are linked. The reality that all of our citizens do not have access to primary care is not just our failure but it is society's as well. We pediatricians face many problems. In developing solutions, historically our profession has never lost sight of the fact that we are a helping and caring discipline. We are an advocate for the poor, advocates for children, advocates for community, and that is a large job. But the challenge is real, and we do not have much time. Now is not the time to be timid. We need to achieve consensus, accepting and acting on the megatrend of securing the future for primary care.
Dizziness is a common reason for visits to primary health care, especially among elderly patients. From a physiotherapeutic perspective, this thesis aims to study the assessment and treatment of dizzy patients in primary health care. Interventions in papers I, III and IV comprised a vestibular rehabilitation programme. In paper I, patients with multisensory dizziness were randomized to intervention group or control group. At follow-up after six weeks and three months, the intervention ...
Full Text Available Pediatricians play a key role in the healthy development of children. Nevertheless, the practice patterns of pediatricians have seldom been investigated. The current study analyzed the nationwide profiles of ambulatory visits to pediatricians in Taiwan, using the National Health Insurance Research Database. From a dataset that was randomly sampled one out of every 500 records among a total of 309,880,000 visits in 2012 in the country, 9.8% (n = 60,717 of the visits were found paid to pediatricians. Children and adolescents accounted for only 69.3% of the visits to pediatricians. Male pediatricians provided 80.5% of the services and the main workforces were those aged 40–49 years. The most frequent diagnoses were respiratory tract diseases (64.7% and anti-histamine agents were prescribed in 48.8% of the visits to pediatricians. Our detailed results could contribute to evidence-based discussions on health policymaking.
“Good morning Mr. Higgs” is a novel educational programme for 6th grade students from all primary schools in Magnesia prefecture in Greece. Supported by the Open Discovery Space EU project, the objective of this programme is to sensitize primary school students towards appreciating and understanding key ideas and scientific discoveries in particle physics by offering them unique opportunities to learn “how big science” goes at CERN, the world’s largest physics laboratory, through real and virtual visits. This ATLAS virtual visit will help prepare the ground for students’ real visit to CERN later this year.
Gisele Damian Antonio
Full Text Available OBJECTIVE To characterize the integration of phytotherapy in primary health care in Brazil. METHODS Journal articles and theses and dissertations were searched for in the following databases: SciELO, Lilacs, PubMed, Scopus, Web of Science and Theses Portal Capes, between January 1988 and March 2013. We analyzed 53 original studies on actions, programs, acceptance and use of phytotherapy and medicinal plants in the Brazilian Unified Health System. Bibliometric data, characteristics of the actions/programs, places and subjects involved and type and focus of the selected studies were analyzed. RESULTS Between 2003 and 2013, there was an increase in publications in different areas of knowledge, compared with the 1990-2002 period. The objectives and actions of programs involving the integration of phytotherapy into primary health care varied: including other treatment options, reduce costs, reviving traditional knowledge, preserving biodiversity, promoting social development and stimulating inter-sectorial actions. CONCLUSIONS Over the past 25 years, there was a small increase in scientific production on actions/programs developed in primary care. Including phytotherapy in primary care services encourages interaction between health care users and professionals. It also contributes to the socialization of scientific research and the development of a critical vision about the use of phytotherapy and plant medicine, not only on the part of professionals but also of the population.
Antonio, Gisele Damian; Tesser, Charles 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 Len FromerDepartment of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USAAbstract: Current primary care patterns for chronic obstructive pulmonary disease (COPD focus on reactive care for acute exacerbations, often neglecting ongoing COPD management to the detriment of patient experience and outcomes. Proactive diagnosis and ongoing multifactorial COPD management, comprising smoking cessation, influenza and pneumonia vaccinations, pulmonary rehabilitation, and symptomatic and maintenance pharmacotherapy according to severity, can significantly improve a patient's health-related quality of life, reduce exacerbations and their consequences, and alleviate the functional, utilization, and financial burden of COPD. Redesign of primary care according to principles of the chronic care model, which is implemented in the patient-centered medical home, can shift COPD management from acute rescue to proactive maintenance. The chronic care model and patient-centered medical home combine delivery system redesign, clinical information systems, decision support, and self-management support within a practice, linked with health care organization and community resources beyond the practice. COPD care programs implementing two or more chronic care model components effectively reduce emergency room and inpatient utilization. This review guides primary care practices in improving COPD care workflows, highlighting the contributions of multidisciplinary collaborative team care, care coordination, and patient engagement. Each primary care practice can devise a COPD care workflow addressing risk awareness, spirometric diagnosis, guideline-based treatment and rehabilitation, and self-management support, to improve patient outcomes in COPD.Keywords: chronic obstructive pulmonary disease, chronic care model, patient-centered medical home, self-management, interdisciplinary care team, coordination of care
Isaac, Kathleen S; Hay, Jennifer L; Lubetkin, Erica I
Addressing cultural competency in health care involves recognizing the diverse characteristics of the patient population and understanding how they impact patient care. Spirituality is an aspect of cultural identity that has become increasingly recognized for its potential to impact health behaviors and healthcare decision-making. We consider the complex relationship between spirituality and health, exploring the role of spirituality in primary care, and consider the inclusion of spirituality in existing models of health promotion. We discuss the feasibility of incorporating spirituality into clinical practice, offering suggestions for physicians.
Rosener, Stephanie E.; Barr, Wendy B.; Frayne, Daniel J.; Barash, Joshua H.; Gross, Megan E.; Bennett, Ian M.
PURPOSE Interconception care (ICC) is recommended to improve birth outcomes by targeting maternal risk factors, but little is known about its implementation. We evaluated the frequency and nature of ICC delivered to mothers at well-child visits and maternal receptivity to these practices. METHODS We surveyed a convenience sample of mothers accompanying their child to well-child visits at family medicine academic practices in the IMPLICIT (Interventions to Minimize Preterm and Low Birth Weight Infants Through Continuous Improvement Techniques) Network. Health history, behaviors, and the frequency of the child’s physician addressing maternal depression, tobacco use, family planning, and folic acid supplementation were assessed, along with maternal receptivity to advice. RESULTS Three-quarters of the 658 respondents shared a medical home with their child. Overall, 17% of respondents reported a previous preterm birth, 19% reported a history of depression, 25% were smoking, 26% were not using contraception, and 58% were not taking folic acid. Regarding advice, 80% of mothers who smoked were counseled to quit, 59% reported depression screening, 71% discussed contraception, and 44% discussed folic acid. Screening for depression and family planning was more likely when the mother and child shared a medical home (P .05). CONCLUSIONS Family physicians provide key elements of ICC at well-child visits, and mothers are highly receptive to advice from their child’s physician even if they receive primary care elsewhere. Routine integration of ICC at these visits may provide an opportunity to reduce maternal risk factors for adverse subsequent birth outcomes. PMID:27401423
Rocafort Gil, Javier; Herrera Molina, Emilio; Fernández Bermejo, Félix; Grajera Paredes María, María Eulalia; Redondo Moralo, María José; Díaz Díez, Fátima; Espinosa Rojas, José Armando
To find out if the activity of palliative care support teams (PCST) does not negatively influences the performance of the primary care "care of terminally ill patients" service. Terminally ill patients cared for at home. Multicentre observational study. The observed variable is the increase in the number of registered patients in primary care, and the number of patients covered between the years 2002 and 2003 and the 4 intervention variables are: total visits, joint visits, assessments, and teaching sessions. The number of patients covered in 2002 was 41.19%, increasing to 45.44% in 2003. The activity rate of the PCST for each 100 000 inhabitants was 526 home visits in 2003, 86.15 joint visits, 313.68 professional assessments, and 23.14 teaching sessions. The joint visits and the teaching sessions were strongly associated with an improvement in the coverage of primary care (Pearson correlation of 0.784 and 0.759, respectively). The total visits were moderately associated (0.525) and the assessments were weakly associated (0.245). Joint visits and teaching sessions of a PCST are associated to an increase in the activity of primary care teams. Assessments and total visits did not have a negative influence.
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.
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. Meth
Jul 31, 2014 ... Key Words: Primary Health Care, Strategies for implementation, Constraints, Alma Ata Declaration, Nigeria. 4th June, 2014. Accepted: ... including family planning; immunization against the ... evolved to meet the challenges associated with these diversities. .... and urban areas in Nigeria with the intention of.
OBJECTIVE: to assess the actual workload of primary-care midwives in the Netherlands. BACKGROUND: In 2000, a strike and large demonstration before parliament convinced everyone of the shortage of midwives and their excessive workload. The government reacted by increasing the capacity of the midwifer
Impetigo is a superficial, but contagious, bacterial infection of the skin that predominantly affects children and is common in primary care. In UK general practice, around half of the people with impetigo are treated with topical fusidic acid. However, bacterial resistance to this antibacterial drug is increasing. Here we discuss how patients with impetigo should be treated.
Journal of Community Medicine and Primary Health Care. 26 (1) 96-107 ... obesity. Specific criteria for MetS developed by. 19 of hypertension. .... Triglycerides 150 mg/dL or more or on Christians 329 (96.2%); and lower grade income.
4 and optimal use. In Nigeria, despite the The main objective of this study is therefore to .... Islam. Others. 185. 205. 5. 46.8. 51.9. 1.3. Utilization (use) of PHC Services and educational qualifications and of low socio-economic .... other zones except in the south-east region. .... primary health care interventions, the evidence is.
Dunham, Daniel P; Marcelo, Karen; Baker, David W
Increasing clinical workload with dwindling compensation has challenged primary care medical practices over the past decade. This has led to more physicians leaving and fewer medical trainees entering primary care. In an effort to make primary care practices viable, many groups routinely charge for providing care that was uncompensated in the past. We initiated a program in our practice that charged for certain after-hour and electronic communications, completion of forms outside of office visits, and failure to show for appointments. We assessed the effect on workload, patient adherence to appointments, and financial outcomes. This initiative decreased our physicians' workload, increased physicians' satisfaction, and produced a modest increase in revenues.
Fisher, Elisa; Hasselberg, Michael; Conwell, Yeates; Weiss, Linda; Padrón, Norma A; Tiernan, Erin; Karuza, Jurgis; Donath, Jeremy; Pagán, José A
Health care delivery and payment systems are moving rapidly toward value-based care. To be successful in this new environment, providers must consistently deliver high-quality, evidence-based, and coordinated care to patients. This study assesses whether Project ECHO(®) (Extension for Community Healthcare Outcomes) GEMH (geriatric mental health)-a remote learning and mentoring program-is an effective strategy to address geriatric mental health challenges in rural and underserved communities. Thirty-three teleECHO clinic sessions connecting a team of specialists to 54 primary care and case management spoke sites (approximately 154 participants) were conducted in 10 New York counties from late 2014 to early 2016. The curriculum consisted of case presentations and didactic lessons on best practices related to geriatric mental health care. Twenty-six interviews with program participants were conducted to explore changes in geriatric mental health care knowledge and treatment practices. Health insurance claims data were analyzed to assess changes in health care utilization and costs before and after program implementation. Findings from interviews suggest that the program led to improvements in clinician geriatric mental health care knowledge and treatment practices. Claims data analysis suggests that emergency room costs decreased for patients with mental health diagnoses. Patients without a mental health diagnosis had more outpatient visits and higher prescription and outpatient costs. Telementoring programs such as Project ECHO GEMH may effectively build the capacity of frontline clinicians to deliver high-quality, evidence-based care to older adults with mental health conditions and may contribute to the transformation of health care delivery systems from volume to value.
Sally R. Greenwald
Full Text Available Purpose: Women with breast cancer have complex and unique gynecologic needs that are challenging to effectively and comprehensively meet in a traditional gynecology visit format. Group medical visits are an effective and well-received model of care in other disease settings and can provide comprehensive health education as an adjunct to one-on-one evaluation and treatment. There are limited data regarding the use of this type of health care delivery in providing gynecology-focused care to women affected by breast cancer. Methods: A group medical visit model was created for gynecology providers to see new breast cancer patient consults. From May 2012 to February 2014, 148 patients (3–6 per group participated in a 1-hour informational session followed by a 15- to 30-minute individual visit with a physician that included history, physical examination and evaluation. We surveyed 101 women who attended these visits to evaluate a group model for providing gynecologic care and educational support to women with breast cancer. Results: Of those who responded to the survey question, 100% agreed or somewhat agreed that their expectations for an initial intake visit were met during the group visit; 81% agreed or somewhat agreed that they felt a group visit was preferable to an individual introductory visit. More than 95% agreed or somewhat agreed that the information was understandable and their questions were answered during the visit. Only 5 respondents expressed dissatisfaction with the additional time commitment for this type of visit. Conclusions: The majority of women surveyed expressed satisfaction with their experience with a group visit format. The women who participated preferred this format compared to an individual intake appointment when establishing gynecology care after breast cancer diagnosis/treatment, regardless of age, menopausal status, cancer stage or hormone receptor status. While further studies are warranted to directly compare and
Henning, George F.; Graybill, Marie; George, John
Purpose: The purpose of this pilot study was to determine the reasons for which migrant agricultural workers in Pennsylvania seek health care. Methods: Participants were individuals 14 years of age and over, actively involved in agricultural labor and presenting for medical care at 6 migrant health care centers. Bilingual health care providers…
Cesar, Juraci A; Mendoza-Sassi, Raul A; Ulmi, Eduardo F; Dall'Agnol, Marinel M; Neumann, Nelson A
This non-randomized community intervention study evaluated the impact of prenatal home visits by community health agents and volunteer leaders from the Children's Mission on prenatal care among poor pregnant women in Rio Grande, Rio Grande do Sul State, Brazil. Previously trained interviewers applied pre-coded questionnaires to the women at home, investigating demographic and reproductive characteristics, socioeconomic status, housing conditions, and prenatal care. Of the 339 pregnant women interviewed, 115 were assigned to the intervention group visited by community health agents, 116 to the group visited by volunteer leaders, and 108 to the control group. Pregnant women visited by community health agents began prenatal visits earlier than other groups, had more prenatal visits, lab tests, and clinical exams, and received more counseling on breastfeeding and iron supplementation. Participation by family members during medical consultations for pregnant women visited by volunteer leaders was higher than for community health agents. Pregnant women visited by community health agents received better prenatal care than the other groups. Home visits can improve the quality of prenatal care for poor women and increase participation by family members (mainly husbands) during the pregnancy.
Collins, Kerry A.; Wolfe, Vicky V.; Fisman, Sandra; DePace, JoAnne; Steele, Margaret
OBJECTIVE To investigate family physicians’ practice patterns for managing depression and mental health concerns among adolescent and adult patients. DESIGN Cross-sectional survey. SETTING London, Ont, a mid-sized Canadian city. PARTICIPANTS One hundred sixty-three family physicians identified through the London and District Academy of Medicine. MAIN OUTCOME MEASURES Practice patterns for managing depression, including screening, pharmacotherapy, psychotherapy, shared care, and training needs. RESULTS Response rate was 63%. Family physicians reported spending a substantial portion of their time during patient visits (26% to 50%) addressing mental health issues, with depression being the most common issue (51% to 75% of patients with mental health issues). About 40% of respondents did routine mental health screening, and 60% screened patients with risk factors for depression. Shared care with mental health professionals was common (care was shared for 26% to 50% of patients). Physicians and patients were moderately satisfied with shared care, but were frustrated by long waiting lists and communication barriers. Most physicians provided psychotherapy to patients in the form of general advice. Differences in practice patterns were observed; physicians treated more adults than adolescents with depression, and they reported greater comfort in treating adults. Although 33% of physicians described using cognitive behavioural therapy (CBT), they reported having little training in CBT. Moderate interest was expressed in CBT training, with a preference for a workshop format. CONCLUSION Although 40% of family physicians routinely screen patients for mental health issues, depression is often not detected. Satisfaction with shared care can be increased through better communication with mental health professionals. Physicians’ management of adolescent patients can be improved by further medical training, consultation, and collaboration with mental health professionals
Clemson, Lindy; Lannin, Natasha A; Wales, Kylie; Salkeld, Glenn; Rubenstein, Laurence; Gitlin, Laura; Barris, Sarah; Mackenzie, Lynette; Cameron, Ian D
To determine whether an enhanced occupational therapy discharge planning intervention that involved pre- and postdischarge home visits, goal setting, and follow-up (the HOME program) would be superior to a usual care intervention in which an occupational therapy in-hospital consultation for planning and supporting discharge to home is provided to individuals receiving acute care. Randomized controlled trial. Acute and medical wards. Individuals aged 70 and older (N = 400). Primary outcomes: activities daily living (ADLs; Nottingham Extended Activities of Daily Living) and participation in life roles and activities (Late Life Disability Index (LLDI)). Occupational therapist recommendations differed significantly between groups (P occupational therapy recommendations as the in-hospital only consultation, which had a greater emphasis on equipment provision, but HOME did not demonstrate greater benefit in global measures of ADLs or participation in life tasks than in-hospital consultation alone. It is not recommended that home visits be conducted routinely as part of discharge planning for acutely hospitalized medical patients. Further work should develop guidelines for quality in-hospital consultation. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.
Thomson O'Brien, M A; Oxman, A D; Davis, D A; Haynes, R B; Freemantle, N; Harvey, E L
Outreach visits have been identified as an intervention that may improve the practice of health care professionals, in particular prescribing. This type of 'face to face' visit has been referred to as university-based educational detailing, public interest detailing, and academic detailing. To assess the effects of outreach visits on improving health professional practice or patient outcomes. We searched MEDLINE up to March 1997, the Research and Development Resource Base in Continuing Medical Education, and reference lists of related systematic reviews and articles. Randomised trials of outreach visits (defined as a personal visit by a trained person to a health care provider in his or her own setting). The participants were health care professionals. Two reviewers independently extracted data and assessed study quality. Eighteen studies were included involving more than 1896 physicians. All of the outreach visit interventions consisted of several components, including written materials and conferences. Reminders or audit and feedback complemented some visits. In 13 studies, the targeted behaviours were prescribing practices. In three studies, the behaviours were preventive services, including counselling for smoking cessation. In two studies, the outreach visits were directed toward improving the general management of common problems encountered in general practice, including asthma, diabetes, otitis media, hypertension, anxiety, and acute bronchitis. All studies examined physician behaviour and in three studies other health professionals such as nurses, nursing home attendants or health care workers were targeted. Positive effects on practice were observed in all studies. Only one study measured a patient outcome. Few studies examined the cost effectiveness of outreach. Educational outreach visits, particularly when combined with social marketing, appear to be a promising approach to modifying health professional behaviour, especially prescribing. Further
Everett, Christine M; Morgan, Perri; Jackson, George L
Team-based care involving physician assistants (PAs) and advance practice nurses (APNs) is one strategy for improving access and quality of care. PA/APNs perform a variety of roles on primary care teams. However, limited research describes the relationship between PA/APN role and patient outcomes. We examined multiple outcomes associated with primary care PA/APN roles. In this cross-sectional survey analysis, we studied adult respondents to the 2010 Health Tracking Household Survey. Outcomes included primary care and emergency department visits, hospitalizations, unmet need, and satisfaction. PA/APN role was categorized as physician only (no PA/APN visits; reference), usual provider (PA/APN provide majority of primary care visits) or supplemental provider (physician as usual provider, PA/APN provide a subset of visits). Multivariable logistic and multinomial logistic regressions were performed. Compared to people with physician only care, patients with PA/APNs as usual providers [5-9 visits RRR=2.4 (CI 1.8-3.4), 10+ visits RRR=3.0 (CI 2.0-4.5): reference 2-4 visits] and supplemental providers had increased risk of having 5 or more primary care visits [5-9 visits RRR=1.3 (CI 1.0-1.6)]. Patients reporting PA/APN as supplemental providers had increased risk of emergency department utilization [2+ visits: RRR 1.8 (CI 1.3, 2.5)], and lower satisfaction [very dissatisfied: RRR 1.8 (CI 1.03-3.0)]. No differences were seen for hospitalizations or unmet need. Healthcare utilization patterns and satisfaction varied between adults with PA/APN in different roles, but reported unmet need did not. These findings suggest a wide range of outcomes should be considered when identifying the best PA/APN role on primary care teams. Copyright © 2016 Elsevier Inc. All rights reserved.
Rasmussen, Matias Sevel; Justesen, Tor Fog; Dohn, Anders Høeg
In the Home Care Crew Scheduling Problem a staff of home carers has to be assigned a number of visits to patients’ homes, such that the overall service level is maximised. The problem is a generalisation of the vehicle routing problem with time windows. Required travel time between visits and tim...
Ricketts, T C
Rural primary care programs were established in areas where there was thought to be no competition for patients. However, evidence from site visits and surveys of a national sample of subsidized programs revealed a pattern of competitive responses by the clinics. In this study of 193 rural primary care programs, mail and telephone surveys produced uniform data on the organization, operation, finances, and utilization of a representative sample of clinics. The programs were found to compete in terms of: (1) price, (2) service mix, (3) staff availability, (4) structural accessibility, (5) outreach, and (6) targeting a segment of the market. The competitive strategies employed by the clinics had consequences that affected their productivity and financial stability. The strategies were related to the perceived missions of the programs, and depended heavily upon the degree of isolation of the program and the targeting of the services. The competitive strategy chosen by a particular program could not be predicted based on service area population and apparent competitors in the service area. The goals and objectives of the programs had more to do with their competitive responses than with market characteristics. Moreover, the chosen strategies may not meet the demands of those markets.
One of the frontiers of astronomy for development is astronomy education for young children. Note that it is not too-much-going-ahead education nor education for so-called gifted children. It is for all children in various situations. As an example, I present "Uchu no O-hanashi," a visiting activity which includeds slide show, story telling, and enjoying pictures on large sheets for children. Not only just for young children, but this activity also aims at intercultural understanding. Sometimes guest educator from abroad join the activity. Video letter exchange was successful even though there is a language barrier. For assessment of the activity, I have recorded the voice of children. I will present various examples of written records and their analysis of activites, at nursery, kindergarten, preschool, after-school day care for primary school children, and other sites. I hope exchanging the record will make a worldwide connection among educators for very young children.
Landers, Glenn; Snyder, Angela; Zhou, Mei
This study compared preventive medical and dental visits of Georgia children in foster care with other children enrolled in Medicaid to determine if utilization differed. Two logistic regressions estimated the likelihood of an annual Health Check screening and the likelihood of at least one dental visit. Compared with children in foster care, children in the adoption assistance ([AOR] .37, 95% confidence interval [CI] = 0.35-0.40), SSI (AOR .37, 95% CI = 0.35-0.38) and low-income (AOR .40, 95% CI = 0.39-0.42) Medicaid categories were less likely to receive an annual Health Check screening. Children in adoption assistance were also less likely to have a dental visit during the study period. Policies require a Health Check visit upon placement into foster care and annual check-ups consistent with pediatric guidelines; we found more Early and Periodic Screening, Detection, and Treatment screenings for foster care children in Georgia than for other children receiving Medicaid.
Judith Ortiz PhD
Full Text Available Background: The Accountable Care Organization (ACO is one of the new models of health care delivery in the United States. To date, little is known about the characteristics of health care organizations that have joined ACOs. We report on the findings of a survey of primary care clinics, the objective of which was to investigate the opinions of clinic management about participation in ACOs and the characteristics of clinic organizational structure that may contribute to joining ACOs or be willing to do so. Methods: A 27-item survey questionnaire was developed and distributed by mail in 3 annual waves to all Rural Health Clinics (RHCs in 9 states. Two dependent variables—participation in ACOs and willingness to join ACOs—were created and analyzed using a generalized estimating equation approach. Results: A total of 257 RHCs responded to the survey. A small percentage (5.2% of the respondent clinics reported that they were participating in ACOs. Rural Health Clinics in isolated areas were 78% less likely to be in ACOs (odds ratio = 0.22, P = .059. Nonprofit RHCs indicated a higher willingness to join an ACO than for-profit RHCs (B = 1.271, P = .054. There is a positive relationship between RHC size and willingness to join an ACO (B = 0.402, P = .010. Conclusion: At this early stage of ACO development, many RHC personnel are unfamiliar with the ACO model. Rural providers’ limited technological and human resources, and the lack of ACO development in rural areas, may delay or prevent their participation in ACOs.
... and the Internet What's a Primary Care Physician (PCP)? KidsHealth > For Parents > What's a Primary Care Physician ( ... getting the right amount of exercise. Types of PCPs Different types of PCPs treat kids and teens. ...
Cho, Kyung-Hwan; Roh, Yong-Kyun
A mismatch in the demand and supply of primary care physicians could give rise to a disorganization of the health care system and public confusion about health care access. There is much evidence in Korea of the existence of a primary care physician shortage. The appropriate required ratio of primary care physicians to the total number of physicians is estimated by analyzing data for primary care insurance consumption in Korea. Sums of primary care expenditure and claims were calculated to estimate the need for primary care physicians by analyzing the nationwide health insurance claims data of the Korean National Medical Insurance Management Corporation (KNMIMC) between the years 1989-1998. The total number of physicians increased 183% from 1989 to 1998. However, the number of primary care physicians including general physicians, family physicians, general internists, and general pediatricians showed an increase of only 169% in those 10 years. The demand for primary care physicians reaches at least 58.6%, and up to 83.7%, of the total number of physicians in Korea. However, the number of primary care physicians comprises up to 22.0% of the total number of active physicians during the same research period, which showed a large gap between demand and supply of primary care physicians in Korea. To provide high quality care overall, a balanced supply of primary care physicians and specialists is required, based on the nation's demand for health services.
Oh, Eui Geum; Lee, Hyun Joo; Kim, Yukyung; Sung, Ji Hyun; Park, Young Su; Yoo, Jae Yong; Woo, Soohee
The purpose of this study was to examine the current status of home care nursing services provided by community health nurses and to identify barriers to the services. A cross-sectional survey was conducted with three types of community health care nurses. Participants were 257 nurses, 46 of whom were hospital based home care nurses, 176 were community based visiting nurses, and 35 were long term care insurance based visiting nurses. A structured questionnaire on 7 domains of home care nursing services with a 4-point Likert scale was used to measure activities and barriers to care. Data were analyzed using SPSS WIN 21.0 program. Hospital based home care nurses showed a high level of service performance activity in the domain of clinical laboratory tests, medications and injections, therapeutic nursing, and education. Community based visiting nurses had a high level of service performance in the reference domain. Long term care insurance based visiting nurses showed a high level of performance in the service domains of fundamental nursing and counseling. The results show that although health care service provided by the three types of community health nurse overlapped, the focus of the service is differentiated. Therefore, these results suggest that existing home care services will need to be utilized efficiently in the development of a new nursing care service for patients living in the community after hospital discharge.
... 45 Public Welfare 1 2010-10-01 2010-10-01 false Primary care. 96.47 Section 96.47 Public Welfare... and Tribal Organizations § 96.47 Primary care. Applications for direct funding of Indian tribes and tribal organizations under the primary care block grant must comply with 42 CFR Part 51c (Grants...
Ruymán Brito-Brito, Pedro; Rodríguez-Ramos, Mercedes; Pérez-García-Talavera, Carlos
This is the case of a 61-year-old patient woman that visits her nurse in Primary Health Care to get the control of blood pressure and glycemia. In the last two years has suffered the loss of her husband and of two brothers beside having lived through other vital stressful events that have taken her to a situation of complicated grief. The care plan is realized using the M. Gordon assessment system and standardized languages NANDA, NOC and NIC. The principal aims were the improvement of the depression level and the improvement in the affliction resolution. As suggested interventions were proposed to facilitate the grief and the derivation to a mental health unit. A follow-up of the patient was realized in nursing consultation at Primary health care to weekly intervals, in the beginning, and monthly, later. The evaluation of the care plan reflects an improvement in the criteria of Prigerson's complicated grief; an increase of the recreative activities; the retreat of the mourning that still she was guarding; as well as an improvement in the control of the blood pressure numbers. The attention of nurses before a case of complicated grief turns out to be complex. Nevertheless the suitable accomplishment of certain interventions orientated to facilitating the grief, with a follow-up in consultation, shows the efficiency. The difficulty in the boarding of the psychosocial problems meets increased at the moment of are necessary the nursing diagnostics adapted for every individual case. The work in group between nurses could improves the consensus.
Doricci, Giovanna Cabral; Guanaes-Lorenzi, Carla; Pereira, Maria José Bistafa
In 2009, the Secretary of State for Health of Sao Paulo created a Program with a view to qualify the primary care in the state. This proposal includes a new job function, namely the articulator of primary care. Due to the scarcity of information about the practice of these new professionals in the scientific literature, this article seeks to analyze how articulators interpret their function and how they describe their daily routines. Thirteen articulators were interviewed. The interviews were duly analyzed by qualitative delineation. The results describe three themes: 1)Roles of the articulator: technical communicator and political advisor; 2) Activities performed to comply with the expected roles, examples being diagnosis of the municipalities, negotiation of proposals, participation in meetings, visits to municipalities; and 3) Challenges of the role, which are configured as challenges to the health reform process, examples being the lack of physical and human resources, activities of professionals in the medical-centered model, among others. The conclusion drawn is that the Program has great potential to provide input for the development and enhancement of Primary Care. Nevertheless, there are a series of challenges to be overcome, namely challenges to the context per se.
Aline do Amaral Zils
Full Text Available Users' satisfaction is an important end-point to evaluate health services. This study has to do with an assessment of the level of user's satisfaction with relation to the last visit held in the primary health care network of Porto Alegre — RS, whose objective is to compare satisfaction of the users that assess the quality of the care process received as being of high APS score with that of the users who evaluate it as low APS score. A cross-sectional study based on the population, using the Primary Care Assessment Tool - PCATool, which enables the classification of the health services at the level of guidance to APS by means of the general score of primary care, defining it as high or low, in accordance with the users' experience. The satisfaction of the user was measured by a questionnaire consisting of twelve questions relative to the last visit, being measured by a 5-item Likert scale: "very good", "good", "regular", "bad" and "very bad". For the analysis, the results were grouped into two classifications, i.e. "satisfied", when referred as "veg good" or "good", and "dissatisfied" when referred to any of the other items. A significant difference was noticed in the 12 variables reflecting satisfaction in several aspects of the visit, showing higher satisfaction in users that classified the service as being of high score. The .general evaluation of the service presented 95.6% and 73.5% of "satisfied" in the services with high and low APS score, respectively (p<0.001. Users of services with high level of guidance to primary care obtain higher satisfaction in their visits. This higher satisfaction can benefit the decision-making process of the patient in face of the medical recommendations made.
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 t
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 t
Brown, Jonathan D.
Systems of care should be defined in a manner that includes primary care. The current definition of systems of care shares several attributes with the definition of primary care: both are defined as community-based services that are accessible, accountable, comprehensive, coordinated, culturally competent, and family focused. However, systems of…
Background: Adequate utilization of antenatal health care services is associated ... Using the formula n=z2p (100−p)/e2, marginal error(e) of 4 %, z at 95 % confidence interval of 1.96, ... cleaning and generation of frequency distribution tables.
Wong, Edwin S; Liu, Chuan-Fen; Hernandez, Susan E; Augustine, Matthew R; Nelson, Karin; Fihn, Stephan D; Hebert, Paul L
Improving access to the Veterans Health Administration (VHA) is a high priority, particularly given statutory mandates of the Veterans Access, Choice and Accountability Act. This study examined whether patient-reported wait times for VHA appointments were associated with future reliance on VHA primary care services. This observational study examined 13,595 VHA patients dually enrolled in fee-for-service Medicare. Data sources included VHA administrative data, Medicare claims and the Survey of Healthcare Experiences of Patients (SHEP). Primary care use was defined as the number of face-to-face visits from VHA and Medicare in the 12 months following SHEP completion. VHA reliance was defined as the number of VHA visits divided by total visits (VHA+Medicare). Wait times were derived from SHEP responses measuring the usual number of days to a VHA appointment with patients' primary care provider for those seeking immediate care. We defined appointment wait times categorically: 0 days, 1day, 2-3 days, 4-7 days and >7 days. We used fractional logistic regression to examine the relationship between wait times and reliance. Mean VHA reliance was 88.1% (95% CI = 86.7% to 89.5%) for patients reporting 0day waits. Compared with these patients, reliance over the subsequent year was 1.4 (p = 0.041), 2.8 (p = 0.001) and 1.6 (p = 0.014) percentage points lower for patients waiting 2-3 days, 4-7 days and >7 days, respectively. Patients reporting longer usual wait times for immediate VHA care exhibited lower future reliance on VHA primary care. Longer wait times may reduce care continuity and impact cost shifting across two federal health programs. Copyright © 2017. Published by Elsevier Inc.
Groenewegen, P.; Heinemann, S.; Greß, S.; Schäfer, W.
Health care needs in the population change through ageing and increasing multimorbidity. Primary health care might accommodate to this through the composition of practices in terms of the professionals working in them. The aim of this article is to describe the composition of primary care practices
Groenewegen, P.P.; Heinemann, Stephanie; Greß, Stefan; Schäfer, Willemijn
Health care needs in the population change through ageing and increasing multimorbidity. Primary health care might accommodate to this through the composition of practices in terms of the professionals working in them. The aim of this article is to describe the composition of primary care practices
Lember, M.; Cartier, T.; Bourgueil, Y.; Dedeu, T.; Hutchinson, A.; Kringos, D.
The way primary care is structured establishes important conditions for both the process of care and its outcomes. In this chapter, the structure of primary care will be discussed according to three dimensions: governance, economic conditions and workforce development. Governance refers to the visi
Lember, M.; Cartier, T.; Bourgueil, Y.; Dedeu, T.; Hutchinson, A.; Kringos, D.
The way primary care is structured establishes important conditions for both the process of care and its outcomes. In this chapter, the structure of primary care will be discussed according to three dimensions: governance, economic conditions and workforce development. Governance refers to the
Kringos, D.; Boerma, W.; Bourgueil, Y.; Cartier, T.; Dedeu, T.; Hasvold, T.; Hutchinson, A.; Lember, M.; Oleszczyk, M.; Pavlick, D.R.
This chapter analyses differences between countries and explains why countries differ regarding the structure and process of primary care. The components of primary care strength that are used in the analyses are health policy-making, workforce development and in the care process itself (see Fig.
Rotar Pavlič, Danica; Zelko, Erika; Vintges, Marga; Willems, Sara; Hanssens, Lise
Abstract Roma populations’ low health status and limited access to health services, including primary care, has been documented in many European countries, and warrants specific health policies and practices. A variety of experiences shows how primary care can adjust its practices to reduce the barriers to primary care for Roma populations. At local level, establishing collaboration with Roma organisations helps primary care to improve mutual relations and quality of care. Mediation has proved to be an effective tool. Skills training of primary care practitioners may enhance their individual competences. Research and international sharing of experiences are further tools to improve primary care for the Roma people. PMID:27703542
Groenewegen, P.P.; Hutten, J.B.F.
As a result of policy changes and developments on the demand side, the importance of technology in primary health care will grow fast. An approach to the implementation of new technologies in primary health care is presented in this article. First we describe the main problems in Dutch primary healt
Swartwout, Kathryn D
A 2012 Institute of Medicine report calls primary and public healthcare workers to action, tasking them with working together to improve population health outcomes. A Practical Playbook released in 2014 enables this public health/primary care integration. Primary care NPs are in an excellent position to lead the charge and make this integration happen.
Ladrillo, Teresita E; Hobdell, Martin H; Caviness, A Chantal
Hospital emergency department (ED) visits for non-urgent care have been increasing since the late 1950s. This study investigated the prevalence and characteristics of pediatric ED visits for dental problems during a five-year period. This retrospective study included newborns through 17-year-olds with dental complaints identified from the electronic register of the ED of Texas Children's Hospital, Houston, between January 1997 and December 2001. The authors described patient characteristics, diagnoses, factors associated with ED use for nontraumatic problems and annual changes in ED visits for dental and nondental complaints. Of the 1,102 subjects, 809 (73.4 percent) had nontraumatic and 293 (26.6 percent) had traumatic dental complaints. The study revealed a 121 percent increase in ED visits for dental complaints and a 66-fold increase in admissions between 1997 and 2001. Of the inpatient admissions, 68 percent were the result of caries and its sequelae. This study revealed a substantial increase in ED visits and hospital admissions for dental problems during the study period. The majority of dental problems were nontraumatic in nature. Dental care experts should be available in ED settings in which increases in such visits are seen. Studies must be conducted to explore ways of keeping patients from seeking care in EDs inappropriately.
Mark, Annabelle L; Shepherd, Ifan D H
This paper considers how NHS Direct is affecting demand for primary care in particular out-of-hours services from GPs. This is reviewed through a 3-year study of NHS Direct and HARMONI, the integrated telephone health helpline based in West London. It describes the policy background and development of the services on the site, and some of the outcomes of the HARMONI commissioned research to answer the question 'Has NHS Direct increased the workload for HARMONI doctors?'. The research adopted both a qualitative and quantitative approach using cross-sectional and longitudinal analysis of the data collected. The analysis of the data reveals the issues as both complex and dynamic in nature. The research shows that while there has been no significant change to the total volume of activity, changes within patient groups notably the elderly and children, and in individual GP practices may be significant. In addition, the changes in organizational arrangements may influence significant changes in referral patterns such as GP out-of-hours visits. This was confirmed in the interview data indicating a link between the change in nurses' role from gatekeeper to patient advocate, which happened when they ceased to be employees of the part-time co-op and began to work instead for the 24 hours, 7 days a week NHS Direct service. The conclusions drawn are that behavioural and organizational changes are at least as significant as the evidence-based computerized decision support software in changing the demand for primary care. Further evidence cited is that a different demand pattern of calls was experienced by those local GPs not integrated into out-of-hours provision at NHS Direct West London at the time of the study.
Christensen, Morten Bondo; Nørøxe, Karen Busk; Moth, Grete
OBJECTIVE: General practitioners are the first point of contact in Danish out-of-hours (OOH) primary care. The large number of contacts implies that prescribing behaviour may have considerable impact on health-care expenditures and quality of care. The aim of this study was to examine...... the prevailing practices for medication prescription in Danish OOH with a particular focus on patient characteristics and contact type. DESIGN AND SETTING: A one-year population-based retrospective observational study was performed of all contacts to OOH primary care in the Central Denmark Region using registry...... data. MAIN OUTCOME MEASURES: Prescriptions were categorised according to Anatomical Therapeutic Chemical Classification (ATC) codes and stratified for patient age, gender and contact type (telephone consultation, clinic consultation or home visit). Prescription rates were calculated as number...
Full Text Available Background: Diabetic foot syndrome is one of the most common and devastating preventable complications of diabetes resulting in major economic consequences for the patients, their families, and the society. Aims & Objectives: The present study was carried out to assess knowledge, attitude and practices of Diabetic Foot Wound Care among the patients suffering from Diabetic Foot and to correlate them with the socio-demographic parameters. Material & Methods: It was a Hospital based cross-sectional study involving clinically diagnosed adult (>18 years patients of Diabetic Foot visiting the Surgery and Medicine OPDs at Teerthankar Mahaveer Medical College & Research Centre, Moradabad, India. Results: Significant association KAP (Knowledge, Attitude and Practices score was seen with age of the patient, education, addiction, family history of Diabetes Mellitus, prior receipt of information regarding Diabetic foot-care practices, compliance towards the treatment and the type of foot wear used. Conclusions: The results highlight areas especially Health education, use of safe footwear and life style adjustments, where efforts to improve knowledge and practice may contribute to the prevention of development of Foot ulcers and amputation.
Department of Veterans Affairs — The Primary Care Management Module (PCMM) was developed to assist VA facilities in implementing Primary Care. PCMM supports both Primary Care and non-Primary Care...
Lader, Malcolm; Tylee, Andre; Donoghue, John
The use of benzodiazepine anxiolytics and hypnotics continues to excite controversy. Views differ from expert to expert and from country to country as to the extent of the problem, or even whether long-term benzodiazepine use actually constitutes a problem. The adverse effects of these drugs have been extensively documented and their effectiveness is being increasingly questioned. Discontinuation is usually beneficial as it is followed by improved psychomotor and cognitive functioning, particularly in the elderly. The potential for dependence and addiction have also become more apparent. The licensing of SSRIs for anxiety disorders has widened the prescribers' therapeutic choices (although this group of medications also have their own adverse effects). Melatonin agonists show promise in some forms of insomnia. Accordingly, it is now even more imperative that long-term benzodiazepine users be reviewed with respect to possible discontinuation. Strategies for discontinuation start with primary-care practitioners, who are still the main prescribers.This review sets out the stratagems that have been evaluated, concentrating on those of a pharmacological nature. Simple interventions include basic monitoring of repeat prescriptions and assessment by the doctor. Even a letter from the primary-care practitioner pointing out the continuing usage of benzodiazepines and questioning their need can result in reduction or cessation of use. Pharmacists also have a role to play in monitoring the use of benzodiazepines, although mobilizing their assistance is not yet routine. Such stratagems can avoid the use of specialist back-up services such as psychiatrists, home care, and addiction and alcohol misuse treatment facilities.Pharmacological interventions for benzodiazepine dependence have been reviewed in detail in a recent Cochrane review, but only eight studies proved adequate for analysis. Carbamazepine was the only drug that appeared to have any useful adjunctive properties for
Halley, Marc D; Anderson, Peter
Primary care physicians today can be expected to capture between 2,000 and 5,000 active patients who consider that physician to be "my physician." The geographic location of primary care physicians affects the payer mix of the hospital and its affiliated subspecialists. Hospital and health system CFOs would be wise to advocate investment in primary care physicians to secure market share. They should also develop compensation plans with a value-volume balance and establish ways to actively manage referrals.
Hyman, D J; Maibach, E W; Flora, J A; Fortmann, S.P.
The active involvement of primary care physicians is necessary in the diagnosis and treatment of elevated blood cholesterol. Empirical evidence suggests that primary care physicians generally initiate dietary and pharmacological treatment at threshold values higher than is currently recommended. To determine current treatment thresholds and establish factors that distinguish physicians who are more likely to initiate therapy at lower cholesterol values, 119 primary care physicians in four nor...
U.S. Department of Health & Human Services — The Comprehensive Primary Care (CPC) initiative is a multi-payer initiative fostering collaboration between public and private health care payers to strengthen...
Epstein, Andrew J; Barry, Colleen L; Fiellin, David A; Busch, Susan H
Most individuals with substance use disorders and with mental disorders do not receive treatment. If treatment options were more attractive, treatment rates might increase. The advantages of novel approaches, including primary care-based treatment and collaborative care in a primary care setting, have been documented. However, less is known about consumers' valuation of these options. The authors assessed monetary valuation of these treatment types compared with usual care in a specialty treatment setting. Contingent valuation methods were used in a Web-based randomized vignette experiment that involved 2,146 individuals who screened positive for a drug or alcohol use disorder or a mental disorder. Participants valued a primary care-based treatment visit over usual care in a specialty treatment setting by $9.00 and a collaborative care visit over usual care in a specialty treatment setting by $5.85.
Marloes Amantia van Bokhoven; Stephanie Anna Lenzen; Jerôme Jean Jacques van Dongen; Ramon Daniëls; Anna Beurskens; Trudy van der Weijden
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
de Villiers, M
A symposium on Learning in Primary Care was held in Cape Town, South Africa, as a pre-conference workshop to the 9th International Ottawa Conference on Medical Education. The aim of this report is to inform medical educationalists of important issues in learning in primary care and to stimulate further debate. Four international speakers gave presentations on their experiences in teaching and learning in primary care. Objective positive outcome measures include acquiring clinical skills equally well in general practice as in hospital, and improved history taking, physical examination and communication skills learning. Students regard the course as an essential requirement for learning and are appreciative of the wider aspect to learning provided by the community, giving a more holistic view of health. A SWOT analysis (strengths, weaknesses, opportunities and threats) of teaching and learning in primary care identified that learning in primary care is of a generalist nature and reality based, but is hampered by a lack of resources. The increased professionalization of teaching in primary care results in better training, cost containment, and improved quality of health care at community level. It is important to focus on turning threats into opportunities. Academic credibility needs to be established by conducting research on learning in primary care and developing the conceptual basis of primary care.
Maddams, Jessica; Miller, Kathryn; Rushforth, Bruno
In the UK, undergraduate curricula have evolved to include a greater proportion of community-based teaching. However, for most students it still remains predominantly a hospital-based training experience. With 50 per cent of all medical graduates in the UK now expected to work in the community, students need to be fully informed about career pathways and opportunities within primary care. A key driver for curriculum change in the UK has been the General Medical Council's guidance in Tomorrow's Doctors, which advocates experience in a variety of health care settings together with career advice at undergraduate level. However, the existing career guidance provision may be inadequate for the current needs of students. We explore what students are doing to combat the lack of primary care focused career guidance: from taking a year out to intercalate in primary care to setting up and running student-led primary care groups. We report on a new UK venture that we hope to launch in consultation with national primary care bodies to provide support and guidance for students considering a career in primary care. Primary care-focused career advice should be incorporated into the undergraduate curriculum. Student-led primary care groups can offer an alternative source of support and guidance. © Blackwell Publishing Ltd 2012.
Mueller, Gary A; Wolf, Stephen; Bacon, Elizabeth; Forbis, Shalini; Langdon, Leora; Lemming, Charlotte
Disorders of the respiratory system are commonly encountered in the primary care setting. The presentations are myriad and this review will discuss some of the more intriguing or vexing disorders that the clinician must evaluate and treat. Among these are dyspnea, chronic cough, chest pain, wheezing, and asthma. Dyspnea and chest pain have a spectrum ranging from benign to serious, and the ability to effectively form a differential diagnosis is critical for reassurance and treatment, along with decisions on when to refer for specialist evaluation. Chronic cough is one of the more common reasons for primary care office visits, and once again, a proper differential diagnosis is necessary to assist the clinician in formulating an appropriate treatment plan. Infant wheezing creates much anxiety for parents and accounts for a large number of office visits and hospital admissions. Common diagnoses and evaluation strategies of early childhood wheezing are reviewed. Asthma is one of the most common chronic diseases of children and adults. The epidemiology, diagnosis, evaluation, treatment, and the patient/parent education process will be reviewed. A relatively new topic for primary care clinicians is cystic fibrosis newborn screening. The rationale, methods, outcomes, and implications will be reviewed. This screening program may present some challenges for clinicians caring for newborns, and an understanding of the screening process will help the clinician communicate effectively with parents of the patient.
Full Text Available Background: Nearly all newborn deaths occur in low- or middle-income countries. Many of these deaths could be prevented through promotion and provision of newborn care practices such as thermal care, early and exclusive breastfeeding, and hygienic cord care. Home visit programmes promoting these practices were piloted in Malawi, Nepal, Bangladesh, and Uganda. Objective: This study assessed changes in selected newborn care practices over time in pilot programme areas in four countries and evaluated whether women who received home visits during pregnancy were more likely to report use of three key practices. Design: Using data from cross-sectional surveys of women with live births at baseline and endline, the Pearson chi-squared test was used to assess changes over time. Generalised linear models were used to assess the relationship between the main independent variable – home visit from a community health worker (CHW during pregnancy (0, 1–2, 3+ – and use of selected practices while controlling for antenatal care, place of delivery, and maternal age and education. Results: There were statistically significant improvements in practices, except applying nothing to the cord in Malawi and early initiation of breastfeeding in Bangladesh. In Malawi, Nepal, and Bangladesh, women who were visited by a CHW three or more times during pregnancy were more likely to report use of selected practices. Women who delivered in a facility were also more likely to report use of selected practices in Malawi, Nepal, and Uganda; association with place of birth was not examined in Bangladesh because only women who delivered outside a facility were asked about these practices. Conclusion: Home visits can play a role in improving practices in different settings. Multiple interactions are needed, so programmes need to investigate the most appropriate and efficient ways to reach families and promote newborn care practices. Meanwhile, programmes must take advantage of
payment for health care services; a widely used strategy to supplement ... and opportunities for sustainable health care financing for low income communities in sub-. Saharan ..... funding and rising costs for health care services, More so, evidence from research studies have ... provider payment method has the potential to.
... in the United States, 2009–2010 Recommend on Facebook Tweet Share Compartir NCHS Data Brief No. 145, March 2014 On This Page Key findings The percentage of routine prenatal care visits at which women saw non-ob/gyn providers generally decreased with age. ...
Anguita-Guimet, A; Ortiz-Molina, J; Sitjar-Martínez de Sas, S; Sisó-Almirall, A; Menacho-Pascual, I; Sebastian-Montal, L
To analyse the benefits of a new organisational model in Primary Care based on the empowerment of professional management compared to standard model (team led by medical director). To improve the quality of care, and patient and professional satisfaction. In February 2009 six family physician (FP) and four administrative staff met to create a self-management group to care for the 10,281 population assigned to them. The total catchment population of the Primary Care (PC) centre was 32,318. Additionally, between March and December 2010 three FP, seven nurses and two administrative staff, were included in the self-management group making the total population served by the self-management group of 16,368, compared to 15,950 patients seen using the standard model. The model gave priority to self-demand management, professional self-coverage, to reduce clinic bureaucracy, greater efficiency and participation in research and teaching. 1) Milestone in Pilot Phase (December-2008 to December-2009): increase in attended population, reduction in clinic visits, significant reduction in delay to be visited by a doctor; significant reduction of complementary tests (x-rays, laboratory tests); increase in use of generic drugs and reduction of expensive and new drugs without added value, and active participation in teaching and clinical trials. 2) Consolidation Phase (December-2010, compared to other professionals working in a standard model in the same centre): self-management group reported a lower percentage of clinic visits and a higher percentage of visits resolved through telephoning the clinic. Furthermore, the self-management group achieved better financial results than the control group (additional medical tests, pharmacy budget). The self-management group had improved job satisfaction compared to control group (measured by Professional Questionnaire QoL-35). The new model has increased professional satisfaction and may improve results in some health indicators
Boerma, W.G.W.; Kringos, D.S.; Verschuuren, M.; Pellny, M.; Baymirova, L.
The Uzbek government has a central role in primary care quality management. On paper, many quality management structures and procedures exist. Now, primary care practice should follow, as NIVEL research – done on the initiative of the World Health Organisation (WHO) – has shown. The results have
Skolarus, Ted A; Holmes-Rovner, Margaret; Northouse, Laurel L; Fagerlin, Angela; Garlinghouse, Carol; Demers, Raymond Y; Rovner, David R; Darwish-Yassine, May; Wei, John T
Although the effectiveness of prostate cancer screening is controversial, screening rates have risen dramatically among primary care providers in the United States. The authors' findings suggest more collaboration among primary care and specialty organizations, especially with respect to decision aid endorsement, is needed to achieve more discriminatory and patient-centered prostate cancer screening.
Boerma, W.G.W.; Kringos, D.S.; Verschuuren, M.; Pellny, M.; Baymirova, L.
The Uzbek government has a central role in primary care quality management. On paper, many quality management structures and procedures exist. Now, primary care practice should follow, as NIVEL research – done on the initiative of the World Health Organisation (WHO) – has shown. The results have bee
Gawaine Powell Davies
Full Text Available Introduction: To fulfil its role of coordinating health care, primary health care needs to be well integrated, internally and with other health and related services. In Australia, primary health care services are divided between public and private sectors, are responsible to different levels of government and work under a variety of funding arrangements, with no overarching policy to provide a common frame of reference for their activities. Description of policy: Over the past decade, coordination of service provision has been improved by changes to the funding of private medical and allied health services for chronic conditions, by the development in some states of voluntary networks of services and by local initiatives, although these have had little impact on coordination of planning. Integrated primary health care centres are being established nationally and in some states, but these are too recent for their impact to be assessed. Reforms being considered by the federal government include bringing primary health care under one level of government with a national primary health care policy, establishing regional organisations to coordinate health planning, trialling voluntary registration of patients with general practices and reforming funding systems. If adopted, these could greatly improve integration within primary health care. Discussion: Careful change management and realistic expectations will be needed. Also other challenges remain, in particular the need for developing a more population and community oriented primary health care.
de Graaf Pim; Rotar Pavlič Danica; Zelko Erika; Vintges Marga; Willems Sara; Hanssens Lise
Roma populations’ low health status and limited access to health services, including primary care, has been documented in many European countries, and warrants specific health policies and practices. A variety of experiences shows how primary care can adjust its practices to reduce the barriers to primary care for Roma populations.
de Graaf Pim
Full Text Available Roma populations’ low health status and limited access to health services, including primary care, has been documented in many European countries, and warrants specific health policies and practices. A variety of experiences shows how primary care can adjust its practices to reduce the barriers to primary care for Roma populations.
Carlisle, R; Avery, A J; Marsh, P
The NHS Plan promises an equitable distribution of resources within primary care. To inform the debate on the extent to which resources should be redistributed we examined the association between primary care activity and deprivation. We used the natural experiment of the organization of primary care in Mansfield, Nottinghamshire, where town centre general practices have patients from electoral wards with a range of socio-economic characteristics who are subject to the same degree of supplier-induced demand and variations in data quality. We used one year's prospective data for two practices with 20,106 patients from 15 electoral wards. We performed linear regression analysis of directly age-standardized rates for different types of primary care activity and primary care morbidity-specific contacts against Townsend and Index of Multiple Deprivation 2000 scores. There were 44 per cent more out-of-hours contacts in more deprived areas (95 per cent confidence interval (CI) 17-70 per cent), 18 per cent more surgery consultations (95 per cent CI 8-27 per cent), and 28 per cent more same-day consultations (95 per cent CI 12-44 per cent). Routine visits by doctors and contacts by district and practice nurses did not have substantial associations with deprivation. Morbidity-specific contacts for psychological problems and respiratory problems were associated with deprivation but there was no significant association for contacts for low back pain, asthma or menopausal problems. Different types of primary care activity and contacts for different morbidities had different associations with deprivation. This makes it difficult to recommend a simple list size adjustment; however, increased activity in deprived wards needs to be recognized in resource allocation, service configuration and performance management in primary care.
Full Text Available BACKGROUND: Caring for patients with multimorbidity is common for generalists, although such patients are often excluded from clinical trials, and thus such trials lack of generalizability. Data on the association between multimorbidity and preventive care are limited. We aimed to assess whether comorbidity number, severity and type were associated with preventive care among patients receiving care in Swiss University primary care settings. METHODS: We examined a retrospective cohort composed of a random sample of 1,002 patients aged 50-80 years attending four Swiss university primary care settings. Multimorbidity was defined according to the literature and the Charlson index. We assessed the quality of preventive care and cardiovascular preventive care with RAND's Quality Assessment Tool indicators. Aggregate scores of quality of provided care were calculated by taking into account the number of eligible patients for each indicator. RESULTS: Participants (mean age 63.5 years, 44% women had a mean of 2.6 (SD 1.9 comorbidities and 67.5% had 2 or more comorbidities. The mean Charlson index was 1.8 (SD 1.9. Overall, participants received 69% of recommended preventive care and 84% of cardiovascular preventive care. Quality of care was not associated with higher numbers of comorbidities, both for preventive care and for cardiovascular preventive care. Results were similar in analyses using the Charlson index and after adjusting for age, gender, occupation, center and number of visits. Some patients may receive less preventive care including those with dementia (47% and those with schizophrenia (35%. CONCLUSIONS: In Swiss university primary care settings, two thirds of patients had 2 or more comorbidities. The receipt of preventive and cardiovascular preventive care was not affected by comorbidity count or severity, although patients with certain comorbidities may receive lower levels of preventive care.
Ng, Chung Wai Mark; How, Choon How; Ng, Yin Ping
Major depression is a common condition seen in the primary care setting. This article describes the suicide risk assessment of a depressed patient, including practical aspects of history-taking, consideration of factors in deciding if a patient requires immediate transfer for inpatient care and measures to be taken if the patient is not hospitalised. It follows on our earlier article about the approach to management of depression in primary care. PMID:28210741
Claire Van Deventer
Full Text Available Improving the quality of clinical care and translating evidence into clinical practice is commonly a focus of primary care research. This article is part of a series on primary care research and outlines an approach to performing a quality improvement cycle as part of a research assignment at a Masters level. The article aims to help researchers design their quality improvement cycle and write their research project proposal.
van Deventer, Claire; Mash, Bob
Improving the quality of clinical care and translating evidence into clinical practice is commonly a focus of primary care research. This article is part of a series on primary care research and outlines an approach to performing a quality improvement cycle as part of a research assignment at a Masters level. The article aims to help researchers design their quality improvement cycle and write their research project proposal.
-Quality Assessment in the Primary care Dear Editor; I have read the article titled as “Implementation of Rogi Kalyan Samiti (RKS) at Primary Health Centre Durvesh” with great interest. Shrivastava et all concluded that assessment mechanism for the achievement of objectives for the suggested RKS model was not successful (1). Hereby I would like to emphasize the importance of quality assessment (QA) especially in the era of newly established primary care implementations in our coun...
This ATLAS Virtual Visit is being conducted with Mrs. Triessl's 4th grade class at the Southdown Primary School in Huntington, NY. The students of Mrs. Triessl's class have been studying together in an innovative Dual-Language (Spanish/English) program since kindergarten. In spite of the extra academic effort this program requires, the curriculum has maintained a strong and increasing focus on science education. The students have begun this year learning about matter and energy and look forward to meeting a real scientist addressing these topics in a laboratory far across the ocean! The school and the district are thrilled to have this opportunity, which they hope will inspire their students toward future participation in their growing K-12 scientific programs (see http://www.hufsd.edu/academics/science/science_index.html). http://atlas-live-virtual-visit.web.cern.ch/atlas-live-virtual-visit/2012/Huntington-2012.html Steven Goldfarb and Kate Shaw in the ATLAS Control Room and students of the 4th grade class a...
Maeseneer, J. De; Driel, M.L. van; Green, L.A.; Weel, C. van
Making evidence from scientific studies available to clinical practice has been expected to directly improve quality of care, but this expectation has not been realised. The notion of quality of care is complex, and quality improvement needs medical, contextual, and policy evidence. In primary care,
Schoenfelder, Tonio; Klewer, Joerg; Kugler, Joachim
Measures of satisfaction of surgical patients can be used to evaluate and redesign the process of care or to complement established procedures to improve quality of services. However, study findings regarding aspects of patient satisfaction are often inconsistent and depend on the setting. The primary goals of this research were to identify factors associated with satisfaction among patients in a surgical setting. Data used in this study were obtained from randomly selected 2699 surgical patients discharged during January-December 2008 from 26 hospitals who responded to a mailed survey. The instrument assessed satisfaction regarding 23 items of perceived care, patient demographic, and visit characteristics. Bivariate and multivariate techniques were used to reveal relations between indicators and overall satisfaction. Bivariate statistics showed strong relations between overall satisfaction and perceived care with weaker findings pertaining to demographic and visit characteristics. The Multivariate logistic regression predicting overall satisfaction demonstrated that patients receiving surgical services predominantly have similar demands and priorities regardless of age and gender. The strongest factors were (P < 0.05) the interpersonal manner of medical practitioners and nurses, organization of operations, admittance, and discharge, as well as perceived length of stay. This study identified factors that are related to satisfaction of surgical patients and indicated the intensity of this relationship. These findings support health care providers and medical practitioners with valuable information to meet needs and preferences of patients receiving surgical services. Copyright © 2010 Elsevier Inc. All rights reserved.
King, James R.
The caring and nurturing of children, which characterize primary education culture, have tended to shape a public perception of primary teaching as "women's work." Several social factors influence men's underrepresentation in the profession of primary education, such as parents not wanting their children exposed to "soft"…
Silberman, Jordan; Tentler, Aleksey; Ramgopal, Rajeev; Epstein, Ronald M
Effective treatments can be rendered useless by poor patient recall of treatment instructions. Studies suggest that patients forget a great deal of important information and that recall can be increased through recall-promoting behaviors (RPBs) like repetition or summarization. To assess how frequently RPBs are used in primary care, and to reveal how they might be applied more effectively. Recordings of 49 unannounced standardized patient (SP) visits were obtained using hidden audiorecorders. All SPs presented with typical gastroesophageal reflux disease symptoms. Transcripts were coded for treatment recommendations and RPBs. Forty-nine primary care physicians. Of 1,140 RPBs, 53.7% were repetitions, 28.2% were communication of the rationale for a treatment, 11.7% were categorizations of treatments (i.e., stating that a treatment could be placed into a treatment category, such as medication-related or lifestyle-related categories), and 3.8% were emphasis of a recommendation's importance. Physicians varied substantially in their use of most RPBs, although no physicians summarized or asked patients to restate recommendations. The number of RPBs was positively correlated with visit length. Primary care physicians apply most RPBs inconsistently, do not utilize several RPBs that are particularly helpful, and may use RPBs inefficiently. Simple principles guiding RPB use may help physicians apply these communication tools more effectively.
Bardach, Shoshana H; Schoenberg, Nancy E
The prevalence of multiple health conditions, or multiple morbidity (MM), is increasing. Providing medical care for adults with MM presents challenges, including balancing disease management with prevention. We conducted in-depth semistructured interviews with 12 primary care physicians to explore their perspectives on prevention counseling among patients with MM. Participants described the complex relationship between disease management and prevention, highlighted the importance of patient motivation, and discussed various strategies to promote receptivity to prevention recommendations. The perceived potential benefits of prevention recommendations encouraged physicians to persist with such counseling, despite challenges presented by visit time constraints, reimbursement procedures, and concerns over futility. Physicians recommended the development of alternate care delivery and reimbursement models to overcome challenges of the existing health care system and to meet the prevention needs of patients with MM. We explore the implications of these findings for maximizing the health and quality of life of adults with MM.
Before surgery - tests; Before surgery - doctor visits ... Pre-op is the time before your surgery. It means "before operation." During this time, you will meet with one of your doctors. This may be your surgeon or primary care ...
Background Older people living in care homes in England have complex health needs due to a range of medical conditions, mental health needs and frailty. Despite an increasing policy expectation that professionals should operate in an integrated way across organisational boundaries, there is a lack of understanding between care homes and the National Health Service (NHS) about how the two sectors should work together, meaning that residents can experience a poor "fit" between their needs, and services they can access. This paper describes a survey to establish the current extent of integrated working that exists between care homes and primary and community health and social services. Methods A self-completion, online questionnaire was designed by the research team. Items on the different dimensions of integration (funding, administrative, organisational, service delivery, clinical care) were included. The survey was sent to a random sample of residential care homes with more than 25 beds (n = 621) in England in 2009. Responses were analysed using quantitative and qualitative methods. Results The survey achieved an overall response rate of 15.8%. Most care homes (78.7%) worked with more than one general practice. Respondents indicated that a mean of 14.1 professionals/ services (other than GPs) had visited the care homes in the last six months (SD 5.11, median 14); a mean of .39 (SD.163) professionals/services per bed. The most frequent services visiting were district nursing, chiropody and community psychiatric nurses. Many (60%) managers considered that they worked with the NHS in an integrated way, including sharing documents, engaging in integrated care planning and joint learning and training. However, some care home managers cited working practices dictated by NHS methods of service delivery and priorities for care, rather than those of the care home or residents, a lack of willingness by NHS professionals to share information, and low levels of respect for
Full Text Available Abstract Background Older people living in care homes in England have complex health needs due to a range of medical conditions, mental health needs and frailty. Despite an increasing policy expectation that professionals should operate in an integrated way across organisational boundaries, there is a lack of understanding between care homes and the National Health Service (NHS about how the two sectors should work together, meaning that residents can experience a poor "fit" between their needs, and services they can access. This paper describes a survey to establish the current extent of integrated working that exists between care homes and primary and community health and social services. Methods A self-completion, online questionnaire was designed by the research team. Items on the different dimensions of integration (funding, administrative, organisational, service delivery, clinical care were included. The survey was sent to a random sample of residential care homes with more than 25 beds (n = 621 in England in 2009. Responses were analysed using quantitative and qualitative methods. Results The survey achieved an overall response rate of 15.8%. Most care homes (78.7% worked with more than one general practice. Respondents indicated that a mean of 14.1 professionals/ services (other than GPs had visited the care homes in the last six months (SD 5.11, median 14; a mean of .39 (SD.163 professionals/services per bed. The most frequent services visiting were district nursing, chiropody and community psychiatric nurses. Many (60% managers considered that they worked with the NHS in an integrated way, including sharing documents, engaging in integrated care planning and joint learning and training. However, some care home managers cited working practices dictated by NHS methods of service delivery and priorities for care, rather than those of the care home or residents, a lack of willingness by NHS professionals to share information, and low
Full Text Available Antibacterial efficacy of formocresol, 2% gluteraldehyde and iodine-potassium iodide was assessed by obtaining cultures at consecutive appointments in multiple visit pulpectomies in primary molars. Formocresol and 2% gluteraldehyde were more effective as intracanal medicaments and caused significant reduction in the counts of aerobic and anaerobic microorganisms, thereby supporting the need for placing intracanal medicaments with antibacterial properties, in multiple visit pulpectomies in primary molars.
infection prevention and control programmes for the protection of patients, patient care givers and healthcare ... laundry, pharmacy etc where there is exposure to a .... unused sterile swabs (10) and culture media plates ..... patient safety.
catastrophic health expenditures (CHE) and risk of being impoverished as a result of cost of care were assessed. Statistical ... Impact and contributors to cost of managing long term conditions in a ... sectors is ongoing, it has become clear that.
birth attendants, and if there is a proper division of labour amongst the three tiers of the health system. 3 ... Obstetric. Care,. Traditional. Birth. Attendants,. Maternal. Mortality,. Neonatal ..... interview believed that sudden onset of labor and.
This was a cross-sectional, multi clinic study involving 265 mothers whose children had erupted at least a tooth and attending the ... parents, health care workers and personal experiences were the sources of beliefs ..... Ethiopians abroad.
Cervical cancer remains a major public health challenge in developing countries ... relation to knowledge on cervical cancer, primary level of education ... Latin America and Southeast Asia. ... practices such as level of awareness, educational.
Smithson, Sarah; Pignone, Michael P
The burden of depression in the United States is substantial. Evidence supports the benefits of screening for depression in all adults, including older patients and pregnant and postpartum women, when coupled with appropriate resources for management of disease. Developing, implementing, and sustaining a high-fidelity screening process is an important first step for improving the care of patients with depression in primary care. Initial treatment for depression should include psychotherapy, pharmacotherapy, or a combination of both. Collaborative care models are evidence-based approaches to depression treatment and follow-up that can be feasibly initiated in the primary care setting. Copyright © 2017 Elsevier Inc. All rights reserved.
Scott, Joan; Trotter, Tracy
With the recent expansion of genetic science, its evolving translation to clinical medicine, and the growing number of available resources for genomics in primary care, the primary care provider must increasingly integrate genetics and genomics into daily practice. Because primary care medicine combines the treatment of acute illness with disease prevention and anticipatory guidance, the primary care provider is in an ideal position to evaluate and treat patients for genetic disease. The notion that genetic knowledge is only rarely needed will have to be replaced with a comprehensive approach that integrates "genetic thinking" into every patient encounter. Genomic competencies will need to be added to the primary care provider's repertoire; such competencies include prevention, assessment, evaluation, and diagnosis of genetic conditions; the ordering and interpreting of genetic tests; communication with families; appropriate referrals; and the management or comanagement of care. The process of deciding when to order genetic tests, what tests to order, and how to interpret the results is complex, and the tests and their results have specific risks and benefits, especially for pediatric patients. The longitudinal nature of primary pediatric care provides the opportunity to obtain and continually update the family history, which is the most powerful initial genetic "test." The ongoing provider-family relationship, coupled with the astounding number of advances in genetic and genomic testing, also necessitates a constant re-evaluation of past diagnosis or nondiagnosis.
Full Text Available -Quality Assessment in the Primary care Dear Editor; I have read the article titled as “Implementation of Rogi Kalyan Samiti (RKS at Primary Health Centre Durvesh” with great interest. Shrivastava et all concluded that assessment mechanism for the achievement of objectives for the suggested RKS model was not successful (1. Hereby I would like to emphasize the importance of quality assessment (QA especially in the era of newly established primary care implementations in our country. Promotion of quality has been fundamental part of primary care health services. Nevertheless variations in quality of care exist even in the developed countries. Accomplishment of quality in the primary care has some barriers like administration and directorial factors, absence of evidence-based medicine practice lack of continuous medical education. Quality of health care is no doubt multifaceted model that covers all components of health structures and processes of care. Quality in the primary care set up includes patient physician relationship, immunization, maternal, adolescent, adult and geriatric health care, referral, non-communicable disease management and prescribing (2. Most countries are recently beginning the implementation of quality assessments in all walks of healthcare. Organizations like European society for quality and safety in family practice (EQuiP endeavor to accomplish quality by collaboration. There are reported developments and experiments related to the methodology, processes and outcomes of quality assessments of health care. Quality assessments will not only contribute the accomplishment of the program / project but also detect the areas where obstacles also exist. In order to speed up the adoption of QA and to circumvent the occurrence of mistakes, health policy makers and family physicians from different parts of the world should share their experiences. Consensus on quality in preventive medicine implementations can help to yield
Kristensen, Troels; Rose Olsen, Kim
Aim: We analyze total operating costs and activities in Danish General Practice units to assess whether there are unexploited economies of scope in the production of primary care services. Methods: We apply stochastic frontier analysis to derive cost functions and associated cost complementarities...... between GP services and overall economies of scope. Data: Cross-section data for a sample of 331 primary care practices with 1-8 GPs from the year 2006. This is a unique combined dataset consisting of survey and register data. Results: We find a trend towards cost complementarities between the production...... economies of scope in the production of GP services. Conclusions: Our preliminary results show that there were overall economies of scope associated with the joint production of a) standard consultations, b) email/phone consultations and c) home visits. Cost complementarities between standard consultations...
Armando Henrique Norman
Atenção Primária (CIAP, mais vinculado ao processo de trabalho como um todo do que à Classificação Internacional das Doenças (CID, que se relaciona mais ao processo de vigilância da morbimortalidade. A CIAP, atualmente na sua segunda versão, classifica o processo de cuidado em três diferentes segmentos: razão de encontro, diagnóstico e processo7. Assim, a CIAP-2 possibilita ao clínico ou pesquisador mudar para uma epidemiologia orientada ao episódio do cuidado, ou seja, permite uma análise ao longo do tempo do episódio de cuidado, na medida que esse se desenvolve, marcado pela transição (ou mudanças na relação entre a razão do encontro ou consulta, diagnóstico e intervenções realizadas. A CIAP-2 também é mais leve e com poucos códigos, se comparada ao CID, pois abarca os problemas mais comuns da prática, com frequência intermediária (definidos por taxa de ocorrência de 1-5/1.000 pacientes/ano ou frequentes (definidos por taxa de ocorrência ? 5/1.000 pacientes/ano7. Essa ferramenta desenvolvida pelos médicos de família é parte integrante da agenda da Organização Mundial da Saúde (WHO – Family International Classification6, entretanto necessita ganhar mais espaço na prática e nas pesquisas em APS no Brasil. A presente edição contribui para essa discussão trazendo três artigos – um de Portugal e dois do Brasil – que abordam o tema da CIAP. O primeiro, Tendência de classificação no Capítulo Z da CIAP-2 entre 2006 e 2011 em um centro de saúde de Medicina Familiar em Coimbra, Portugal, faz uma reflexão sobre o aumento do uso de códigos referentes a problemas sociais, que talvez reflita a crise econômica pela qual está passando Portugal. Já os artigos dos autores brasileiros versam sobre a aplicabilidade da CIAP como ferramenta de estudo da demanda em APS. O artigo A methodological proposal to research patients’ demands and pre-test probabilities in a paper form in primary care settings oferece uma
Van Cleave, Jeanne; Heisler, Michele; Devries, Jeffrey M; Joiner, Terence A; Davis, Matthew M
To compare parents of children with special health care needs (CSHCN) with other parents to determine parents' expectations and priorities for discussing concerns related to a child's acute or chronic illness at well-child care visits, the association of unmet expectations and priorities with satisfaction, and whether discussing illness displaces prevention topics. Written, self-administered survey of parents at well-child care visits. Two community-based pediatric practices in suburban southeast Michigan. Five hundred parents with children aged 6 months to 12 years. Having a special health care need. Expectations and priorities for discussing illness-related topics (chronic and acute illnesses, medications, specialist referrals, and effects of health on life overall), actual discussion regarding illness and preventive topics, and satisfaction. Compared with parents of children without chronic conditions, parents of CSHCN were more likely to expect to discuss their child's illness (81% vs 92%, respectively; P parents of CSHCN ranked illness among their top 3 priorities (vs 53% of other parents [P Parents of CSHCN reported discussing a mean of 3.2 illness topics, as compared with a mean of 2.2 illness topics for other parents (P expectation for discussing illness was associated with higher odds of lower satisfaction (for parents of CSHCN: odds ratio, 7.2; 95% confidence interval, 2.9-18.3; for other parents: odds ratio, 3.0; 95% confidence interval, 1.7-5.5). Discussing more illness topics was associated with discussing more preventive topics (P expected and highly prioritized at well-child care visits, particularly for parents of CSHCN. Unmet expectations are associated with lower satisfaction. Incorporating illness concerns at well-child care visits may improve chronic disease management.
Armando Henrique Norman
Full Text Available A Revista Brasileira de Medicina de Família e Comunidade (RBMFC encerra o ano de 2013 com uma edição em comemoração ao nascimento da Dra. Barbara Starfield em 18 de dezembro (18/12/1932 - 10/6/2011. A foto da capa, intitulada “Desayuno en Buitrago de Lozoya” retrata a amizade entre Barbara Starfield, seu marido Neil “Tony” Holtzman e Juan Gérvas e Mercedes Pérez Fernández (autora da foto, na qual desfrutam e compartilham a vida à mesa. A mesa também faz referência a uma característica marcante de Starfield: a de nutriz (do latim nuctrix, que possui a capacidade de nutrir; que sustenta. Como afirmou seu marido Tony: - “Ela fez isso por meio de sua pesquisa, sua paixão altruísta e sua orientação àqueles que se preocupam com as pessoas, a justiça e a verdade”1.O editorial especial para esta edição foi escrito pelo Dr. Juan Gérvas e reflete a importância de se avaliar a qualidade da atenção primária à saúde (APS a fim de que ela possa, continuamente, se fortalecer. Em decorrência disso, todos os artigos desta edição versam sobre o Instrumento de Avaliação da Atenção Primária, em inglês Primary Care Assessment Tool (PCATool, sua validação, adaptação e aplicação para a APS2. Starfield e colaboradores desenvolveram, no The Johns Hopkins Populations Care Policy Center for the Underserved Populations, o PCATool, instrumento que permite mensurar a presença e a extensão dos atributos essenciais e derivados da APS3. Os quatro atributos essenciais da APS: a acesso de primeiro contato; b continuidade do cuidado; c abrangência (comprehensiveness; e d coordenação dos cuidados são subcomponentes do acesso e, portanto, a qualidade dos serviços passa pela melhoria de estruturas e processos (efetividade que garantam o acesso tanto no nível individual – atendendo os indivíduos e suas necessidades em saúde – como no nível populacional, em que o acesso volta-se à dimensão ética da
Elmore, James L.
Dissociative disorders have a lifetime prevalence of about 10%. Dissociative symptoms may occur in acute stress disorder, posttraumatic stress disorder, somatization disorder, substance abuse, trance and possession trance, Ganser's syndrome, and dissociative identity disorder, as well as in mood disorders, psychoses, and personality disorders. Dissociative symptoms and disorders are observed frequently among patients attending our rural South Carolina community mental health center. Given the prevalence of mental illness in primary care settings and the diagnostic difficulties encountered with dissociative disorders, such illness may be undiagnosed or misdiagnosed in primary care settings. We developed an intervention model that may be applicable to primary care settings or helpful to primary care physicians. Key points of the intervention are identification of dissociative symptoms, patient and family education, review of the origin of the symptoms as a method of coping with trauma, and supportive reinforcement of cognitive and relaxation skills during follow-up visits. Symptom recognition, Education of the family, Learning new skills, and Follow-up may be remembered by the mnemonic device SELF. We present several cases to illustrate dissociative symptoms and our intervention. Physicians and other professionals using the 4 steps and behavioral approaches will be able to better recognize and triage patients with dissociative symptoms. Behaviors previously thought to be secondary to psychosis or personality disorders may be seen in a new frame of reference, strengthening the therapeutic alliance while reducing distress and acting-out behaviors. PMID:15014580
Crampton, Peter; Davis, Peter; Lay-Yee, Roy
Community-governed non-profit primary care organisations started developing in New Zealand in the late 1980s with the aim to reduce financial, cultural and geographical barriers to access. New Zealand's new primary health care strategy aims to co-ordinate primary care and public health strategies with the overall objective of improving population health and reducing health inequalities. The purpose of this study is to carry out a detailed examination of the composition and characteristics of primary care teams in community-governed non-profit practices and compare them with more traditional primary care organisations, with the aim of drawing conclusions about the capacity of the different structures to carry out population-based primary care. The study used data from a representative national cross-sectional survey of general practitioners in New Zealand (2001/2002). Primary care teams were largest and most heterogeneous in community-governed non-profit practices, which employed about 3% of the county's general practitioners. Next most heterogeneous in terms of their primary care teams were practices that belonged to an Independent Practitioner Association, which employed the majority of the country's general practitioners (71.7%). Even though in absolute and relative terms the community-governed non-profit primary care sector is small, by providing a much needed element of professional and organisational pluralism and by experimenting with more diverse staffing arrangements, it is likely to continue to have an influence on primary care policy development in New Zealand.
Samuelson, M.; Tedeschi, P.; Aarendonk, D.; Cuesta, C. de la; Groenewegen, P.
Primary care is the central pillar of health care. The increasingly complex health needs of the population and individual patients in a changing society can only be met by promoting interprofessional collaboration (IpC) within primary care teams. The aim of this Position Paper of the European Forum
Swoboda, W; Hermens, T
Internal medicine specialists involved in primary care will have a leading part in the treatment of geriatric patients with complex healthcare needs in the future. Approved models like specialized geriatric practices, ambulant or mobile geriatric rehabilitation and special geriatric services for nursing homes are available. Essential is a geriatric qualification that fits with the tasks of an internist in primary care. An incentive payment system has to be created for this purpose to improve the treatment of elderly patients.
Previously, the main focus of primary health care practices was to diagnose and treat patients. The identification of risk factors for disease and the prevention of chronic conditions have become a part of everyday practice. This paper provides an argument for training primary health care (PHC) practitioners in health promotion, while encouraging them to embrace innovation within their practice to streamline the treatment process and improve patient outcomes. Electronic modes of communication...
Bregnhøj, Lisbeth; Thirstrup, Steffen; Kristensen, Mogens Brandt
OBJECTIVE: To describe the prevalence of inappropriate prescribing in primary care in Copenhagen County, according to the Medication Appropriateness Index (MAI) and to identify the therapeutic areas most commonly involved. SETTING: A cross-sectional study was conducted among 212 elderly ( >65 years...... most commonly involved in inappropriate prescribing were medications for treatment of peptic ulcer, cardiovascular medications, anti-inflammatory medications, antidepressants, hypnotics and anti-asthmatics. CONCLUSION: The overall prescribing quality in primary care in Copenhagen County, Denmark...
Lifestyle Changes and the Risk of Colorectal Cancer among. Immigrants in the United .... food rich in red meat, animal fat, sugars and refined of CRC in Africa .... region to improve health care delivery and secure the is obtainable in the UK, ...
proir permission to their pregnant wives to seek care studies, a husband ... two or three male CHOs, while a female CHO getting safe blood, given prior permission for comes once a week .... and note taker, both of whom were native speakers.
Background An intensive care unit (ICU) admission is a stressful event for the patient and the patient’s family. Several studies demonstrated symptoms of anxiety, depression, and posttraumatic stress disorder in family members of patients admitted to ICU. Some studies recognize that the open visitation policy (OVP) is related to a reduction in symptoms of anxiety and depression for the patient and an improvement in family satisfaction. However, some issues have been presented as barriers for ...
Yaya, Sanni; Bishwajit, Ghose; Ekholuenetale, Michael; Shah, Vaibhav; Kadio, Bernard; Udenigwe, Ogochukwu
Although ANC services are increasingly available to women in low and middle-income countries, their inadequate use persists. This suggests a misalignment between aims of the services and maternal beliefs and circumstances. Owing to the dearth of studies examining the timing and adequacy of content of care, this current study aims to investigate the timing and frequency of ANC visits in Ethiopia. Data was obtained from the nationally representative 2011 Ethiopian Demographic and Health Survey (EDHS) which used a two-stage cluster sampling design to provide estimates for the health and demographic variables of interest for the country. Our study focused on a sample of 10,896 women with history of at least one childbirth event. Percentages of timing and adequacy of ANC visits were conducted across the levels of selected factors. Variables which were associated at 5% significance level were examined in the multivariable logistic regression model for association between timing and frequency of ANC visits and the explanatory variables while controlling for covariates. Furthermore, we presented the approach to estimate marginal effects involving covariate-adjusted logistic regression with corresponding 95%CI of delayed initiation of ANC visits and inadequate ANC attendance. The method used involved predicted probabilities added up to a weighted average showing the covariate distribution in the population. Results indicate that 66.3% of women did not use ANC at first trimester and 22.3% had ANC less than 4 visits. The results of this study were unique in that the association between delayed ANC visits and adequacy of ANC visits were examined using multivariable logistic model and the marginal effects using predicted probabilities. Results revealed that older age interval has higher odds of inadequate ANC visits. More so, type of place of residence was associated with delayed initiation of ANC visits, with rural women having the higher odds of delayed initiation of ANC
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.
2Department of Health Policy and Management, Faculty of Public Health, College of Medicine and University ... 86 (21%) had primary school education, 210 (51.3%) were married, and 357 (87.3%) were employed. ...... patient satisfaction and behavioral intentions in. 5. .... Psychological Assessment 1995; 7 (3):309-319.
Pawełczyk, Agnieszka; Pawełczyk, Tomasz; Bielecki, Jan
This paper analyzes and synthesizes the literature on primary care specialty choice. Motivation for choosing medicine and its impact on recruitment to different types of medical work has been presented. Factors that influence medical students and young doctors to change specialty preference have also been explored. Variables, such as gender, martial status, age, income expectations and prestige, that affect medical students' specialty selection decisions for primary care, have been examined. Personality profiles of primary care physician have been evaluated and the influence of communication skills and knowledge of social psychology on his/her work have been analyzed. It is presented that other traits, such as patient-centeredness, needs to serve society and value orientation, is also associated with increases in numbers of students choosing primary care. The analyze shows that the preference for primary care is connected with being interested in diverse patients and health problems and also with being people-orientated. A survey conducted into Polish medical students' attitudes to primary care and family medicine is presented. There is a negative perception of family medicine among Polish students and doctors because of its long work hours and less time for family, insufficient diagnostic possibilities and monotony It is chosen because of lack of other possibilities, difficulties in employment and opportunity to become 'a specialist' in short time.
Background A constructive patient safety culture is a main prerequisite for patient safety and improvement initiatives. Until now, patient safety culture (PSC) research was mainly focused on hospital care, however, it is of equal importance in primary care. Measuring PSC informs practices on their s
Beasley, John W.; Starfield, Barbara; van Weel, Chris; Rosser, Walter W.; Haq, Cynthia L.
A strong primary health care system is essential to provide effective and efficient health care in both resource-rich and resource-poor countries. Although a direct link has not been proven, we can reasonably expect better economic status when the health of the population is improved. Research in pr
Beasley, J.W.; Starfield, B.; Weel, C. van; Rosser, W.W.; Haq, C.L.
A strong primary health care system is essential to provide effective and efficient health care in both resource-rich and resource-poor countries. Although a direct link has not been proven, we can reasonably expect better economic status when the health of the population is improved. Research in pr
Beasley, J.W.; Starfield, B.; Weel, C. van; Rosser, W.W.; Haq, C.L.
A strong primary health care system is essential to provide effective and efficient health care in both resource-rich and resource-poor countries. Although a direct link has not been proven, we can reasonably expect better economic status when the health of the population is improved. Research in
We do not need a crystal ball to see the future. Our web-based future has already arrived in all other aspects of our lives--even our mobile phones. The tools for progress--Personal Health Records, Social Networks, and Online medical information--are widely available. The demand is at hand--Millennials are flexing consumer muscles as they enter the healthcare market. Real "Health Care Reform" requires fundamental changes in practice--which in turn requires effective use of information technologies and adaption to changing consumer expectations. The VHA and the MHS are uniquely capable of leveraging political, academic and technological forces to help move American health care through this millennial transformation. Federal health systems are positioned to demonstrate the value of innovation as America seeks healthcare reform.
Gutiérrez Pérez, M Isabel; Lucio-Villegas Menéndez, M Eulalia; González, Laura López; Lluch, Natalia Aresté; Morató Agustí, M Luisa; Cachafeiro, Santiago Pérez
Wounds can be classified according to their mechanism of action into surgical or traumatic (which may be incision wounds, such as those provoked by a sharp object; contusions, caused by a blunt force; puncture wounds, caused by long, sharp objects; lacerations, caused by tears to the tissue; or bites, which have a high risk of infection and consequently should not be sutured). Wounds can also be classified by their healing process into acute or chronic (pressure ulcers, vascular ulcers, neuropathic ulcers, acute wounds with torpid clinical course). The use of antiseptics in any of these wounds is usually limited to cleaning and initial care -up to 48 hours- and to washing of hands and instruments. The use of antiseptics in chronic or persistent wounds is more debatable. The same is true of burns, in which the use of formulations that encourage hydration is recommended. In the pediatric population, the use of antiseptics with a known safety profile and low absorption is usually recommended, especially in the care of the umbilical cord, in which evidence supports the use of chlorhexidine gluconate. Another use of antiseptics is the care of wounds produced by procedures used in body esthetics, such as piercings; in these procedures, it is advisable to use transparent antiseptics that allow visualization of the technique. Copyright © 2014 Elsevier España, S.L. All rights reserved.
Full Text Available Introduction: The primary health centers and community health centers (CHCs offer an opportunity for early diagnosis and treatment, dental health education, and institution of preventive measures in the remote areas. Aim: To assess the level of utilization of dental health care services and to determine barriers that prevent utilization of dental health-care services among the patients visiting CHCs in Nellore District, Andhra Pradesh. Materials and Methods: A cross-sectional study was carried out among 600 patients aged 20 years and above visiting the randomly selected 10 CHCs during May 2015 in Nellore District. A multistage sampling method was followed. The source of data was primary in nature and it was obtained through self-administered questionnaire. Data was entered and analyzed using a software program IBM SPSS Statistics version 22 (Armonk, NY: IBM Corp (P < 0.05. Results: Only 36% of patients had visited the dentist in the last 12 months. Males (54% visited dentist more frequently than females (46%. The most common reported reasons for the last dental visit were pain or a dental emergency (71%, followed by restorative treatment (17% and other reasons (12%. The most commonly reported reasons for not seeking dental care were “Not needed unless having pain” by 360 (60%, “I do not think dental diseases are very serious” by 304 (51%, “I have fear of dental procedures” by 290 (48.6%,“Lack of time” by 235 (45.6%, “Dental treatment is expensive” by 200 (33.3%, and “The dentist is at a long distance” by 158 (26.8%. Conclusions: Our findings suggest that only a small portion of population visited a dentist in previous year. Most of them believe that visiting dentist is necessary only for pain relief.
Full Text Available BACKGROUND: 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. METHODS: Postal surveys with all healthcare professionals and a random sample of 100 patients with Type 2 diabetes from 99 UK primary care practices. RESULTS: 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. CONCLUSIONS: 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.
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
Nyamtema Angelo S
Full Text Available Abstract Background Antenatal care (ANC provides an important opportunity for pregnant women with a wide range of interventions and is considered as an important basic component of reproductive health care. Methods In 2008, severe maternal morbidity audit was established at Saint Francis Designated District Hospital (SFDDH, in Kilombero district in Tanzania, to ascertain substandard care and implement interventions. In addition, a cross-sectional descriptive study was carried out in 11 health facilities within the district to assess the quality of ANC and underlying factors in a broader view. Results Of 363 severe maternal morbidities audited, only 263 (72% ANC cards were identified. Additionally, 121 cards (with 299 ANC visits from 11 facilities were also reviewed. Hemoglobin and urine albumin were assessed in 22% – 37% and blood pressure in 69% - 87% of all visits. Fifty two (20% severe maternal morbidities were attributed to substandard ANC, of these 39 had severe anemia and eclampsia combined. Substandard ANC was mainly attributed to shortage of staff, equipment and consumables. There was no significant relationship between assessment of essential parameters at first ANC visit and total number of visits made (Spearman correlation coefficient, r = 0.09; p = 0.13. Several interventions were implemented and others were proposed to those in control of the health system. Conclusions This article reflects a worrisome state of substandard ANC in rural Tanzania resulting from inadequate human workforce and material resources for maternal health, and its adverse impacts on maternal wellbeing. These results suggest urgent response from those in control of the health system to invest more resources to avert the situation in order to enhance maternal health in this country.
March Cerdá, Joan Carles; Oviedo-Joekes, Eugenia; Romero Vallecillos, Manuel; Prieto Rodríguez, María Angeles; Danet, Alina
To evaluate the dynamics and establish the emotional map of 8 primary care teams. Descriptive, cross-sectional and multi-site study. Primary care centers in Granada, Cádiz and Málaga, Spain. Simple random sampling of 8 health centers and 272 primary care professionals. A self administered questionnaire with 10 Likert-type questions. Answers were classified by items, media and mode. Leadership is not integrated (0.42 points). Relationships between workers show rivalry, burnout and little sensation of being part of a team, but they are united by support and trust. There is a moderate enthusiasm of team objectives (1.36 points). Professional self esteem is generally positive (1.89 points). Emotional climate of the teams recorded medium values. Aspects as regards integrating leadership and increased enthusiasm towards the common work project need to be improved, following the inter-professional collaborative care model.
Grove, Lexie R; Olesiuk, William J; Ellis, Alan R; Lichstein, Jesse C; DuBard, C Annette; Farley, Joel F; Jackson, Carlos T; Beadles, Christopher A; Morrissey, Joseph P; Domino, Marisa Elena
Primary care-based medical homes could improve the coordination of mental health care for individuals with schizophrenia and comorbid chronic conditions. The objective of this paper is to examine whether persons with schizophrenia and comorbid chronic conditions engage in primary care regularly, such that primary care settings have the potential to serve as a mental health home. We examined the annual primary care and specialty mental health service utilization of adult North Carolina Medicaid enrollees with schizophrenia and at least one comorbid chronic condition who were in a medical home during 2007-2010. Using a fixed-effects regression approach, we also assessed the effect of medical home enrollment on utilization of primary care and specialty mental health care and medication adherence. A substantial majority (78.5%) of person-years had at least one primary care visit, and 17.9% had at least one primary care visit but no specialty mental health services use. Medical home enrollment was associated with increased use of primary care and specialty mental health care, as well as increased medication adherence. Medical home enrollees with schizophrenia and comorbid chronic conditions exhibited significant engagement in primary care, suggesting that primary-care-based medical homes could serve a care coordination function for persons with schizophrenia. Copyright © 2017 Elsevier Inc. All rights reserved.
I present a historical study of the role played by the World Health Organization and UNICEF in the emergence and diffusion of the concept of primary health care during the late 1970s and early 1980s. I have analyzed these organizations' political context, their leaders, the methodologies and technologies associated with the primary health care perspective, and the debates on the meaning of primary health care. These debates led to the development of an alternative, more restricted approach, known as selective primary health care. My study examined library and archival sources; I cite examples from Latin America.
Full Text Available Purpose: This article reviews the impact of successive experiments in the development of primary care organisations in England and assesses the long-term importance of English primary care groups for the integration of health and community and health and social care and the deinstitutionalisation of hospital care. Theory: Governments in a number of Western countries are attempting to improve the efficiency, appropriateness and equity of their health systems. One of the main ways of doing this is to devolve provision and commissioning responsibility from national and regional organisations to more local agencies based in primary care. Such primary care organisations are allocated budgets that span both primary and secondary (hospital services and also, potentially, social care. Method: This article is based on a systematic review of the literature forthcoming from the UK Government's Department of Health-funded evaluations of successive primary care organisational developments. These include total purchasing pilots, GP commissioning group pilots, personal medical services pilots and primary care groups and trusts. Results: Primary care organisations in England have proved to be a catalyst in facilitating the development of integrated care working between primary and community health services. Conversely, primary care organisations have proved less effective in promoting integration between health and social care agencies where most progress has been made at the strategic commissioning level. The development of primary care trusts in England is heralding an end to traditional community hospitals. Conclusions: The development of primary care groups in England are but an intermediate step of a policy progression towards future primary care-based organisations that will functionally integrate primary and community health services with local authority services under a single management umbrella.
Kayingo, Gerald; Deon Kidd, Vasco; Gilani, Owais; Warner, Mary L
The goal of t his study was to describe the characteristics of primary care teams, activities, and ro les of physician assistant (PA) students as they encounter various primary care sites. An electronic survey was distributed to second year PA students in 12 programs who had completed at least 4 weeks in a primary care rotation. Of the 179 students who responded (response rate 41 %), 88% had completed their primary care rotations in urban settings, mostly in private practices (53%). Physician assistant students reported encountering many types of health care providers on their teams, and the 2 most favored features of the rotations were the interactions with their supervising clinicians and clinical responsibilities. About 68% interacted with other health profession students during their rotation(interprofessional experiential learning). Almost all students completed histories, physical examinations, and treatment plans, but less than 30% reported involvement in billing or care coordination and less than 10% participated in quality improvement projects. More than 60% were satisfied with team-based and interprofessional practices encountered during their primary care rotations, and 39% were more than likely to pursue primary care careers. Team-based prima ry ca re had a positive impact on students, but more exposure to underserved clinical settings, care coordination, quality improvement, and billing is needed to prepare PA students for the practice of the future. This study is t he first of its kind to explore the relationship between primary care sites and PA training in the era of health care reform.
Rodríguez, José E.; Fornari, Alice B.
Background: Efforts to increase medical student knowledge regarding obesity are needed in medical school curriculum. This article examines a third year medical student intervention utilizing obesity group visits. Description: In our third-year family medicine clerkship, we implemented the Health not Cosmetics pilot intervention as part of a Community Oriented Primary Care experience. The intervention consisted of weekly group visits run by third and fourth year medical students to teach lif...
The inadequate planning of health professionals in Spain has boosted the way out of doctors overseas. The United Kingdom is one of the countries chosen by Spanish doctors to develop their job. The National Health Service is a health system similar to the Spanish one. Health care services are financing mainly through taxes. The right to health care is linked to the citizen condition. The provision of health care is a mix-up of public and private enterprises. Primary Care is much closed to Spanish Primary Care. Doctors are "self-employed like" professionals. They can set their surgeries in a free area previously designed by the government. They have the right to make their own team and to manage their own budget. Medical salary is linked to professional capability and curriculum vitae. The main role of a General Practitioner is the prevention. Team work and coordination within primary and specialised care is more developed than in Spain. The access to diagnostic tests and to the specialist is controlled through waiting lists. General Practitioners work as gate-keepers. Patients may choose freely their doctor and consultations and hospital care are free at the point of use. Within the United Kingdom there are also health regions with problems due to inequalities to access and to treatment. There is a training path and the access to it is by Curricula. The number of training jobs is regulated by the local needs. Continuing education is compulsory and strictly regulated local and nationally. The National Health Service was the example for the Spanish health reform in 1986. While Spanish Primary health care is of quality, the efficiency of the health system would improve if staff in Primary Care settings were managed in a similar way to the British's.
Ramona S DeJesus
Full Text Available Ramona S DeJesus1, Kristin S Vickers2, Robert J Stroebel1, Stephen S Cha31Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA; 2Department of Psychiatry and Psychology, Mayo Clinic, MN, USA; 3Department of Biostatistics, Mayo Clinic, Rochester, MN, USAPurpose: The collaborative care model, using care managers, has been shown to be effective in achieving sustained treatment outcomes in chronic disease management. Little effort has been made to find out patient preferences for chronic disease care, hence, we conducted a study aimed at identifying these.Methods: A 20-item questionnaire, asking for patients’ and providers’ preferences and perceptions, was mailed out to 1000 randomly selected patients in Olmsted County, Minnesota, identified through a diabetes registry to have type 2 diabetes mellitus, a prototypical prevalent chronic disease. Surveys were also sent to 42 primary care providers.Results: There were 254 (25.4% patient responders and 28 (66% provider responders. The majority of patients (>70% and providers (89% expressed willingness to have various aspects of diabetes care managed by a care manager. Although 75% of providers would be comfortable expanding the care manager role to other chronic diseases, only 39.5% of patient responders would be willing to see a care manager for other chronic problems. Longer length of time from initial diagnosis of diabetes was associated with decreased patient likelihood to work with a care manager.Conclusion: Despite study limitations, such as the lack of validated measures to assess perceptions related to care management, our results suggest that patients and providers are willing to collaborate with a care manager and that both groups have similar role expectations of a care manager.Keywords: care manager, collaborative care, patient preference, diabetes care
Herrel, Lindsey A; Ayanian, John Z; Hawken, Scott R; Miller, David C
Although Accountable Care Organizations (ACOs) are defined by the provision of primary care services, the relationship between the intensity of primary care and population-level utilization and costs of health care services has not been examined during early implementation of Medicare Shared Savings Program (MSSP) ACOs. Our objective was to evaluate the association between primary care focus and healthcare utilization and spending in the first performance period of the Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs). In this retrospective cohort study, we divided the 220 MSSP ACOs into quartiles of primary care focus based on the percentage of all ambulatory evaluation and management services delivered by a PCP (internist, family physician, or geriatrician). Using multivariable regression, we evaluated rates of utilization and spending during the initial performance period, adjusting for the percentage of non-white patients, region, number of months enrolled in the MSSP, number of beneficiary person years, percentage of dual eligible beneficiaries and percentage of beneficiaries over the age of 74. The proportion of ambulatory evaluation and management services delivered by a PCP ranged from 46% (highest quartile, ACOs with greatest PCP focus). ACOs in the highest quartile of PCP focus had higher adjusted rates of utilization of acute care hospital admissions (328 per 1000 person years vs 292 per 1000 person years, p = 0.01) and emergency department visits (756 vs 680 per 1000 person years, p = 0.02) compared with ACOs in the lowest quartile of PCP focus. ACOs in the highest quartile of PCP focus achieved no greater savings per beneficiary relative to their spending benchmarks ($142 above benchmark vs $87 below benchmark, p = 0.13). Primary care focus was not associated with increased savings or lower utilization of healthcare during the initial implementation of MSSP ACOs.
Grumbach, Kevin; Bodenheimer, Thomas
In health care settings, individuals from different disciplines come together to care for patients. Although these groups of health care personnel are generally called teams, they need to earn true team status by demonstrating teamwork. Developing health care teams requires attention to 2 central questions: who is on the team and how do team members work together? This article chiefly focuses on the second question. Cohesive health care teams have 5 key characteristics: clear goals with measurable outcomes, clinical and administrative systems, division of labor, training of all team members, and effective communication. Two organizations are described that demonstrate these components: a private primary care practice in Bangor, Me, and Kaiser Permanente's Georgia region primary care sites. Research on patient care teams suggests that teams with greater cohesiveness are associated with better clinical outcome measures and higher patient satisfaction. In addition, medical settings in which physicians and nonphysician professionals work together as teams can demonstrate improved patient outcomes. A number of barriers to team formation exist, chiefly related to the challenges of human relationships and personalities. Taking small steps toward team development may improve the work environment in primary care practices.
Riley, Anthony J; Harding, Geoffrey; Underwood, Martin R; Carter, Yvonne H
Homelessness is a social problem that affects all facets of contemporary society. This paper discusses the concept of homelessness in terms of its historical context and the dominance of the pervasive 'victim blaming' ideologies, which, together with the worldwide economic changes that have contributed to a fiscal crisis of the state, and the resultant policies and circumstances, have led to an increase in the number of 'new homeless' people. This paper attempts to challenge the dominant political discourse on homelessness. The widespread healthcare problems and heterogeneity of homeless people have a particular impact on health services, with many homeless people inappropriately accessing local accident and emergency (A&E) departments because of barriers inhibiting adequate access to primary care. A number of primary care schemes have been successfully implemented to enable the homeless to have better access to appropriate care. However, there is no consistency in the level of services around the United Kingdom (UK), and innovations in service are not widespread and by their nature they are ad hoc. Despite the successes of such schemes, many homeless people still access health care inappropriately. Until homeless people are fully integrated into primary care the situation will not change. The question remains, how can appropriate access be established? A start can be made by building on some of the positive work that is already being done in primary care, but in reality general practitioners (GPs) will be 'swimming against the tide' unless a more integrated policy approach is adopted to tackle homelessness.
Yawn, Barbara P; Bertram, Susan; Wollan, Peter
Primary care asthma management is often not compatible with national evidence-based guidelines. The objective of this study was to assess the feasibility and impact of the Asthma APGAR tools to enhance implementation of asthma guideline-compatible management in primary care practices. Twenty-four primary care practices across the US. This is a mixed methods study. Quantitative data were used to assess changes in guideline recommended asthma management including use of daily controller therapy, planned care visits, and education and information documentation before and after implementation of the Asthma APGAR. Qualitative data from focus group sessions were used to assess health care professional and patient perceived usability and value of the Asthma APGAR tools during office visits for asthma. Implementing the Asthma APGAR tools in the 24 practices was associated with enhanced asthma visit-related medical record documentation including significant increases in recording of activity limitations due to asthma and asthma symptom frequency, asthma medication nonadherence, asthma triggers, and the patients' perceived response to therapy (p < 0.01 for each item). Some care processes also increased significantly including assessment of inhaler technique and prescribing of daily controller therapy among patients with persistent asthma. Focus groups of patients and of clinical staff reported that the Asthma APGAR tools were easy to use, "made sense" and "improved care" was given and received. The Asthma APGAR tools are feasible to implement in primary care practices and their implementation is associated with increased guideline-compliant asthma management.
Durán-Arenas, Luis; Salinas-Escudero, Guillermo; Granados-García, Víctor; Martínez-Valverde, Silvia
Access to health services is a social basic determinant of health in Mexico unlike what happens in developed countries. The demand for health services is focused on primary care, but the design meets only the supply of hospital care services. So it generates a dissonance between the needs and the effective design of health services. In addition, the term affiliation refers to population contributing or in the recruitment process, that has been counted as members of these social security institutions (SS) and Popular Insurance (SP). In the case of Instituto Mexicano del Seguro Social (IMSS) three of four contributors are in contact with health services; while in the SP, this indicator does not exist. Moreover, the access gap between health services is found in the health care packages so that members of the SS and SP do not have same type of coverage. The question is: which model of health care system want the Mexicans? Primary care represents the first choice for increasing the health systems performance, as well as to fulfill their function of social protection: universal access and coverage based on needs, regardless whether it is a public or private health insurance. A central aspect for development of this component is the definition of the first contact with the health system through the creation of a primary health care team, led by a general practitioner as the responsible of a multidisciplinary health team. The process addresses the concepts of primary care nursing, consumption of inputs (mainly medical drugs), maintenance and general services. Adopting a comprehensive strategy that will benefit all Mexicans equally and without discrimination, this primary care system could be financed with a total operating cost of approximately $ 22,809 million by year.
Full Text Available Abstract Background To explain why rates of colorectal cancer (CRC screening including fecal occult blood testing (FOBT, flexible sigmoidoscopy (FS, colonoscopy (CS, and barium enema (BE, are low, this study assessed determinants of CRC screening from medical records. Methods Data were abstracted from patients aged ≥64 years selected from each clinician from 30 diverse primary care practices (n = 981. Measurements included the rates of annual FOBT, ever receiving FOBT, ever receiving FS/CS/BE under a combination variable, endoscopy/barium enema (EBE. Results Over five years, 8% had received annual FOBT, 53% had ever received FOBT and 22% had ever received EBE. Annual FOBT was negatively associated with female gender, odds ratio (OR = .23; 95% confidence interval = .12–.44 and positively associated with routinely receiving influenza vaccine, OR = 2.55 (1.45–4.47; and more office visits: 3 to Conclusion Overall CRC screening rates were low, but were related to the number of primary care office visits. FOBT was related to immunization status, suggesting the possible benefit of linking these preventive services.
Maria Cristina Barbaro
Full Text Available OBJECTIVE: evaluate prenatal care for adolescents in health units, in accordance with the attributes of Primary Health Care (PHC guidelines. METHOD: quantitative study conducted with health professionals, using the Primary Care Assessment Tool-Brazil to assess the presence and extent of PHC attributes. RESULTS: for all the participating units, the attribute Access scored =6.6; the attributes Longitudinality, Coordination (integration of care, Coordination (information systems and Integrality scored =6.6, and the Essential Score =6.6. Comparing basic units with family health units, the attribute scores were equally distributed; Accessibility scored =6.6, the others attributes scored =6.6; however, in the basic units, the Essential Score was =6.6 and, in the family health units, =6.6. CONCLUSION: expanding the coverage of family health units and the training of professionals can be considered strategies to qualify health care.
Effective communication requires direct interaction between the hospitalist and the primary care provider using a standardized method of information exchange with the opportunity to ask questions and assign accountability for follow-up roles. The discharge summary is part of the process but does not provide the important aspects of handoff, such as closed loop communication and role assignments. Hospital discharge is a significant safety risk for patients, with more than half of discharged patients experiencing at least one error. Hospitalist and primary care providers need to collaborate to develop a standardized system to communicate about shared patients that meets handoff requirements. Copyright © 2014 Elsevier Inc. All rights reserved.
Davis, Melinda M; Bond, Lynne A.; Howard, Alan; Sarkisian, Catherine A.
Purpose: Expectations regarding aging (ERA) in community-dwelling older adults are associated with personal health behaviors and health resource usage. Clinicians’ age expectations likely influence patients’ expectations and care delivery patterns; yet, limited research has explored clinicians’ age expectations. The Expectations Regarding Aging Survey (ERA-12) was used to assess (a) age expectations in a sample of primary care clinicians practicing in the United States and (b) clinician chara...
Chen, Jonathan H; Hom, Jason; Richman, Ilana; Asch, Steven M; Podchiyska, Tanya; Johansen, Nawal Atwan
Long-term opioid use for noncancer pain is increasingly prevalent yet controversial given the risks of addiction, diversion, and overdose. Prior literature has identified the problem and proposed management guidelines, but limited evidence exists on the actual effectiveness of implementing such guidelines in a primary care setting.A multidisciplinary working group of institutional experts assembled comprehensive guidelines for chronic opioid prescribing, including monitoring and referral recommendations. The guidelines were disseminated in September 2013 to our medical center's primary care clinics via in person and electronic education.We extracted electronic medical records for patients with noncancer pain receiving opioid prescriptions (Rxs) in seasonally matched preintervention (11/1/2012-6/1/2013) and postintervention (11/1/2013-6/1/2014) periods. For patients receiving chronic (3 or more) opioid Rxs, we assessed the rates of drug screening, specialty referrals, clinic visits, emergency room visits, and quantity of opioids prescribed.After disseminating guidelines, the percentage of noncancer clinic patients receiving any opioid Rxs dropped from 3.9% to 3.4% (P = 0.02). The percentage of noncancer patients receiving chronic opioid Rxs decreased from 2.0% to 1.6% (P = 0.03). The rate of urine drug screening increased from 9.2% to 17.3% (P = 0.005) amongst noncancer chronic opioid patients. No significant differences were detected for other metrics or demographics assessed.An educational intervention for primary care opioid prescribing is feasible and was temporally associated with a modest reduction in overall opioid Rx rates. Provider use of routine drug screening increased, but overall rates of screening and specialty referral remained low despite the intervention. Despite national pressures to introduce opioid prescribing guidelines for chronic pain, doing so alone does not necessarily yield substantial changes in clinical practice.
Arredondo-Provecho, Ana Belén; Broco-Barredo, Manuel; Alcalá-Ponce de León, Teresa; Rivera-Álvarez, Araceli; Jiménez Trujillo, Isabel; Gallardo-Pino, Carmen
Morbidity associated to partner violence against women (PVAW) justify these patients repeated visits to Health Services. Primary Care is the ideal place for detectión and first aid, due to its easy accesibility and continuated assistance. Nevertheless, numbers show important difficulties to achieve this goal. Our aim is to find out the level of knowledge, opinions, awareness about organizacional barriers and improvement proposals suggested by the workers of primary care. Cross-sectional descriptive study using an anonymous and voluntary survey during the months of August and September 2010, targeted to all professionals who perform their work in a Primary Care Area of Madrid. We made a descriptive analysis of variables and used chi(2) to compare the answers. Answer rate is 170 (21.4%). There are stereotypes regarding battered woman and perpetrador. 118 (70.7%) professionals believe that this is a major problem and 154 (91.7%) that usually goes unnoticed. 91 (55.2%) know their legal commitments. 73 (51.8%) think that there are organizational barriers, among them: the burden of care 50(29%), lack of specific training 40(23.5), lack of knowledge about the procedure to be followed 20(11.8%) and about the professional responsabilities 12 (7%). All profesional categoríes showed an average level of knowledge, except for social workers that was high. Primary Care workers think that PVAW is an important issue that usually goes unnoticed. Half of them know the legal commitments o detección. There are organizacional barriers and stereotypes.
Kinjo, Kentaro; Sairenji, Tomoko; Koga, Hidenobu; Osugi, Yasuhiro; Yoshida, Shin; Ichinose, Hidefumi; Nagai, Yasunori; Imura, Hiroshi; South-Paul, Jeannette E; Meyer, Mark; Honda, Yoshihisa
Physician-led home visit care with medical teams (Zaitaku care) has been developed on a national scale to support those who wish to stay at home at the end of life, and promote a system of community-based integrated care in Japan. Medical care at the end of life can be expensive, and is an urgent socioeconomic issue for aging societies. However medical costs of physician-led home visits care have not been well studied. We compared the medical costs of Zaitaku care and hospital care at the end of life in a rapidly aging community in a rural area in Japan. A cross-sectional study was performed to compare the total medical costs during patients' final days of life (30 days or less) between Zaitaku care and hospital care from September 2012 to August 2013 in Fukuoka Prefecture, Japan. Thirty four patients died at home under Zaitaku care, and 72 patients died in the hospital during this period. The average daily cost of care during the last 30 days did not differ significantly between the two groups. Although Zaitaku care costs were higher than hospital care costs in the short-term (≦10 days, Zaitaku care $371.2 vs. Hospital care $202.0, p = 0.492), medical costs for Zaitaku care in the long-term care (≧30 days) were less than that of hospital care ($155.8 vs. $187.4, p = 0.055). Medical costs of Zaitaku care were less compared with hospital care if incorporated early for long term care, but it was high if incorporated late for short term care. For long term care, medical costs for Zaitaku care was 16.7% less than for hospitalization at the end of life. This physician-led home visit care model should be an available option for patients who wish to die at home, and may be beneficial financially over time.
Karin C. Ringsberg
Full Text Available Some patients with an asthma diagnosis have a poor controlled asthma. One explanation may be an incorrect diagnosis. Aim. The aim of the study was to diagnose and classify patients with non-infectious lower respiratory tract problems in primary health care using internationally applied diagnostic criteria and diagnostic tests. Patients and Methods. New adult patients visiting a primary health care centre due to lower airway problems were included. The diagnostic tests included FEV1, FVC, PEF, two questionnaires, methacholine test, and skin prick test. Results. The patients (n=43 could be divided into four groups: asthma (28%, asthma-like disorder (44%, idiopathic cough (12%, and a nonreversible bronchial obstructive group (16%. The asthma and asthma-like groups showed similar patterns of airway symptoms and trigger factors, not significantly separated by a special questionnaire. Phlegm, heavy breathing, chest pressure/pain, cough, and wheezing were the most common symptoms. Physical exercise and scents were the dominating trigger factors. Conclusions. Nonobstructive asthma-like symptoms seem to be as common as bronchial asthma in primary health care. Due to the similarities in symptoms and trigger factors the study supports the hypothesis that asthma and nonobstructive asthma-like disorders are integrated in the same “asthma syndrome,” including different mechanisms, not only bronchial obstruction.
Background: Visitation of patients admitted at intensive care units (ICUs) is a controversial issue in the field of health care. It is commonly believed that the presence of family members might bring about physiological changes, such as tachycardia and hypertension, in ICU patients. Aim: This study aimed to evaluate the effects of scheduled visitation on the physiological indices of conscious patients at the ICU. Method: This experimental study was conducted on 90 conscious patients admitted...
Chapman, Susan A; Blash, Lisel K
To identify and describe new roles for medical assistants (MAs) in innovative care models that improve care while providing training and career advancement opportunities for MAs. Primary data collected at 15 case study sites; 173 key informant interviews and de-identified secondary data on staffing, wages, patient satisfaction, and health outcomes. Researchers used snowball sampling and screening calls to identify 15 organizations using MAs in new roles. Conducted site visits from 2010 to 2012 and updated information in 2014. Thematic analysis explored key topics: factors driving MA role innovation, role description, training required, and wage gains. Categorized outcome data in patient and staff satisfaction, quality of care, and efficiency. New MA roles included health coach, medical scribe, dual role translator, health navigator, panel manager, cross-trained flexible role, and supervisor. Implementation of new roles required extensive training. MA incentives and enhanced compensation varied by role type. New MA roles are part of a larger attempt to reform workflow and relieve primary care providers. Despite some evidence of success, spread has been limited. Key challenges to adoption included leadership and provider resistance to change, cost of additional MA training, and lack of reimbursement for nonbillable services. © Health Research and Educational Trust.
Jan L. Losby
Full Text Available Objectives: Increasing demands on primary care providers have created a need for systems-level initiatives to improve primary care delivery. The purpose of this article is to describe and present outcomes for 2 such initiatives: the Pennsylvania Academy of Family Physicians’ Residency Program Collaborative (RPC and the St Johnsbury Vermont Community Health Team (CHT. Methods: Researchers conducted case studies of the initiatives using mixed methods, including secondary analysis of program and electronic health record data, systematic document review, and interviews. Results: The RPC is a learning collaborative that teaches quality improvement and patient centeredness to primary care providers, residents, clinical support staff, and administrative staff in residency programs. Results show that participation in a higher number of live learning sessions resulted in a significant increase in patient-centered medical home recognition attainment and significant improvements in performance in diabetic process measures including eye examinations (14.3%, P = .004, eye referrals (13.82%, P = .013, foot examinations (15.73%, P = .003, smoking cessation (15.83%, P = .012, and self-management goals (25.45%, P = .001. As a community-clinical linkages model, CHT involves primary care practices, community health workers (CHWs, and community partners. Results suggest that CHT members successfully work together to coordinate comprehensive care for the individuals they serve. Further, individuals exposed to CHWs experienced increased stability in access to health insurance (P = .001 and prescription drugs (P = .000 and the need for health education counseling (P = .000. Conclusion: Findings from this study indicate that these 2 system-level strategies have the promise to improve primary care delivery. Additional research can determine the extent to which these strategies can improve other health outcomes.
Kristensen, Dorte V; Sundler, Annelie J; Eide, Hilde; Hafskjold, Linda; Ruud, Iren; Holmström, Inger K
To describe the characteristics of communication practice in home care visits between older people (over 65 years old) and nurse assistants and to discuss the findings from a person-centered perspective. The older population is increasing worldwide, along with the need for healthcare services in the person's home. To achieve a high-quality care, person-centered communication is crucial. A descriptive design with a qualitative inductive approach was used. Fifteen audio recordings of naturally occurring conversations between 12 nurse assistants and 13 older people in Norway were analysed by qualitative content analysis. Four categories were revealed through analysis: (i) supporting older people's connection to everyday life; (ii) supporting older people's involvement in their own care; (iii) attention to older people's bodily and existential needs; and (iv) the impact of continuity and predictability on older people's well-being. The communication between the older people and the nurse assistants during home care visits was mainly task-oriented, but also related to the person. The older people were involved in the tasks to be carried out and humour was part of the communication. Greater attention was paid to bodily than existential needs. The communication was connected with the older people's everyday life in several ways. Time frames and interruptions concern the older people; hearing and speech impairments were a challenge to communication. To enhance person-centred communication, further studies are needed, especially intervention studies for healthcare professionals and students. Being responsive to older people's subjective experiences is important in meeting their needs in home care. Communication that addresses the need for trust and predictability is important for older people. Responding to existential needs require more attention. The home care setting has an impact on communication. © 2017 John Wiley & Sons Ltd.
Noël Polly H
Full Text Available Abstract Background Efforts to improve the care of patients with chronic disease in primary care settings have been mixed. Application of a complex adaptive systems framework suggests that this may be because implementation efforts often focus on education or decision support of individual providers, and not on the dynamic system as a whole. We believe that learning among clinic group members is a particularly important attribute of a primary care clinic that has not yet been well-studied in the health care literature, but may be related to the ability of primary care practices to improve the care they deliver. To better understand learning in primary care settings by developing a scale of learning in primary care clinics based on the literature related to learning across disciplines, and to examine the association between scale responses and chronic care model implementation as measured by the Assessment of Chronic Illness Care (ACIC scale. Methods Development of a scale of learning in primary care setting and administration of the learning and ACIC scales to primary care clinic members as part of the baseline assessment in the ABC Intervention Study. All clinic clinicians and staff in forty small primary care clinics in South Texas participated in the survey. Results We developed a twenty-two item learning scale, and identified a five-item subscale measuring the construct of reciprocal learning (Cronbach alpha 0.79. Reciprocal learning was significantly associated with ACIC total and sub-scale scores, even after adjustment for clustering effects. Conclusions Reciprocal learning appears to be an important attribute of learning in primary care clinics, and its presence relates to the degree of chronic care model implementation. Interventions to improve reciprocal learning among clinic members may lead to improved care of patients with chronic disease and may be relevant to improving overall clinic performance.
Meijler, F.L.; Tweel, I. van der
A better understanding of the pathophysiologic mechanisms that determine the random pattem of ventricular rhythm may assist the primary care physician in treating and guiding atrial fibrillation patients. These mechanisms also form the basis for our understanding of drug action and effect on ventric
Wilson, A.; Windak, A.; Oleszczyk, M.; Wilm, S.; Hasvold, T.; Kringos, D.
This chapter will be devoted to the dimensions which have been grouped in the framework as “process” and that focus on essential features of service delivery in primary care. In addition to the breadth of services delivered, a comparative overview will be provided of variation in access to services,
The aim of this thesis is to assess diagnostic strategies in patients suspected of heart failure (defined as a syndrome in which patients suffer from the inability of the heart to supply sufficient blood flow to meet the needs of the body) in primary care. B-type Natriuretic Peptide (BNP or NT-proBN
Honkoop, Pieter Jacob
Asthma is a common non-communicable respiratory disease. In this thesis we analysed three different management strategies for adult patients with asthma in primary care. In the first, we targeted the currently recommended aim of ‘Controlled asthma’, which means patients experience hardly any symptom
B.W.V. Schouten (Boris); A.M. Bohnen (Arthur); B.W. Koes (Bart); J.A.N. Verhaar (Jan); S.M. Bierma-Zeinstra (Sita); A.M. Lievense (Annet)
markdownabstractBACKGROUND: Trochanteric pain is the second most important diagnosis of hip problems presenting in primary care, but its incidence and prognosis in this context is largely unknown. AIM: To determine the 1- and 5-year prognoses of trochanteric pain and the
In patients suspected of deep venous thrombosis (DVT) in primary care, it is a challenge to discriminate the patients with DVT from those without DVT. The risk of missing the diagnosis and the risk of unnecessary referral and treatment with a potential harmful therapy has to be balanced by the prima
Gindner, L.; Tilemann, L.; Schermer, T.R.J.; Dinant, G.J.; Meyer, F.J.; Szecsenyi, J.; Schneider, A.
BACKGROUND: To evaluate the sensitivity, specificity and predictive values of spirometry for the diagnosis of chronic obstructive pulmonary disease (COPD) and asthma in patients suspected of suffering from an obstructive airway disease (OAD) in primary care. METHODS: Cross sectional diagnostic study
Beasley, J W; Hahn, D L; Wiesen, P; Plane, M B; Manwell, L
A significant portion of research project costs is incurred before the receipt of grant funds. This poses a problem for the initiation of primary care research, especially in community practice settings. Potential investigators need financial support for staff time, training, pilot work, and grant proposal writing if primary care researchers are to compete successfully for grant funds. To find this support, we need to understand and eventually quantify the actual costs of research with attention to those that are incurred before the receipt of grant funds. We outline 10 phases of the research process and provide a model for understanding where costs are incurred and by whom. Costs include those associated with maintaining practice interest in research, supporting practice participation, and disseminating research findings. They may be incurred by either an academic center or a research network, by the practices and physicians themselves, or by an extramural funding source. The needed investment for initiating primary care research can be itemized and, with further research, quantified. This will enhance the arguments for capital investments in the primary care research enterprise.
B.W.V. Schouten (Boris); A.M. Bohnen (Arthur); B.W. Koes (Bart); J.A.N. Verhaar (Jan); S.M. Bierma-Zeinstra (Sita); A.M. Lievense (Annet)
markdownabstractBACKGROUND: Trochanteric pain is the second most important diagnosis of hip problems presenting in primary care, but its incidence and prognosis in this context is largely unknown. AIM: To determine the 1- and 5-year prognoses of trochanteric pain and the predictive
Honkoop, Pieter Jacob
Asthma is a common non-communicable respiratory disease. In this thesis we analysed three different management strategies for adult patients with asthma in primary care. In the first, we targeted the currently recommended aim of ‘Controlled asthma’, which means patients experience hardly any symptom
Martin-Misener, Ruth; Kilpatrick, Kelley; Donald, Faith; Bryant-Lukosius, Denise; Rayner, Jennifer; Valaitis, Ruta; Carter, Nancy; Miller, Patricia A; Landry, Véronique; Harbman, Patricia; Charbonneau-Smith, Renee; McKinlay, R James; Ziegler, Erin; Boesveld, Sarah; Lamb, Alyson
To identify recommendations for determining patient panel/caseload size for nurse practitioners in community-based primary health care settings. Scoping review of the international published and grey literature. The search included electronic databases, international professional and governmental websites, contact with experts, and hand searches of reference lists. Eligible papers had to (a) address caseload or patient panels for nurse practitioners in community-based primary health care settings serving an all-ages population; and (b) be published in English or French between January 2000 and July 2014. Level one testing included title and abstract screening by two team members. Relevant papers were retained for full text review in level two testing, and reviewed by two team members. A third reviewer acted as a tiebreaker. Data were extracted using a structured extraction form by one team member and verified by a second member. Descriptive statistics were estimated. Content analysis was used for qualitative data. We identified 111 peer-reviewed articles and grey literature documents. Most of the papers were published in Canada and the United States after 2010. Current methods to determine panel/caseload size use large administrative databases, provider work hours and the average number of patient visits. Most of the papers addressing the topic of patient panel/caseload size in community-based primary health care were descriptive. The average number of patients seen by nurse practitioners per day varied considerably within and between countries; an average of 9-15 patients per day was common. Patient characteristics (e.g., age, gender) and health conditions (e.g., multiple chronic conditions) appear to influence patient panel/caseload size. Very few studies used validated tools to classify patient acuity levels or disease burden scores. The measurement of productivity and the determination of panel/caseload size is complex. Current metrics may not capture
Full Text Available Stephen Gillam Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK Abstract: Pay-for-performance (P4P schemes have become increasingly common in primary care, and this article reviews their impact. It is based primarily on existing systematic reviews. The evidence suggests that P4P schemes can change health professionals' behavior and improve recorded disease management of those clinical processes that are incentivized. P4P may narrow inequalities in performance comparing deprived with nondeprived areas. However, such schemes have unintended consequences. Whether P4P improves the patient experience, the outcomes of care or population health is less clear. These practical uncertainties mirror the ethical concerns of many clinicians that a reductionist approach to managing markers of chronic disease runs counter to the humanitarian values of family practice. The variation in P4P schemes between countries reflects different historical and organizational contexts. With so much uncertainty regarding the effects of P4P, policy makers are well advised to proceed carefully with the implementation of such schemes until and unless clearer evidence for their cost–benefit emerges. Keywords: financial incentives, pay for performance, quality improvement, primary care
Lymbery, M; Millward, A
This paper examines the establishment of social work within primary health care settings in Great Britain, following the passage of the National Health Service and Community Care Act in 1990. Although the improvement of relationships between social workers and primary health care teams has been promoted for a number of years, the advent of formal policies for community care has made this a priority for both social services and health. This paper presents interim findings from the evaluation of three pilot projects in Nottinghamshire, Great Britain. These findings are analysed from three linked perspectives. The first is the extent to which structures and organisations have worked effectively together to promote the location of social workers within health care settings. The second is the impact of professional and cultural factors on the work of the social worker in these settings. The third is the effect of interpersonal relationships on the success of the project. The paper will conclude that there is significant learning from each of these perspectives which can be applied to the future location of social workers to primary health care.
Full Text Available Previously, the main focus of primary health care practices was to diagnose and treat patients. The identification of risk factors for disease and the prevention of chronic conditions have become a part of everyday practice. This paper provides an argument for training primary health care (PHC practitioners in health promotion, while encouraging them to embrace innovation within their practice to streamline the treatment process and improve patient outcomes. Electronic modes of communication, education and training are now commonplace in many medical practices. The PHC sector has a small window of opportunity in which to become leaders within the current model of continuity of care by establishing their role as innovators in the prevention, treatment and management of disease. Not only will this make their own jobs easier, it has the potential to significantly impact patient outcomes.
Macinko, James; Montenegro, Hernán; Nebot Adell, Carme; Etienne, Carissa
At the 2003 meeting of the Directing Council of the Pan American Health Organization (PAHO), the PAHO Member States issued a mandate to strengthen primary health care (Resolution CD44. R6). The mandate led in 2005 to the document "Renewing Primary Health Care in the Americas. A Position Paper of the Pan American Health Organization/WHO [World Health Organization]," and it culminated in the Declaration of Montevideo, an agreement among the governments of the Region of the Americas to renew their commitment to primary health care (PHC). Scientific data have shown that PHC, regarded as the basis of all the health systems in the Region, is a key component of effective health systems and can be adapted to the range of diverse social, cultural, and economic conditions that exist. The new, global health paradigm has given rise to changes in the population's health care needs. Health services and systems must adapt to address these changes. Building on the legacy of the International Conference on Primary Health Care, held in 1978 in Alma-Ata (Kazakhstan, Union of Soviet Socialist Republics), PAHO proposes a group of strategies critical to adopting PHC-based health care systems based on the principles of equity, solidarity, and the right to the highest possible standard of health. The main objective of the strategies is to develop and/or strengthen PHC-based health systems in the entire Region of the Americas. A substantial effort will be required on the part of health professionals, citizens, governments, associations, and agencies. This document explains the strategies that must be employed at the national, subregional, Regional, and global levels.
Simonaitis, Linas; Belsito, Anne; Cravens, Gary; Shen, Changyu; Overhage, J Marc
The goal of the Enhanced Medication History (EMH) project is to provide medication histories to ambulatory primary care practices in the Indiana Network for Patient Care. Medications were aggregated from three different sources of pharmacy data (Medicaid, SureScripts, and the county health system of Indianapolis). Dispensing events were assembled into the Continuity of Care Document (CCD), and presented to clinicians as RxNorm Clinical Drugs. The EMH project completed 46 weeks of operation in a community health center in Indianapolis. Medication Histories were generated for 10498 office visits for 4449 distinct patients. Seven (of nine) attending physicians responded to a written survey and found the Medication Histories useful (3.9±0.4 on a scale of 1 to 5). Implementation of the EMH project demonstrated the successful use (as well as the challenging aspects) of the CCD and the RxNorm terminology in the outpatient clinical setting.
Many pregnant women in Africa who access professional antenatal care do not receive all the WHO-recommended components of care. Using Demographic and Health Survey (DHS) data from Kenya, Malawi and Nigeria, this study assesses the relationship of education level with the quality of antenatal care received and highlights how the number of antenatal visits mediates this relationship. The results show that a large proportion of the effect of education level on quality of care is direct, while only a small portion is mediated through the number of antenatal visits. Efforts to improve pregnancy outcomes for under-privileged women should focus on removing structural barriers to access, strengthening the technical and interpersonal skills of providers, and addressing providers' biases and discriminatory practices towards these women. Such efforts should also seek to empower underprivileged women to insist on quality antenatal care by explaining what to expect during an antenatal visit.
Asthma is the most commonly encountered chronic disease in children. Periodic assessment of asthma severity and control is an integral part of asthma management, but patients with uncontrolled asthma don't always schedule routine asthma care visits. The aim of this project was to improve asthma control and severity screening in a primary care setting by using a validated tool for all visits for patients with a diagnosis of asthma aged 4-21 years. Our QI team developed a protocol to administer...
Carbone, Paul S; Farley, Megan; Davis, Toby
The earliest sign of autism in children is the delayed attainment of social skill milestones, including joint attention, social orienting, and pretend play. Language impairment is a common, but less specific, sign of autism. Repetitive behaviors and restricted interests may not be noted until after social skill and communication impairments are exhibited. Physicians should perform developmental surveillance at all well-child visits, and the American Academy of Pediatrics recommends administering an autism-specific screening tool at the 18- and 24-month visits. A referral for comprehensive diagnostic evaluation is appropriate if concerns arise from surveillance, screening, or parental observations. The goals of long-term management are to maximize functional independence and community engagement, minimize maladaptive behaviors, and provide family and caregiver support. Physicians play an important role in coordinating care through an interdisciplinary team; referring families for specialized services; and treating children's associated conditions, including sleep disturbances, gastrointestinal problems, anxiety, and hyperactivity. Autism is a lifelong condition, but early recognition, diagnosis, and treatment can improve the prognosis, whereas associated medical conditions, psychiatric conditions, and intellectual disability can worsen the prognosis.
In 2007, a new wave of local reforms involving choice for the population and privatisation of providers was initiated in Swedish primary care. Important objectives behind reforms were to strengthen the role of primary care and to improve performance in terms of access and responsiveness. The purpose of this article was to compare the characteristics of the new models and to discuss changes in financial incentives for providers and challenges regarding governance from the part of county councils. A majority of the models being introduced across the 21 county councils can best be described as innovative combinations between a comprehensive responsibility for providers and significant degrees of freedom regarding choice for the population. Key financial characteristics of fixed payment and comprehensive financial responsibility for providers may create financial incentives to under-provide care. Informed choices by the population, in combination with reasonably low barriers for providers to enter the primary care market, should theoretically counterbalance such incentives. To facilitate such competition is indeed a challenge, not only because of difficulties in implementing informed choices but also because the new models favour large and/or horizontally integrated providers. To prevent monopolistic behaviour, county councils may have to accept more competition as well as more governance over clinical practice than initially intended.
Rogan, Lisa; Boaden, Ruth
Purpose Principal-agent theory (PAT) has been used to understand relationships among different professional groups and explain performance management between organisations, but is rarely used for research within primary care. The purpose of this paper is to explore whether PAT can be used to attain a better understanding of performance management in primary care. Design/methodology/approach Purposive sampling was used to identify a range of general practices in the North-west of England. Interviews were carried out with directors, managers and clinicians in commissioning and regional performance management organisations and within general practices, and the data analysed using matrix analysis techniques to produce a case study of performance management. Findings There are various elements of the principal-agent framework that can be applied in primary care. Goal alignment is relevant, but can only be achieved through clear, strategic direction and consistent interpretation of objectives at all levels. There is confusion between performance measurement and performance management and a tendency to focus on things that are easy to measure whilst omitting aspects of care that are more difficult to capture. Appropriate use of incentives, good communication, clinical engagement, ownership and trust affect the degree to which information asymmetry is overcome and goal alignment achieved. Achieving the right balance between accountability and clinical autonomy is important to ensure governance and financial balance without stifling innovation. Originality/value The principal-agent theoretical framework can be used to attain a better understanding of performance management in primary care; although it is likely that only partial goal alignment will be achieved, dependent on the extent and level of alignment of a range of factors.
Anandarajah, Gowri; Gupta, Priya; Jain, Nupur; El Rayess, Fadya; Goldman, Roberta
Development, evaluation and dissemination of primary care innovations are essential for the future of health care; however, primary care physicians including family physician, lag behind hospital-based physicians in research productivity. Family medicine residencies struggle to implement scholarly skills training programmes for busy family physicians. The Primary Care Scholarly Development Program (PC-SDP) aimed to empower residents to incorporate innovation with scholarship into future practice, by facilitating successful resident scholarly projects and reducing perceived barriers. Educational intervention. The required PC-SDP was piloted through a family medicine residency programme in the USA. Key elements included: rigorous but achievable requirements; emphasis on Boyer's scholarship of application, teaching and discovery; resident engagement, through the support of their 'professional passions'; basic research training; multilevel mentoring; and modest curriculum time. A mixed-methods longitudinal evaluation included: (1) a qualitative study of intervention class; (2) assessing the scholarly output of the intervention class versus the comparison class; and (3) a follow-up survey of both groups after 3 or 4 years. Data were analysed from all 25 residents in the classes of 2008 and 2009 (12 intervention; 13 comparison). Qualitative interviews of residents from the intervention group revealed that their initial feelings of trepidation about scholarly work gave way to feelings of accomplishment and confidence in their ability to integrate scholarship into busy careers. Residents in the intervention group had a greater volume of scholarly output at graduation, and follow-up surveys suggest that they value incorporating scholarship into their careers more so than physicians from the comparison group. The PC-SDP seems to foster enthusiasm for scholarship by supporting residents' professional passions and facilitating successful projects. This may foster improved
Zinszer, Kate; Charland, Katia; Kigozi, Ruth; Dorsey, Grant; Kamya, Moses R; Buckeridge, David L
To illustrate the use of a new method for defining the catchment areas of health-care facilities based on their utilization. The catchment areas of six health-care facilities in Uganda were determined using the cumulative case ratio: the ratio of the observed to expected utilization of a facility for a particular condition by patients from small administrative areas. The cumulative case ratio for malaria-related visits to these facilities was determined using data from the Uganda Malaria Surveillance Project. Catchment areas were also derived using various straight line and road network distances from the facility. Subsequently, the 1-year cumulative malaria case rate was calculated for each catchment area, as determined using the three methods. The 1-year cumulative malaria case rate varied considerably with the method used to define the catchment areas. With the cumulative case ratio approach, the catchment area could include noncontiguous areas. With the distance approaches, the denominator increased substantially with distance, whereas the numerator increased only slightly. The largest cumulative case rate per 1000 population was for the Kamwezi facility: 234.9 (95% confidence interval, CI: 226.2-243.8) for a straight-line distance of 5 km, 193.1 (95% CI: 186.8-199.6) for the cumulative case ratio approach and 156.1 (95% CI: 150.9-161.4) for a road network distance of 5 km. Use of the cumulative case ratio for malaria-related visits to determine health-care facility catchment areas was feasible. Moreover, this approach took into account patients' actual addresses, whereas using distance from the facility did not.
Cássia Regina de Paula Paz
Full Text Available Objective.Assess the need for incorporation of palliative care in primary health care (PHC through the characterization of users eligible for this type of care, enrolled in a program for devices dispensing. Methods. Descriptive study of case series conducted in 14 health units in São Paulo (Brazil in 2012. It was included medical records of those enrolled in a program for users with urinary and fecal incontinence, and it was applied Karnofsky Performance Scale Index (KPS to identify the indication of palliative care. Results. 141 of the 160 selected medical records had KPS information. Most cases (98.3%, 138/141 had performance below 70% and, therefore, patients were eligible for palliative care. The most frequent pathologies was related to chronic degenerative diseases (46.3%, followed by disorders related to quality of care during pregnancy and childbirth (24.38%. Conclusion. It is necessary to include palliative care in PHC in order to provide comprehensive, shared and humanized care to patients who need this.
de Paula Paz, Cássia Regina; Reis Pessalacia, Juliana Dias; Campos Pavone Zoboli, Elma Lourdes; Ludugério de Souza, Hieda; Ferreira Granja, Gabriela; Cabral Schveitzer, Mariana
Assess the need for incorporation of palliative care in primary health care (PHC) through the characterization of users eligible for this type of care, enrolled in a program for devices dispensing. Descriptive study of case series conducted in 14 health units in São Paulo (Brazil) in 2012. It was included medical records of those enrolled in a program for users with urinary and fecal incontinence, and it was applied Karnofsky Performance Scale Index (KPS) to identify the indication of palliative care. 141 of the 160 selected medical records had KPS information. Most cases (98.3%, 138/141) had performance below 70% and, therefore, patients were eligible for palliative care. The most frequent pathologies was related to chronic degenerative diseases (46.3%), followed by disorders related to quality of care during pregnancy and childbirth (24.38%). It is necessary to include palliative care in PHC in order to provide comprehensive, shared and humanized care to patients who need this.
Full Text Available Abstract Background Primary Health Care (PHC is increasingly being introduced into undergraduate medical education. In Greece, the Faculty of Medicine of the University of Crete was the first to introduce a 4-week long training in primary health care. This paper presents the experiences gained from the initial implementation of the teaching of practice-based primary care in rural Crete and reports on the assessment scale that was developed. Methods 284 students' case write-ups from the 6 primary care units (PCUs where they were allocated for the period 1990 to 1994 were analysed. The demographic data of the students and patients and the number of home visits were studied. Content analysis of the students' write-ups was carried out, using an assessment scale consisting of 10 dichotomous variables, in order to quantify eight (8 primary qualitative criteria. Results Internal reliability was estimated by the index KR20 = 0.67. Face and content validity was found to conform to the standards set for the course, while logistic linear regression analysis showed that the quality criteria could be used as an assessment scale. The number of home visits carried out varied between the various different PCUs (p Conclusion The primary health care course achieved the objectives of introducing students to comprehensive, community oriented care, although there was variation between the PCUs. The assessment scale that was developed to analyse the case-write ups of the students provided data that can be used to evaluate the course.
Pullicino, Glorianne; Sciortino, Philip; Calleja, Neville; Schäfer, Willemijn; Boerma, Wienke; Groenewegen, Peter
Demographic changes, technological developments and rising expectations require the analysis of public-private primary care (PC) service provision to inform policy makers. We conducted a descriptive, cross-sectional study using the dataset of the Maltese arm of the QUALICOPC Project to compare the PC patients' experiences provided by public-funded and private (independent) general practitioners in Malta. Seven hundred patients from 70 clinics completed a self-administered questionnaire. Direct logistic regression showed that patients visiting the private sector experienced better continuity of care with more difficulty in accessing out-of-hours care. Such findings help to improve (primary) healthcare service provision and resource allocation.
Mundt, Marlon P.; Gilchrist, Valerie J.; Fleming, Michael F.; Zakletskaia, Larissa I.; Tuan, Wen-Jan; Beasley, John W.
PURPOSE Cardiovascular disease is the leading cause of mortality and morbidity in the United States. Primary care teams can be best suited to improve quality of care and lower costs for patients with cardiovascular disease. This study evaluates the associations between primary care team communication, interaction, and coordination (ie, social networks); quality of care; and costs for patients with cardiovascular disease. METHODS Using a sociometric survey, 155 health professionals from 31 teams at 6 primary care clinics identified with whom they interact daily about patient care. Social network analysis calculated variables of density and centralization representing team interaction structures. Three-level hierarchical modeling evaluated the link between team network density, centralization, and number of patients with a diagnosis of cardiovascular disease for controlled blood pressure and cholesterol, counts of urgent care visits, emergency department visits, hospital days, and medical care costs in the previous 12 months. RESULTS Teams with dense interactions among all team members were associated with fewer hospital days (rate ratio [RR] = 0.62; 95% CI, 0.50–0.77) and lower medical care costs (−$556; 95% CI, −$781 to −$331) for patients with cardiovascular disease. Conversely, teams with interactions revolving around a few central individuals were associated with increased hospital days (RR = 1.45; 95% CI, 1.09–1.94) and greater costs ($506; 95% CI, $202–$810). Team-shared vision about goals and expectations mediated the relationship between social network structures and patient quality of care outcomes. CONCLUSIONS Primary care teams that are more interconnected and less centralized and that have a shared team vision are better positioned to deliver high-quality cardiovascular disease care at a lower cost. PMID:25755035
Álvarez-Cordovés, M M; Mirpuri-Mirpuri, P G; Gonzalez-Losada, J; Chávez-Díaz, B
We present a case of a patient diagnosed with glioblastoma multiforme refractory to treatment. Glioblastoma multiforme is the most common primary brain tumour and unfortunately the most aggressive, with an estimated mortality of about 90% in the first year after diagnosis. In our case the patient had reached a stage of life where quality of life was importsnt, with palliative care being the only recourse. The family is the mainstay in the provision of care of terminally ill patients, and without their active participation it would be difficult to achieve the objectives in patient care. We must also consider the family of the terminally ill in our care aim, as its members will experience a series of changes that will affect multiple areas where we should take action. Copyright © 2012 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España. All rights reserved.
... 42 Public Health 4 2010-10-01 2010-10-01 false Primary care case management services. 440.168... care case management services. (a) Primary care case management services means case management related... services. (b) Primary care case management services may be offered by the State— (1) As a voluntary option...
Bitar, George W; Springer, Paul; Gee, Robert; Graff, Chad; Schydlower, Manuel
Several major policy reports describe the central role of primary care in improving the delivery of behavioral health care services to children and adolescents. Although primary care providers are uniquely positioned to provide these services, numerous obstacles hinder the integration of these services, including time, clinic management and organization issues, training, and resources. Although many of these obstacles have been described in the literature, few studies have investigated these issues from the first-person perspective of front-line providers. The purpose of this study, therefore, is to provide an in-depth description of primary care providers' attitudes and perceptions of adolescent behavioral health care across a diversity of primary care settings (i.e., Federally Qualified Health Center [FQHC], FQHC-Look Alike, school-based, military). Sixteen focus groups were conducted at 5 primary care clinics. Thematic analysis was used to analyze the focus group data. Obstacles to integration are presented as well as strategies to overcome these challenges, using training and education, working groups, and community collaboratives.
Hestbæk, Lise; Munck, Anders; Hartvigsen, Lisbeth;
Study Design. Baseline description of a multicenter cohort study. Objective. To describe patients with low back pain (LBP) in both chiropractic and general practice in Denmark. Background. To optimize standards of care in the primary healthcare sector, detailed knowledge of the patient populations...... in different settings is needed. In Denmark, most LBP-patients access primary healthcare through chiropractic or general practice. Methods. Chiropractors and general practitioners recruited adult patients seeking care for LBP. Extensive baseline questionnaires were obtained and descriptive analyses presented...... separately for general and chiropractic practice patients, Mann-Whitney rank sum test and Pearson's chi-square test, were used to test for differences between the two populations. Results. Questionnaires were returned from 934 patients in chiropractic practice and 319 patients from general practice. Four out...
Fleming, Sara A; Gutknecht, Nancy C
Naturopathy is a distinct type of primary care medicine that blends age-old healing traditions with scientific advances and current research. Naturopathy is guided by a unique set of principles that recognize the body's innate healing capacity, emphasize disease prevention, and encourage individual responsibility to obtain optimal health. Naturopathic treatment modalities include diet and clinical nutrition, behavioral change, hydrotherapy, homeopathy, botanical medicine, physical medicine, pharmaceuticals, and minor surgery. Naturopathic physicians (NDs) are trained as primary care physicians in 4-year, accredited doctoral-level naturopathic medical schools. At present, there are 15 US states, 2 US territories, and several provinces in Canada, Australia, and New Zealand that recognize licensure for NDs. Published by Elsevier Inc.
Bowie, Paul; Jeffcott, Shelly
In the second paper of this series, we provide a brief overview of the scientific discipline of human factors and ergonomics (HFE). Traditionally the HFE focus in healthcare has been in acute hospital settings which are perceived to exhibit characteristics more similar to other high-risk industries already applying related principles and methods. This paper argues that primary care is an area which could benefit extensively from an HFE approach, specifically in improving the performance and well-being of people and organisations. To this end, we define the purpose of HFE, outline its three specialist sub-domains (physical, cognitive and organisational HFE) and provide examples of guiding HFE principles and practices. Additionally, we describe HFE issues of significance to primary care education, improvement and research and outline early plans for building capacity and capability in this setting.
Rindfleisch, J Adam
Energy medicine modalities, also known as biofield therapies, are perhaps the most mysterious and controversial complementary alternative medicine therapies. Although many of these approaches have existed for millennia, scientific investigation of these techniques is in its early stages; much remains to be learned about mechanisms of action and efficacy. These techniques are increasingly used in clinical and hospital settings and can be incorporated into an integrative primary care practice. This article describes several energy medicine and biofield therapies and outlines key elements they hold in common. Several specific approaches are described. Research findings related to the efficacy of energy medicine are summarized, and proposed mechanisms of action and safety issues are discussed. Guidelines are offered for primary care providers wishing to advise patients about energy medicine or to integrate it into their practices, and Internet and other resources for obtaining additional information are provided.
Goldberg, D. P.; Reed, G. M.; Robles, R.
Objective A World Health Organization (WHO) field study conducted in five countries assessed proposals for Bodily Stress Syndrome (BSS) and Health Anxiety (HA) for the Primary Health Care Version of ICD-11. BSS requires multiple somatic symptoms not caused by known physical pathology and associated...... with BSS or HA, 70.4% were identified as having both conditions. Participants had an average of 10.9 somatic symptoms. Patients who presented somatic symptoms across multiple body systems were more disabled than patients with symptoms in a single system. Most referred patients (78.9%) had co...... without identifiable physical pathology. Although highly co-occurring with each other and with mood and anxiety disorders, BSS and HA represent distinct constructs that correspond to important presentations in primary care. © 2016 Elsevier Inc....
Vives-Relats, Carme; Ferré-Grau, Carme; Rodero-Sánchez, Virtudes; Cid-Buera, Dolors
This case discussion starts from the Uncertainty Theory of illness of Merle Mishel, who raised the idea that even without a solution to the uncertainty, a person should accept it as a part of their life and reinterpret it as an opportunity to promote a new view of life governed by probability. The author proposes theoretical concepts that allow the phenomena experienced by family caregivers to be approached from the perspective of their experiences and stress. It establishes uncertainty and indecisiveness as contradictions that should not create anxiety permanently. This can be released gradually, if we create lines of flight though the care. Among these lines are located the Problem Solving Method as a strategy useful in primary health care to reduce the uncertainty of the caregivers. This article describes the outcome of Isabel, a 63- year-old female family caregiver of her dependent mother and her daughter with anorexia. The primary care nurse identifies the problem of weariness of the care-givers role and that of conflict of decisions during home visits. It describes the assessment made from the main concepts of the theory and the work with the care-givers by the problem solving method in order to reduce anxiety and help to mobilize internal resources and increase their welfare.
Sayed Mahdi Madani
Full Text Available the primary health cares are among the individuals’ primary rights and their outsourcing can pave the way to more suitable use of resources for the field inside and outside of the organization and in this way make possible the better cares. The aim of this study was to determine the type of primary health cares that can be outsourced in Iran; this study embarked upon specifying which one, among the primary health cares, has ability of being outsourced by contractors outside the organization. This applied study has been done by a descriptive and cross-sectional method. According to the other studies at first a general framework was founded; hence the main framework with respect to the opinions of 30 experts. Thereafter a questionnaire was compiled for ensuring its correctness and gathering other experts’ opinions. The method of experts’ judgment was used for validity and for its reliability with distribution of 30 copies the method of calculating Cronbach’ salpha, which was 0.925. Then it was distributed among experts and 786 questionnaires were completed and collected; by using the method of factor of factor and confirmatory analysis as well as the descriptive statistics we embarked upon investigating and deducing the results. For statistical investigation the software SPSS21 and AMOS20 were used. In the factor of outsourcing activities one factor only covering 55.25% of variables variance was discovered. The results suggest that the item q10, “possibility of outsourcing the concrete activities”, with factor load of 0.791 and the item q6, "outsourcing and standardization", with factor load of 0.668 have respectively the highest load and the lowest one in the definition of the factor of cares of outsourcing. The more the primary health cares are more concrete, more simple, more standardized and have the further differentiability, their successful outsourcing is highly possible; in addition only those activities are able to be
Mendelsohn, Alan L.; Dreyer, Benard P.; Brockmeyer, Carolyn A.; Berkule-Silberman, Samantha B.; Huberman, Harris S.; Tomopoulos, Suzy
Objectives To determine whether pediatric primary care–based programs to enhance parenting and early child development reduce media exposure and whether enhanced parenting mediates the effects. Design Randomized controlled trial. Setting Urban public hospital pediatric primary care clinic. Participants A total of 410 mother-newborn dyads enrolled after childbirth. Interventions Patients were randomly assigned to 1 of 2 interventions, the Video Interaction Project (VIP) and Building Blocks (BB) interventions, or to a control group. The VIP intervention comprised 1-on-1 sessions with a child development specialist who facilitated interactions in play and shared reading through review of videotapes made of the parent and child on primary care visit days; learning materials and parenting pamphlets were also provided. The BB intervention mailed parenting materials, including age-specific newsletters suggesting activities to facilitate interactions, learning materials, and parent-completed developmental questionnaires (Ages and Stages questionnaires). Outcome Measures Electronic media exposure in the home using a 24-hour recall diary. Results The mean (SD) exposure at 6 months was 146.5 (125.0) min/d. Exposure to VIP was associated with reduced total duration of media exposure compared with the BB and control groups (mean [SD] min/d for VIP, 131.6 [118.7]; BB, 151.2 [116.7]; control, 155.4 [138.7]; P=.009). Enhanced parent-child interactions were found to partially mediate relations between VIP and media exposure for families with a ninth grade or higher literacy level (Sobel statistic=2.49; P=.01). Conclusion Pediatric primary care may represent an important venue for addressing the public health problem of media exposure in young children at a population level. Trial Registration clinicaltrials.gov Identifier: NCT00212576 PMID:21199979
Murray, Mark; Berwick, Donald M
Delay of care is a persistent and undesirable feature of current health care systems. Although delay seems to be inevitable and linked to resource limitations, it often is neither. Rather, it is usually the result of unplanned, irrational scheduling and resource allocation. Application of queuing theory and principles of industrial engineering, adapted appropriately to clinical settings, can reduce delay substantially, even in small practices, without requiring additional resources. One model, sometimes referred to as advanced access, has increasingly been shown to reduce waiting times in primary care. The core principle of advanced access is that patients calling to schedule a physician visit are offered an appointment the same day. Advanced access is not sustainable if patient demand for appointments is permanently greater than physician capacity to offer appointments. Six elements of advanced access are important in its application balancing supply and demand, reducing backlog, reducing the variety of appointment types, developing contingency plans for unusual circumstances, working to adjust demand profiles, and increasing the availability of bottleneck resources. Although these principles are powerful, they are counter to deeply held beliefs and established practices in health care organizations. Adopting these principles requires strong leadership investment and support.
Breathlessness is a high-volume problem with 10% of adults experiencing the symptom daily placing a heavy burden on the health and wider economy. As it worsens, they enter the specialist and hospital-based symptom services where costs quickly escalate and people may find themselves in a place not of their choosing. For many, their care will be delivered by a disease or organ specialist and can find themselves passing between physicians without coordination for symptom support. General practitioners (GPs) will be familiar with this scenario and can often feel out of their depth. Recent advances in our thinking about breathlessness symptom management can offer opportunities and a sense of hope when the GP is faced with this situation. Original research, reviews and other findings over the last 12-18 months that pertain to the value that general practice and the wider primary care system can add, include opportunities to help people recognize they have a problem that can be treated. We present systems that support decisions made by primary healthcare professionals and an increasingly strong case that a solution is required in primary care for an ageing and frail population where breathlessness will be common. Primary care practitioners and leaders must start to realize the importance of recognizing and acting early in the life course of the person with breathlessness because its impact is enormous. They will need to work closely with public health colleagues and learn from specialists who have been doing this work usually with people near to the end of life translating the skills and knowledge further upstream to allow people to live well and remain near home and in their communities.
Full Text Available This article is part of the series on African primary care research and focuses on participatory action research. The article gives an overview of the emancipatory-critical research paradigm, the key characteristics and different types of participatory action research. Following this it describes in detail the methodological issues involved in professional participatory action research and running a cooperative inquiry group. The article is intended to help students with writing their research proposal.
Neergaard, Mette Asbjørn; Jensen, Anders Bonde; Olesen, Frede
sectors.METHOD. A number of focus group interviews were conducted with three types of subgroups: 1) Bereaved relatives, 2) GPs and 3) Various health-care-professionals, namely community nurses, hospital physicians and GPs. The interviews were transcribed and analysed according to a phenomenological......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...
Full Text Available Paolo Mannelli,1 Li-Tzy Wu1–41Department of Psychiatry and Behavioral Sciences, 2Department of Medicine, 3Duke Clinical Research Institute, Duke University Medical Center, 4Center for Child and Family Policy, Sanford School of Public Policy, Duke University, Durham, NC, USARecent reports on prescription opioid misuse and abuse have described unprecedented peaks of a national crisis and the only answer is to expand prevention and treatment, including different levels of care.1 Nonetheless, concerns remain about the ability of busy primary care settings to manage problem opioid users along with other patients. In particular, proposed extensions of buprenorphine treatment, a critically effective intervention for opioid use disorder (OUD, are cautiously considered due to the potential risk of misuse or abuse.2 General practitioners are already facing this burden daily in the treatment of chronic pain, and expert supervision and treatment model adjustment are needed to help improve outcomes. Approximately 20% of patients in primary care have noncancer pain symptoms, with most of them receiving opioid prescriptions by their physicians, and their number is increasing.3 Pain diagnoses are comparable in severity to those of tertiary centers and are complicated by significant psychiatric comorbidity, with a measurable lifetime risk of developing OUD.4,5 Some primary care physicians report frustration about opioid abuse and diversion by their patients; support from pain specialists would improve their competence, the quality f their performance, and the ability to identify patients at risk of opioid misuse.6 Thus, buprenorphine treatment should not be adding to a complex clinical scenario. To this end, the promising models of care emphasize the integration of medical with psychological and pharmacological expertise for the management of OUD.
Finkler, S A; Knickman, J R; Hanson, K L
This article presents findings from a national demonstration program to improve the long-term financial viability of small not-for-profit primary care health centers. The program initiatives and their implementation are described in some detail. A standard pre/post study design was used to measure the impact of the initiatives on general outcome measures, financial ratios, and the utilization of management techniques. Overall, demonstration centers showed improvement over the study period. Notable short-term improvements included significant growth in the volume of patient visits and increased profit. Observed changes also revealed an increased use of sophisticated management techniques, expected to positively affect longer-term financial health. The findings suggest that improving the financial viability of health centers need not be expensive.
Eshet, I; Van Relta, R; Margalit, A; Baharir, Z
This department of family medicine has been challenged with helping a group of Russian immigrant physicians find places in primary care clinics, quickly and at minimal expense. A 3-month course was set up based on the Family Practice Residency Syllabus and the SFATAM approach, led by teachers and tutors from our department. 30 newly immigrated Russian physicians participated. The course included: lectures and exercises in treatment and communication with patients with a variety of common medical problems in the primary care setting; improvement of fluency in Hebrew relevant to the work setting; and information on the function of primary care and professional clinics. Before-and-after questionnaires evaluating optimal use of a 10- minute meeting with a client presenting with headache were administered. The data showed that the physicians had learned to use more psychosocial diagnostic question and more psychosocial interventions. There was a cleared trend toward greater awareness of the patient's environment, his family, social connections and work. There was no change in biomedical inquiry and interventions but a clear trend to a decrease in recommendations for tests and in referrals. The authors recommend the following didactic tools: adopting a biopsychosocial attitude, active participation of students in the learning situation, working in small groups, use of simulations and video clips, and acquiring basic communication experience.
Full Text Available Objective: To explore the distribution of HIV among the pregnant women visiting a tertiary care hospital in Kathmandu. Methods: A total of 1 440 blood samples from pregnant women were collected and tested for antiHIV antibodies using rapid screening assay kits and ELISA in Paropakar Maternity and Women ’s Hospital during May to November, 2011. Results: The overall sero-prevalence of HIV among pregnant women was 0.62%, the prevalence being highest (1.4% in age group 35-39 years old, and during second trimester of gestation (0.75%. Similarly, it was found to be highest among the illiterates (1.92%, commercial sex worker (10.00% and those having multiple sexual partners (30.00%. Conclusions: Sero-prevalence of HIV infection was higher among the pregnant women of Kathmandu.
Rohrer, James E; Angstman, Kurt B; Bartel, Gregory A
Retail medicine clinics have become widely available. However, few studies have been published that compare retail clinic costs of care to standard medical visits for similar patients. The purpose of this study was to compare standard medical costs during a 6-month period after visiting a retail medical clinic to care received in a conventional medical office setting. Medical records of primary care patients (both adults and children) seen in a large group practice in Minnesota in 2008 were analyzed for this study. Two groups of patients were studied: those who used a retail walk-in clinic (N = 141) and a comparison group who used regular office care for same-day, acute visits (N = 137). Patients treated for 5 common conditions (pink eye, sore throat, viral illness, bronchitis, and cough) were selected. The dependent variables were standard costs using federal rates and the rank of standard costs. Multiple linear regression analysis was used to adjust for differences between groups. Median costs did not differ between sites ($126.30 for usual care and $88.10 for retail, P = 0.139); mean cost ranks were 132.5 for usual care and 115.6 for retail (P = 0.088). After adjusting for previous visit history, age, and sex, patients who received care in the retail setting had lower standard costs and lower cost rank than patients who received usual care (b = -52.9 [P = 0.006] and b = -24.5 [P = 0.021], respectively). After selection of cases with common conditions and adjustment for unequal variances, age, sex, and number of office visits in the previous 6 months, our retail clinic appeared to reduce medical costs for patients during the 6-month period after the index visit.
Morera-Llorca, Miquel; Romeu-Climent, José Enrique; Lera-Calatayud, Guillem; Folch-Marín, Blanca; Palop-Larrea, Vicente; Vidal-Rubio, Sonia
Despite the high prevalence of mental health problems among patients attending primary care, diagnosis and treatment of these disorders remain inadequate. Sound training of primary care physicians in how to manage mental health problems is needed to reduce the health, economic and social impact associated with these disorders. Among other elements, there is a need for cooperation between primary care physicians and mental health services. Distinct models are available for such collaboration. In 2006, our health department started a collaboration between these two levels of heath care, using a liaison model. Delays until the first specialist visit were reduced and satisfaction among health professionals increased, although these results should be interpreted with caution. Evidence has recently accumulated on the usefulness of the collaborative model, but evaluation of this model and extrapolation of its results are complex. We intend to evaluate our model more thoroughly, similar to other projects in our environment. Copyright © 2014 SESPAS. Published by Elsevier Espana. All rights reserved.
Fleming, M; Manwell, L B
Primary health care providers identify and treat many patients who are at risk for or are already experiencing alcohol-related problems. Brief interventions--counseling delivered by primary care providers in the context of several standard office visits--can be a successful treatment approach for many of these patients. Numerous trials involving a variety of patient populations have indicated that brief interventions can reduce patients' drinking levels, regardless of the patients' ages and gender. In clinical practice, brief interventions can help reduce the drinking levels of nondependent drinkers who drink more than the recommended limits, facilitate therapy and abstinence in patients receiving pharmacotherapy, and enhance the effectiveness of assessment and treatment referral in patients who do not respond to brief interventions alone. Despite the evidence for their usefulness, however, brief interventions for alcohol-related problems have not yet been widely implemented in primary care settings.
Aleem, Sohaib; Lasky, Rosalind; Brooks, W Blair; Batsis, John A
Obesity recognition in primary care is important to address the epidemic. We aimed to evaluate primary care clinician-reported documentation, management practices, beliefs and attitudes toward obesity compared to body mass index (BMI) calculation, obesity prevalence and actual documentation of obesity as an active problem in electronic health record in a rural academic center. Our target population for previously validated clinician survey was 56 primary care providers working at 3 sites. We used calendar year 2012 data for assessment of baseline system performance for metrics of documentation of BMI in primary care visits, and proportion of visits in patients with obesity with obesity as a problem. Standard statistical methods assessed the data. Survey response rate was 91%. Average age of respondents was 48.9 years and 62.7% were females. 72.5% clinicians reported having normal BMI. The majority of clinicians reported regularly documenting obesity as an active problem, and utilized motivational interviewing and basic good nutrition and healthy exercise. Clinicians identified lack of discipline and exercise time, access to unhealthy food and psychosocial issues as major barriers. Most denied disliking weight loss discussion or patients taking up too much time. In 21,945 clinic visits and 11,208 annual preventive care visits in calendar year 2012, BMI was calculated in 93% visits but obesity documentation as an active problem only 27% of patients meeting BMI criteria for obesity. Despite high clinician-reported documentation of obesity as an active problem, actual obesity documentation rates remained low in a rural academic medical center. Copyright © 2015 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Hersh, Lauren; Salzman, Brooke; Snyderman, Danielle
Health literacy includes a set of skills needed to make appropriate health decisions and successfully navigate the health care system. These skills include reading, writing, numeracy, communication, and, increasingly, the use of electronic technology. National data indicate that more than one-third of U.S. adults have limited health literacy, which contributes to poor health outcomes and affects patient safety, and health care access and quality. Although there are a number of tools that screen for limited health literacy, they are primarily used for research. Routinely screening patients for health literacy has not been shown to improve outcomes and is not recommended. Instead, multiple professional organizations recommend using universal health literacy precautions to provide understandable and accessible information to all patients, regardless of their literacy or education levels. This includes avoiding medical jargon, breaking down information or instructions into small concrete steps, limiting the focus of a visit to three key points or tasks, and assessing for comprehension. Additionally, printed information should be written at or below a fifth- to sixth-grade reading level. Visual aids, graphs, or pictures can enhance patient understanding, as can more concrete presentation of numerical information.
Montes de Oca, Maria; Aguirre, Carlos; Lopez Varela, Maria Victorina; Laucho-Contreras, Maria E; Casas, Alejandro; Surmont, Filip
Background COPD, asthma, and asthma–COPD overlap increase health care resource consumption, predominantly because of hospitalization for exacerbations and also increased visits to general practitioners (GPs) or specialists. Little information is available regarding this in the primary care setting. Objectives To describe the prevalence and number of GP and specialist visits for any cause or due to exacerbations in patients with COPD, asthma, and asthma–COPD overlap. Methods COPD was defined as post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio <0.70; asthma was defined as prior medical diagnosis, wheezing in the last 12 months, or wheezing plus reversibility (post-bronchodilator FEV1 or FVC increase ≥200 mL and ≥12%); asthma–COPD overlap was defined as post-bronchodilator FEV1/FVC <0.70 plus prior asthma diagnosis. Health care utilization was evaluated as GP and/or specialist visits in the previous year. Results Among the 1,743 individuals who completed the questionnaire, 1,540 performed acceptable spirometry. COPD patients had a higher prevalence of any medical visits to any physician versus those without COPD (37.2% vs 21.8%, respectively) and exacerbations doubled the number of visits. The prevalence of any medical visits to any physician was also higher in asthma patients versus those without asthma (wheezing: 47.2% vs 22.7%; medical diagnosis: 54.6% vs 21.6%; wheezing plus reversibility: 46.2% vs 23.8%, respectively). Asthma patients with exacerbations had twice the number of visits versus those without an exacerbation. The number of visits was higher (2.8 times) in asthma–COPD overlap, asthma (1.9 times), or COPD (1.4 times) patients versus those without these respiratory diseases; the number of visits due to exacerbation was also higher (4.9 times) in asthma–COPD overlap, asthma (3.5 times), and COPD (3.8 times) patients. Conclusion COPD, asthma, and asthma–COPD overlap increase the prevalence of
As part of the primary care strategy, the Governments of the Americas have included the agricultural and animal health sectors among the public health activities of the Plan of Action. This means that both sectors--agricultural and veterinary--must be guided in their work by a multidisciplinary and multisectoral approach, with full community participation. Hence, it is certain that both the study of veterinary medicine and the practice of the profession in the Region will have to be reoriented so that they may be more fully integrated with the primary care strategy. The reorientation of animal health activities is the subject of this paper. There can be no doubt that animal health has a vital part to play in improving the quality of human life and that veterinary practice itself offers excellent opportunities for building a sense of personal and community responsibility for the promotion, care, and restoration of health. Through their contact with the rural population while caring for their livestock (an integral part of the rural socioeconomic structures), the veterinarian and animal health assistant establish close bonds of trust not only with farmers, but with their families and the entire community as well; they are thus well placed to enlist community participation in a variety of veterinary public health activities such as zoonoses control, hygiene programs, and so forth. While the goal of the Plan of action is to extend primary care to the entire population, the lack of material and human resources requires that priority attention be given to the needs of the more vulnerable groups, including the extremely poor living in rural and urban areas. These are the groups at greatest risk from the zoonoses still present in the Americas. In the face of these facts, it is clear that primary care in the animal health field should be based on the application in each country of proven, effective, appropriate technology by personnel who, whether new or retrained, are well
Livesay, Sarah; Gilliam, Alicia; Mokracek, Marilyn; Sebastian, Sherly; Hickey, Joanne V
A quality improvement project was undertaken by Neuro-ICU nurses to determine possible effects from open visitation. From a quality improvement perspective, nurses' concerns were investigated along with their perceptions about open visitation to determine a need for visitation policy revision. Vast variability in nurses' interpretation and implementation of individualized open visitation policy suggested a need for the following: staff education about the policy and its implementation, a review of the literature to determine the validity of concerns about deleterious physiologic effects on neuroscience patients from visitation, and improved communication among nurses about visitation.
Islam, M R; Odland, J O
Antenatal and postnatal care services are significant interventions to improve maternal health and prevent maternal and infant deaths. However, these services are poorly developed in Bangladesh, particularly among Indigenous women. This study examined factors associated with antenatal and postnatal care visits among the Mru, the most underprivileged Indigenous people in Bangladesh. This cross-sectional study used both quantitative and qualitative methods. In total, 374 currently married Mru women with at least one child aged 5 years or younger were selected from 3 upazilas (sub-districts) of Bandarban District, Bangladesh for survey. In addition, in-depth interviews were performed with 26 Mru leaders, Mru women, traditional midwives, village 'doctors', school teachers, health and non-government organization workers. Associations between antenatal and postnatal care visits and the women's backgrounds characteristics were assessed by bivariate and multivariate analyses. The traditional Mru prenatal and postnatal practices potentially inhibited women from seeking care. Both antenatal (11.2%) and postnatal (6.4%) care visits among the Mru women were lower than the national level. Most visits were to traditional midwives in their rural villages, rather than to health complexes or hospitals. The main reasons for lack of antenatal and postnatal care were travelling distance to care and transportation problems. Multivariate analysis revealed factors associated with antenatal care were the respondent's place of residence, age, level of education, distance to the service centers and exposure to any mass media. Similar results were obtained with regard to postnatal care visits. This study suggests that cultural issues, distance, infrastructure and socioeconomic status are important determinants of maternal healthcare-seeking behavior. Healthcare delivery systems and appropriate education programs should be developed at the village level to improve the health of mothers and
Holler, Christine Puck; Wichmann, Sine; Nielsen, Søren Loumann
In Copenhagen, Denmark, patients in need of prehospital emergency assistance dial 112 and may then receive evaluation and treatment by physicians (from the Mobile Emergency Care Unit (MECU)). ST-elevation myocardial infarction (STEMI) is a severe condition leaving only a limited time frame to del...... diagnosis on the scene and, furthermore, to compare these on-scene diagnoses with the primary discharge diagnoses from hospital....
Raue, Patrick J; Ghesquiere, Angela R; Bruce, Martha L
The National Strategy for Suicide Prevention (2012) has set a goal to reduce suicides by 20% within 5 years. Suicide rates are higher in older adults compared to most other age groups, and the majority of suicide completers have visited their primary care physician in the year before suicide. Primary care is an ideal setting to identify suicide risk and initiate mental health care. We review risk factors for late-life suicide; methods to assess for different levels of suicidality; and recent research developments regarding both effective assessment and management of suicide risk among older primary care patients. We highlight that broader scale screening of suicide risk may be considered in light of findings that suicidality can occur even in the absence of major risk factors like depression. We also highlight collaborative care models targeting suicide risk, and recent innovative interventions that aim to prevent the development of suicidal ideation and suicidal behavior.
Allo, Julio A.; Cuello, Deanna; Zhang, Yi; Reddy, Suresh K.; Azhar, Ahsan
Abstract Background: Health care professionals may have limited exposure to home-based care. There is no published literature that has described the experiences and satisfaction of participation in patient home visits (PHV). Objective: The objective of this article is to describe the characteristics of PHV, our approach, and evaluation by participants over a nine-year period. Methods: We conducted a review of surveys completed by participants in PHV from 2005–2013. All participants anonymously completed the evaluation questionnaires at the end of PHVs. Different PHV assessment forms were used for the 2005–2010 and 2011–2013 time periods. Results: A total of 34 PHVs were conducted with 106 patients and approximately 750 participants with a mean of 3 patients and 22 participants per PHV between 2005 and 2013. For 18 PHVs there are 317 surveys completed with 353 participants, making it a 90% response rate. Responding participants were physicians 125/543 (23%) and other professionals 418/543 (77%). In both time periods of 2005–2010 and 2011–2013 a survey with a 1 (completely agree) to 5 (completely disagree) scale was used. Agreeing that PHV was an effective teaching tool during 2005–2010 were 335/341 (98%); during 2011–2013, 191/202 (95%) agreed that PHV provided increased understanding and sharing of best practices in palliative care. Conclusions: PHV was perceived by participants as an effective way of providing interactive community education. A broad range of themes were addressed, and the participants reported high levels of learning in all domains of palliative care. There were no cases of patient or relative expression of distress as a result of PHV. PMID:26652056
Nik Sherina Hanafi
Full Text Available Continuity of care is an important quality outcome of patient care. This study aimed to investigate the relationship between personal continuity and blood pressure (BP control among the patients with hypertension in an academic primary care centre. Between January and May 2012, we conducted a retrospective review of medical records of patients with hypertension who had been followed up for at least 1 year in the Primary Care Clinic, University of Malaya Medical Centre, Malaysia. In this setting, doctors who provided care for hypertension included postgraduate family medicine trainees, non-trainee doctors and academic staff. Systematic random sampling (1:4 was used for patient selection. BP control was defined as less than 130/80 mm Hg for patients with diabetes mellitus, proteinuria and chronic kidney disease and less than 140/90 mm Hg for all other patients. Continuity of care was assessed using the usual provider continuity index (UPCI, which is the ratio of patient visits to the usual provider to the total number of visits to all providers in 1 year. A UPC index of zero denotes no continuity while an index of one reflects perfect continuity with only the usual provider. We reviewed a total of 1060 medical records. The patients' mean age was 62.0 years (SD 10.4. The majority was women (59.2% and married (85.7%. The mean number of visits in a year was 3.85 (SD 1.36. A total of 72 doctors had provided consultations (55 postgraduate family medicine trainees, 8 non-trainee doctors and 9 academic staff. The mean UPCI was 0.43 (SD 0.34. Target BP was achieved in 42% of the patients. There was no significant relationship between BP control and personal continuity after adjustment for total number of visits. Continuity of care was not associated with BP control in our centre. Further studies are needed to explore the reasons for this.
Hanafi, Nik Sherina; Abdullah, Adina; Lee, Ping Yein; Liew, Su May; Chia, Yook Chin; Khoo, Ee Ming
Continuity of care is an important quality outcome of patient care. This study aimed to investigate the relationship between personal continuity and blood pressure (BP) control among the patients with hypertension in an academic primary care centre. Between January and May 2012, we conducted a retrospective review of medical records of patients with hypertension who had been followed up for at least 1 year in the Primary Care Clinic, University of Malaya Medical Centre, Malaysia. In this setting, doctors who provided care for hypertension included postgraduate family medicine trainees, non-trainee doctors and academic staff. Systematic random sampling (1:4) was used for patient selection. BP control was defined as less than 130/80 mm Hg for patients with diabetes mellitus, proteinuria and chronic kidney disease and less than 140/90 mm Hg for all other patients. Continuity of care was assessed using the usual provider continuity index (UPCI), which is the ratio of patient visits to the usual provider to the total number of visits to all providers in 1 year. A UPC index of zero denotes no continuity while an index of one reflects perfect continuity with only the usual provider. We reviewed a total of 1060 medical records. The patients' mean age was 62.0 years (SD 10.4). The majority was women (59.2%) and married (85.7%). The mean number of visits in a year was 3.85 (SD 1.36). A total of 72 doctors had provided consultations (55 postgraduate family medicine trainees, 8 non-trainee doctors and 9 academic staff). The mean UPCI was 0.43 (SD 0.34). Target BP was achieved in 42% of the patients. There was no significant relationship between BP control and personal continuity after adjustment for total number of visits. Continuity of care was not associated with BP control in our centre. Further studies are needed to explore the reasons for this.
Elizabeth A Blain
Full Text Available Elizabeth A Blain, Timothy J CraigPenn State Hershey Medical Center, Hershey, PA, USAObjective: To determine the use of spirometry in family practice, internal medicine, and pediatric outpatient settings.Methods: Data were collected from 45 outpatient offices in the central Pennsylvania area via phone survey that asked a set of four questions: 1 Do you have spirometry in your office? 2 Do you use spirometry for asthma patients? 3 In what situation do you use spirometry for? 4 Do you use spirometry more for chronic obstructive pulmonary disease (COPD or asthma? Results: It was found that pediatricians used spirometry 66% of the time, family practitioners 47% of the time, and internal medicine practitioners 60% of the time. Of those who did not use spirometry, 94% stated that they refer to a hospital if they required spirometry and 6% referred to subspecialists if the patient required spirometry. 10% of pediatricians performed the test on each asthma visit, otherwise the others used it only for exacerbations or as a baseline. No internists used spirometry regularly for asthma patients, and 22% used it more for COPD. In family practice only 14% used spirometry routinely at each visit for asthma patients.Conclusions: Pediatricians used spirometry more often in the outpatient setting than other specialists, followed closely by internal medicine physicians. Family practice physicians were the least likely to use spirometry. Multiple barriers seemed to prevent routine use of spirometry, but no one barrier accounted for the majority.Keywords: spirometry, asthma, primary care
Sarvotham Tinnu S
Full Text Available Abstract Background Travellers' diarrhoea is the most common health problem among international travellers and much of the burden falls on general practitioners. We assessed whether sentinel surveillance based in primary care could be used to monitor changes in the epidemiology of travellers' diarrhoea. Methods A sentinel surveillance scheme of 30 volunteer general practices distributed throughout Wales provides weekly reports of consultations for eight infectious diseases to the national Communicable Disease Surveillance Centre. Travellers' diarrhoea was introduced as a new reportable infection in July 2002. Results Between 1 July 2002 and 31 March 2005 there were 90 reports of travellers' diarrhoea. The mean annual consultation rate was 15.2 per 100,000 population (95% confidence interval: 12.2–18.7, with the highest rates in summer, in people aged 15–24 years, and in travellers to Southern Europe. A higher proportion of travellers than expected had visited destinations outside Europe and North America when compared to the proportion of all United Kingdom travellers visiting these destinations (38% vs. 11%; Chi2 = 53.3, p Conclusion Sentinel surveillance has the potential to monitor secular trends in travellers' diarrhoea and to help characterise population groups or travel destinations associated with higher risk.
Full Text Available BACKGROUND: Current approaches for AD prediction are based on biomarkers, which are however of restricted availability in primary care. AD prediction tools for primary care are therefore needed. We present a prediction score based on information that can be obtained in the primary care setting. METHODOLOGY/PRINCIPAL FINDINGS: We performed a longitudinal cohort study in 3.055 non-demented individuals above 75 years recruited via primary care chart registries (Study on Aging, Cognition and Dementia, AgeCoDe. After the baseline investigation we performed three follow-up investigations at 18 months intervals with incident dementia as the primary outcome. The best set of predictors was extracted from the baseline variables in one randomly selected half of the sample. This set included age, subjective memory impairment, performance on delayed verbal recall and verbal fluency, on the Mini-Mental-State-Examination, and on an instrumental activities of daily living scale. These variables were aggregated to a prediction score, which achieved a prediction accuracy of 0.84 for AD. The score was applied to the second half of the sample (test cohort. Here, the prediction accuracy was 0.79. With a cut-off of at least 80% sensitivity in the first cohort, 79.6% sensitivity, 66.4% specificity, 14.7% positive predictive value (PPV and 97.8% negative predictive value of (NPV for AD were achieved in the test cohort. At a cut-off for a high risk population (5% of individuals with the highest risk score in the first cohort the PPV for AD was 39.1% (52% for any dementia in the test cohort. CONCLUSIONS: The prediction score has useful prediction accuracy. It can define individuals (1 sensitively for low cost-low risk interventions, or (2 more specific and with increased PPV for measures of prevention with greater costs or risks. As it is independent of technical aids, it may be used within large scale prevention programs.
Trotter, Tracy L; Martin, Helen M
The family history is a critical element in pediatric medicine and represents the gateway to the molecular age of medicine for both pediatric clinicians and their patients. The pediatric clinician has several opportunities to obtain a family history and multiple clinical and educational uses for that information. Available methods include paper and digital forms, classical pedigrees, online programs, and focused family history at the time of a new diagnosis or problem. Numerous barriers impede the application of family history information to primary pediatric practice. The most common barrier is the limited amount of time the typical primary care encounter allows for its collection. The family history can be used in many facets of pediatric practice: (1) as a diagnostic tool and guide to testing and evaluation; (2) to identify patterns of inheritance; and (3) as a patient-education tool. The most exciting future use of family history is as a tool for public health and preventive medicine. More accurately identifying children at risk for common chronic conditions such as diabetes, asthma, and cardiovascular disease could change the primary care clinician's approach to pediatric medicine.
Post, Tim; Walma van der Molen, Juliette H.
Technology-oriented company visits could potentially provide children with a stimulating "real-world" setting to develop more broad and positive images of and attitudes toward technology and technical professions. The present study was the first to explore whether children's images of and attitudes toward technology, technical…
Post, Tim; Post, Tim; Walma van der Molen, Julie Henriëtte
Technology-oriented company visits could potentially provide children with a stimulating ‘real-world’ setting to develop more broad and positive images of and attitudes toward technology and technical professions. The present study was the first to explore whether children’s images of and attitudes
Post, Tim; Walma van der Molen, Juliette H.
Technology-oriented company visits could potentially provide children with a stimulating "real-world" setting to develop more broad and positive images of and attitudes toward technology and technical professions. The present study was the first to explore whether children's images of and attitudes toward technology, technical…
Post, Tim; Walma van der Molen, Juliette H.
Technology-oriented company visits could potentially provide children with a stimulating "real-world" setting to develop more broad and positive images of and attitudes toward technology and technical professions. The present study was the first to explore whether children's images of and attitudes toward technology, technical…
Post, Tim; Walma van der Molen, Juliette H.
Technology-oriented company visits could potentially provide children with a stimulating ‘real-world’ setting to develop more broad and positive images of and attitudes toward technology and technical professions. The present study was the first to explore whether children’s images of and attitudes
Joseph, Tina; Hale, Genevieve M; Eltaki, Sara M; Prados, Yesenia; Jones, Renee; Seamon, Matthew J; Moreau, Cynthia; Gernant, Stephanie A
The accountable care organization (ACO) is an innovative health care delivery model centered on value-based care. ACOs consisting of primary care providers are increasingly becoming commonplace in practice; however, medication management remains suboptimal. As experts in medication management, pharmacists perform direct patient care and assist in the transition from one provider to another, which places them in an ideal position to manage multiple aspects of patient care. Pharmacist-provided care has been shown to reduce drug expenditures, hospital readmissions, length of stay, and emergency department visits. Although pharmacists have become key team members of interdisciplinary teams within traditional care settings, their role has often been overlooked in the primary care-based ACO. In 2015, Nova Southeastern University College of Pharmacy founded the Accountable Care Organization Research Network, Services, and Education (ACORN SEED), a team of pharmacy practice faculty dedicated to using innovative approaches to patient care, while providing unique learning experiences for pharmacy students by partnering with ACOs in the South Florida region. Five opportunities are presented for pharmacists to improve medication use specifically in primary care-based ACOs: medication therapy management, annual wellness visits, chronic disease state management, chronic care management, and transitions of care. Several challenges and barriers that prevent the full integration of pharmacists into primary care-based ACOs include lack of awareness of pharmacist roles in primary care; complex laws and regulations surrounding clinical protocols, such as collaborative practice agreements; provider status that allows compensation for pharmacist services; and limited access to medical records. By understanding and maximizing the role of pharmacists, several opportunities exist to better manage the medication-use process in value-based care settings. As more organizations realize
Even though most countries have committed to primary health care (PHC), South Africa, a middle-income country, has an inadequate PHC system. The poor system has roots in the colonial period and apartheid reinforces this system. Race, class, and place of residence determine the type of health care individuals receive. South Africa falls far short of all 5 principles of PHC. Just 12% of the health budget goes to 40% of the population who live in the homelands which shows the inequitable distribution of health care resources and inadequate quality health care for all. Similarly, South Africa has not altered its communication and education techniques to improve preventive and promotive health services. It has not implemented any successful national campaigns such as a campaign against diarrhea deaths. South Africa does not make good use of available appropriate technology such as breast feeding, oral rehydration, refrigeration, and the ventilated improved pit latrine which lead to health for all. People in South Africa discuss community participation but it is not likely to occur without general political democracy. Some people have made local attempts at community participation but they tend to use inflexible means and request either cash or contributions in kind from people who have little. The elite in South Africa has not recognized the need to correct socioeconomic inequalities. The Population Development Plan Programme among white farmer-owners has showed some support for a multisectoral approach to improve health care, however. For example, it acknowledges that non-health-care interventions such as better salaries, literacy, and living conditions, lead to better health. The Department of National Health has discussed improved coordination of the budget to allow priority determination of national PHD and manpower plans. Nongovernmental organizations are beginning to use the PHC approach instead of the charitable approach.
García-Molina Sáez, Celia; Urbieta Sanz, Elena; Madrigal de Torres, Manuel; Piñera Salmerón, Pascual; Pérez Cárceles, María D
To quantify and to evaluate the reliability of Primary Care (PC) computerised medication records of as an information source of patient chronic medications, and to identify associated factors with the presence of discrepancies. A descriptive cross-sectional study. General Referral Hospital in Murcia. Patients admitted to the cardiology-chest diseases unit, during the months of February to April 2013, on home treatment, who agreed to participate in the study. Evaluation of the reliability of Primary Care computerised medication records by analysing the concordance, by identifying discrepancies, between the active medication in these records and that recorded in pharmacist interview with the patient/caregiver. Identification of associated factors with the presence of discrepancies was analysed using a multivariate logistic regression. The study included a total of 308 patients with a mean of 70.9 years (13.0 SD). The concordance of active ingredients was 83.7%, and this decreased to 34.7% when taking the dosage into account. Discrepancies were found in 97.1% of patients. The most frequent discrepancy was omission of frequency (35.6%), commission (drug added unjustifiably) (14.6%), and drug omission (12.7%). Age older than 65 years (1.98 [1.08 to 3.64]), multiple chronic diseases (1.89 [1.04 to 3.42]), and have a narcotic or psychotropic drug prescribed (2.22 [1.16 to 4.24]), were the factors associated with the presence of discrepancies. Primary Care computerised medication records, although of undoubted interest, are not be reliable enough to be used as the sole source of information on patient chronic medications when admitted to hospital. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.
Westhoff, Gisela; Dörner, Thomas; Zink, Angela
Patients with primary SS (pSS) are frequently suffering from multiple enduring disorders that raise the risk of work disability and require treatment by various health-care specialists. We aimed at determining predictors of physician visits and work disability in pSS patients. Physician visits within the past 6 months, employment status and sick leave were compared among 176 female pSS patients and 115 age-matched controls. Dryness, pain, fatigue and depression were assessed by rating scales of the EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI), the Profile of Fatigue and Discomfort (PROFAD) and Patient Health Questionnaire depression measurements (PHQ-9). Factors associated with an increased number of physician visits and inability to work were determined by multivariate logistic regression analysis. Patients and controls were comparable in age and education, but differed significantly in the prevalence of depression (38.1 vs 7.9%, P high ratings for the statement 'I have had difficulties to keep going, was easily worn out or lacking in energy' had a highly increased risk of not being gainfully employed (adjusted OR 4.1; 95% CI 1.5, 11.2; P < 0.001). In pSS, lack of stamina and/or depression cause a higher level of individual and societal burden than dry eyes and mouth. Fatigue and depression deserve more recognition as treatment targets in pSS.
Sabando Carranza, J A; Cortés Martinez, M; Calvo Carrasco, D
Several cases of mucocele have been treated in our Primary Health Care centre. These are benign lesions, relatively frequent (2.5/1000), which is caused by a retention of mucous from the minor salivary glands into the oral cavity, mainly at the level of the lower lip. The experience in their treatment in this centre is presented, along with a review of the literature to see if our treatment was correct. Copyright © 2015 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.
Ross, Andrew; Mash, Bob
This is the second article in the series on African primary care research. The article focuses on how to search for relevant evidence in the published literature that can be used in the development of a research proposal. The article addresses the style of writing required and the nature of the arguments for the social and scientific value of the proposed study, as well as the use of literature in conceptual frameworks and in the methods. Finally, the article looks at how to keep track of the literature used and to reference it appropriately.
Full Text Available This is the second article in the series on African primary care research. The article focuses on how to search for relevant evidence in the published literature that can be used in the development of a research proposal. The article addresses the style of writing required and the nature of the arguments for the social and scientific value of the proposed study, as well as the use of literature in conceptual frameworks and in the methods. Finally, the article looks athow to keep track of the literature used and to reference it appropriately.
Leung, Marcia A; Flaherty, Anna; Zhang, Julia A; Hara, Jared; Barber, Wayne; Burgess, Lawrence
The primary care physician's role in recognizing sudden sensorineural hearing (SSNHL) loss and delivering initial treatment is critical in the management of the syndrome. This role involves recognizing its clinical symptoms, distinguishing it from conductive hearing loss with the Weber tuning fork or the Rauch hum test, and urgent administration of high dose oral corticosteroids. Diagnosis and treatment should not be delayed for audiometric testing or referral to otolaryngology. This paper provides an update on the initial evaluation and treatment of this syndrome based on the literature and clinical guideline recommendations.
Kurtz, Kenneth J.
The recent establishment of primary care residencies at the University of Nevada School of Medicine has raised important questions about local priorities in the training of physicians to provide primary care for adults. Because the amount of money available for health care training is decreasing, these questions also have national importance. Primary care internal medicine, not synonymous with general internal medicine, offers distinct advantages to patients over family practice adult care and primary care offered by internist subspecialists. The University of Nevada has a singular opportunity to organize a strong primary care internal medicine residency, but national problems of internal medicine emphasis exist. Nationwide changes in internal medicine residency programs (ongoing) and American Board of Internal Medicine nationalization of the fledgling primary care internal medicine fellowship movement are suggested. Specifically proposed is an extra year for primary care training with a single examination after four years, producing general internists with a primary care “minor.” Alternately, and ideally, there would be a full two-year primary care fellowship with a separate internal medicine primary care subspecialty board examination. Either of the above options would provide necessary training and academic credibility for primary care internists, and would redirect internal medicine certification and training. PMID:7072246
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
Hart, Huberta E.; Rutten, Guy E H M
In the Netherlands so-called Diabetes Care Groups organize the primary diabetes care centrally with delegation to different health care providers. A training course for general practitioners who would like to become experts in diabetology in the primary care setting meets the need to guide the quali
Interprofessional Relations; Primary Health Care/Organization & Administration; Diabetes Mellitus, Type 2/Prevention & Control; Primary Prevention/Methods; Risk Reduction Behavior; Randomized Controlled Trial; Life Style
Full Text Available Background: Visitation of patients admitted at intensive care units (ICUs is a controversial issue in the field of health care. It is commonly believed that the presence of family members might bring about physiological changes, such as tachycardia and hypertension, in ICU patients. Aim: This study aimed to evaluate the effects of scheduled visitation on the physiological indices of conscious patients at the ICU. Method: This experimental study was conducted on 90 conscious patients admitted at the ICU of Ganjavian Hospital in Dezful, Iran in 2014. Patients were randomly divided into two groups of intervention and control. In the control group, patient visits were carried out in accordance with normal procedures of the ward. In the intervention group, patients were visited by relatives and family members for 30 minutes, preferably in evening shifts. Physiological indices of the patients were recorded before, during and after scheduled visitation. Data analysis was performed in SPSS V.18 using independent T-test and one-way ANOVA with repeated measures. Results: In this study, mean age of patients in the intervention and control groups was 42.1±19.1 and 39.4±19.6 years, respectively. In the intervention group, systolic blood pressure had a more significant reduction at 10 and 30 minutes after visitation compared to the control group (independent T-test, P0.05. Implications for Practice: According to the results of this study, scheduled visitation by family members caused no significant differences in the physiological indices of ICU patients. It is recommended that future studies be conducted as to confirm this finding and revise patient visitation policies in hospitals.
Green Michael E
Full Text Available Abstract Purpose To evaluate the appropriateness of potential data sources for the population of performance indicators for primary care (PC practices. Methods This project was a cross sectional study of 7 multidisciplinary primary care teams in Ontario, Canada. Practices were recruited and 5-7 physicians per practice agreed to participate in the study. Patients of participating physicians (20-30 were recruited sequentially as they presented to attend a visit. Data collection included patient, provider and practice surveys, chart abstraction and linkage to administrative data sets. Matched pairs analysis was used to examine the differences in the observed results for each indicator obtained using multiple data sources. Results Seven teams, 41 physicians, 94 associated staff and 998 patients were recruited. The survey response rate was 81% for patients, 93% for physicians and 83% for associated staff. Chart audits were successfully completed on all but 1 patient and linkage to administrative data was successful for all subjects. There were significant differences noted between the data collection methods for many measures. No single method of data collection was best for all outcomes. For most measures of technical quality of care chart audit was the most accurate method of data collection. Patient surveys were more accurate for immunizations, chronic disease advice/information dispensed, some general health promotion items and possibly for medication use. Administrative data appears useful for indicators including chronic disease diagnosis and osteoporosis/ breast screening. Conclusions Multiple data collection methods are required for a comprehensive assessment of performance in primary care practices. The choice of which methods are best for any one particular study or quality improvement initiative requires careful consideration of the biases that each method might introduce into the results. In this study, both patients and providers were
Green, Michael E; Hogg, William; Savage, Colleen; Johnston, Sharon; Russell, Grant; Jaakkimainen, R Liisa; Glazier, Richard H; Barnsley, Janet; Birtwhistle, Richard
To evaluate the appropriateness of potential data sources for the population of performance indicators for primary care (PC) practices. This project was a cross sectional study of 7 multidisciplinary primary care teams in Ontario, Canada. Practices were recruited and 5-7 physicians per practice agreed to participate in the study. Patients of participating physicians (20-30) were recruited sequentially as they presented to attend a visit. Data collection included patient, provider and practice surveys, chart abstraction and linkage to administrative data sets. Matched pairs analysis was used to examine the differences in the observed results for each indicator obtained using multiple data sources. Seven teams, 41 physicians, 94 associated staff and 998 patients were recruited. The survey response rate was 81% for patients, 93% for physicians and 83% for associated staff. Chart audits were successfully completed on all but 1 patient and linkage to administrative data was successful for all subjects. There were significant differences noted between the data collection methods for many measures. No single method of data collection was best for all outcomes. For most measures of technical quality of care chart audit was the most accurate method of data collection. Patient surveys were more accurate for immunizations, chronic disease advice/information dispensed, some general health promotion items and possibly for medication use. Administrative data appears useful for indicators including chronic disease diagnosis and osteoporosis/ breast screening. Multiple data collection methods are required for a comprehensive assessment of performance in primary care practices. The choice of which methods are best for any one particular study or quality improvement initiative requires careful consideration of the biases that each method might introduce into the results. In this study, both patients and providers were willing to participate in and consent to, the collection and
Kastner, Theodore A.; Walsh, Kevin K.
Lack of sufficient accessible community-based health care services for individuals with developmental disabilities has led to disparities in health outcomes and an overreliance on expensive models of care delivered in hospitals and other safety net or state-subsidized providers. A functioning community-based primary health care model, with an…
Almeida, Patty Fidelis de; Santos, Adriano Maia Dos
To analyze the breadth of care coordination by Primary Health Care in three health regions. This is a quantitative and qualitative case study. Thirty-one semi-structured interviews with municipal, regional and state managers were carried out, besides a cross-sectional survey with the administration of questionnaires to physicians (74), nurses (127), and a representative sample of users (1,590) of Estratégia Saúde da Família (Family Health Strategy) in three municipal centers of health regions in the state of Bahia. Primary Health Care as first contact of preference faced strong competition from hospital outpatient and emergency services outside the network. Issues related to access to and provision of specialized care were aggravated by dependence on the private sector in the regions, despite progress observed in institutionalizing flows starting out from Primary Health Care. The counter-referral system was deficient and interprofessional communication was scarce, especially concerning services provided by the contracted network. Coordination capacity is affected both by the fragmentation of the regional network and intrinsic problems in Primary Health Care, which poorly supported in its essential attributes. Although the health regions have common problems, Primary Health Care remains a subject confined to municipal boundaries. Analisar o alcance da coordenação do cuidado pela Atenção Primária à Saúde em três regiões de saúde. Trata-se de estudo de caso, com abordagem quantitativa e qualitativa. Foram realizadas 31 entrevistas semiestruturadas com gestores municipais, regionais e estaduais e estudo transversal com aplicação de questionários para médicos (74), enfermeiros (127) e amostra representativa de usuários (1.590) da Estratégia Saúde da Família em três municípios-sede de regiões de saúde do estado da Bahia. A função de porta de entrada preferencial pela Atenção Primária à Saúde deparava-se com forte concorrência de servi
Vilà Falgueras, Maite; Cruzate Muñoz, Carlota; Orfila Pernas, Francesc; Creixell Sureda, Joan; González López, María Pilar; Davins Miralles, Josep
To estimate the prevalence of burnout and the perception of teamwork in Primary Care teams from Barcelona. Multicenter cross-sectional. Primary Health Care Teams from Barcelona. Institut Català de la Salut. All permanent employees or temporary professionals of all categories from 51 teams (N=2398). A total of 879 responses (36.7%) were obtained. The Maslach Burnout Inventory questionnaire, with 3 dimensions, was sent by emotional exhaustion (AE), depersonalization (DP), and personal accomplishment (RP). Burnout is considered present when two or more dimensions scored high marks. Perception of teamwork and evaluation of leaders was evaluated using an ad hoc questionnaire. The prevalence of burnout was17.2% (two or more dimensions affected), and 46.2% had at least one of the three dimensions with a high level. A high level of AE was found in 38.2%, of DP in 23.8%, and 7.7% had low RP. Almost half (49.2%) believe that teamwork is encouraged in their workplace. Social workers overall, have a higher average of dimensions affected at a high level, followed by administrative personnel, dentists, doctors and nurses (pteamwork had more emotional exhaustion, depersonalization and higher level of burnout in general (pTeamwork and appreciating their leaders protect from burnout. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.
Brenes Bermúdez, F J; Cozar Olmo, J M; Esteban Fuertes, M; Fernández-Pro Ledesma, A; Molero García, J M
Despite the high incidence of urinary incontinence (UI), health professional awareness of this disease is low, which in itself is not serious but significantly limits the lives of the patients. The Primary Care associations, Sociedad Española de Médicos de Atención Primaria [SEMERGEN], Sociedad Española de Médicos Generales y de Familia [SEMG], Sociedad Española de Medicina de Familia y Comunitaria [semFYC]) along with the Asociación Española de Urología (EAU) have developed this consensus with the proposal of making GPs aware, and to help them in the diagnosis, treatment and referral to Urologists. The first goal in primary care must be the detection of UI, thus an opportunistic screening at least once in the lifetime of asymptomatic women > 40 years old and asymptomatic men > 55 years old. The diagnosis, based on medical history and physical examination, must determine the type and severity of the UI in order to refer severe cases to the Urologist. Except for overactive bladder (OAB), non-pharmacological conservative treatment is the first approach to uncomplicated UI in females and males. Antimuscarinics are the only drugs that have demonstrated efficacy and safety in urge urinary incontinence (UUI) and OAB. In men with mixed symptoms, excluding severe obstruction cases, a combination therapy of alpha-blockers and antimuscarinics should be chosen.
Catalán, Arantxa; Borrell, Francesc; Pons, Angels; Amado, Ester; Baena, José Miguel; Morales, Vicente
The Institut Català de la Salut (ICS) has designed and integrated in electronic clinical station of primary care a new software tool to support the prescription of drugs, which can detect on-line certain medication errors. The software called PREFASEG (stands for Secure drug prescriptions) aims to prevent adverse events related to medication use in the field of primary health care (PHC). This study was made on the computerized medical record called CPT, which is used by all PHC physicians in our institution -3,750- and prescribing physicians through it. PREFASEG integrated in eCAP in July 2010 and six months later we performed a cross-sectional study to evaluate their usefulness and refine their design. The software alerts on-line in 5 dimensions: drug interactions, redundant treatments, allergies, contraindications of drugs with disease, and advises against drugs in over 75 years. PREFASEG generated 1,162,765 alerts (1 per 10 high treatment), with the detection of therapeutic duplication (62%) the most alerted. The overall acceptance rate is 35%, redundancies pharmacological (43%) and allergies (26%) are the most accepted. A total of 10,808 professionals (doctors and nurses) have accepted some of the recommendations of the program. PREFASEG is a feasible and highly efficient strategy to achieve an objective of Quality Plan for the NHS.
Gutiérrez Angulo, María Luisa; Amenabar Azurmendi, Miren Dolores; Cuesta Solé, María Lourdes; Prieto Esteban, Irene; Mancebo Martínez, Sara; Iglesias Alonso, Amparo
To ascertain the prevalence of obesity and overweight recording in primary care (PC) clinical records. A descriptive, cross-sectional study. The study was conducted in three urban, primary care centers in Gipuzkoa. 620 computerized clinical records randomly selected from a population of 63,820. Patient age older than 14 years was the only inclusion criterion. Recording of the clinical episode referring to obesity and/or overweight. Other variables included age, sex, body mass index (BMI), waist circumference, comorbidity (diabetes, hypertension, heart failure, among others), and variability of the record made by healthcre professionals at each center. Statistical analysis included a Chi-square test or a Fisher's test for low frequencies. A value of P<.05 was considered significant. Analysis was performed using SPSS(®) v.21 software. Prevalence of recorded obesity was 6%, and 78.4% of those with recorded obesity were women. Overweight was recorded in 3% of subjects, of which 33.2% were women. BMI was recorded in 170 cases (27%). At least one comorbidity was found in 241 subjects (39%). Association of BMI with presence of comorbidity was statistically significant (P=.0001). Recording of obesity was associated to presence of comorbidity (P =.0002). This study confirmed that prevalence of obesity is underestimated, mainly because it is inadequately recorded in clinical histories; that prevalence increases in the presence of other risk factors; and that there is a significant variability in data collection between healthcare professionals. Copyright © 2013 SEEN. Published by Elsevier Espana. All rights reserved.
Bolduc, Philip; Roder, Navid; Colgate, Emily; Cheeseman, Sarah H
With the advent of antiretroviral therapy and improved access to care, the average life expectancy of patients with HIV infection receiving optimal treatment approaches that of patients in the general population. AIDS-related opportunistic infections and malignancies are no longer the primary issues; instead, traditional age- and lifestyle-related conditions are a growing concern. Patients with HIV infection are at higher risk of cardiovascular disease, diabetes, hypertension, and some non-AIDS-related cancers than patients in the general population. Family physicians need to be knowledgeable about screening for and managing chronic comorbid conditions as this population ages. Health maintenance, including appropriate vaccinations, prophylaxis against opportunistic infections, and routine screening for sexually transmitted infections, remains an important part of care. As HIV infection becomes a chronic condition, emerging strategies in prevention, including preexposure prophylaxis, fall within the scope of practice of the family physician.
Full Text Available OBJECTIVE: To study frequency and associated factors for care giving among elderly patients visiting a teaching hospital in Karachi, Pakistan. METHODOLOGY: A cross sectional questionnaire-based study was conducted at the Community Health Centre (CHC, Aga Khan University Hospital (AKUH Karachi, Pakistan from September to November 2009. All individuals, visiting the CHC and aged 65 years or above were interviewed after taking written informed consent. RESULTS: A total of 400 elderly completed the interview. Majority were females, 65-69 years age, More than half of the individuals ie: 227 (85% had received Care Giver experience for assistance and among these 195(72% had care provided by an immediate family member. A large proportion of them stated that their Care Givers managed to provide less than four hours in a day for care giving. Around 37% showed substantial improvement in their relationship with the care givers. About 70% of the respondents stated that the care provided by the Care Giver improved their quality of life. CONCLUSION: Elderly care is provided by majority of the family members resulting in increased satisfaction level, however small number still not satisfied due to unfulfilled need of these older people. This demands that efforts should be made to strengthen the family support by increasing awareness regarding elderly care and arranging support system by the government.
Shearer, David S
The present article discusses the integration of a civilian prescribing psychologist into a primary care clinic at Madigan Army Medical Center. A description of the role of the prescribing psychologist in this setting is provided. The author asserts that integrating prescribing psychology into primary care can improve patient access to skilled behavioral health services including psychotherapeutic and psychopharmacologic treatment. Potential benefits to the primary care providers (PCPs) working in primary care clinics are discussed. The importance of collaboration between the prescribing psychologist and PCP is emphasized. Initial feedback indicates that integration of a prescribing psychologist into primary care has been well received in this setting.
Goff, Sarah L; Murphy, Lorna; Knee, Alexander B; Guhn-Knight, Haley; Guhn, Audrey; Lindenauer, Peter K
To evaluate the effectiveness of Buena Salud, a multidisciplinary enhanced primary care program for Medicaid Managed Care patients at a community health center serving a low-income Hispanic community. Controlled before-and-after observational study. We extracted data from the electronic health record for patients aged 18 to 64 years with a) type 2 diabetes (T2D) enrolled in the Buena Salud program between August 2011 and January 2012 and b) randomly selected control patients with T2D who had been seen at the study health center during the same time frame. Outcomes included process measures (eg, number of glycosylated hemoglobin measures in a year), target lab and blood pressure values, and utilization measures (eg, emergency department visits). Demographics and other potential confounders were also extracted. We used a difference-in-differences (DID) analysis to estimate the effect of the intervention. A total of 72 Buena Salud patients with T2D and 247 control patients with T2D were included in the analysis. The Buena Salud group had a greater increase in the percentage of patients with guideline-concordant measurement of microalbumin/creatinine (DID = 22.2%; P = .008), a trend toward fewer hospitalizations than controls, and a mean rise in diastolic blood pressure. We did not find differences in other outcome or utilization measures. A recently implemented enhanced primary care program had minimal impact on T2D process, outcome, and utilization measures for patients in this study. However, there were some promising trends, and it is possible that the intervention may demonstrate more of an effect as the program matures.
Beyer, Martin; Gerlach, Ferdinand M; Erler, Antje
In its 2009 report the Federal Advisory Council on the Assessment of Developments in the Health Care System developed a model of Primary Care Practices for future general practice-based primary care. This article presents the theoretical background of the model. Primary care practices are seen as developed organisations requiring changes at all system levels (interaction, organisation, and health system) to ensure sustainability of primary care functions in the future. Developments of the elements comprising the health care system may be compared to the developments and proposals observed in other countries. In Germany, however, the pace of these developments is relatively slow.
Stevanović, Ranko; Stanić, Arsen; Varga, Sinisa
The Croatian Ministry of Health started a health care system computerization project aimed at strengthening the collaboration among health care institutions, expert groups and individual health care providers. A tender for informatic system for Primary Health Care (PHC) general practice, pediatrics and gynecology, a vital prerequisite for project realization, has now been closed. Some important reasons for undertaking the project include rationalization of drug utilization, savings through a reduced use of specialists, consultants and hospitalization, then achievement of better cooperation, work distribution, result linking, data quality improvement (by standardization), and ensuring proper information-based decision making. Keeping non-standardized and thus difficult to process data takes too much time of the PHC team time. Since, however, a vast amount of data are collected on only a few indicators, some important information may remain uncovered. Although decisions made by health authorities should rely on evidence and processed information, the authorities spend most of the time working with raw data from which their decisions ultimately derive. The Informatic Technology (IT) in PHC is expected to enable a different approach. PHC teams should be relieved from the tedious task of data gathering and the authorities enabled to work with the information rather than data. The Informatics Communication Technology (ICT) system consists of three parts: hardware (5000 personal computers for work over the Internet), operative system with basic software (editor, etc.), and PHC software for PHC teams. At the national level (National Public Health Informatics System), a software platform will be built for data collection, analysis and distribution. This data collection will be based on the International Classification of Primary Care (ICPC-2) standard to ensure the utilization of medical records and quality assessment. The system permits bi-directional data exchange between
Allwright Shane PA
Full Text Available Abstract Background An industrial dispute between prison doctors and the Irish Prison Service (IPS took place in 2004. Part of the resolution of that dispute was that an independent review of prison medical and support services be carried out by a University Department of Primary Care. The review took place in 2008 and we report here on the principal findings of that review. Methods This study utilised a mixed methods approach. An independent expert medical evaluator (one of the authors, DT inspected the medical facilities, equipment and relevant custodial areas in eleven of the fourteen prisons within the IPS. Semistructured interviews took place with personnel who had operational responsibility for delivery of prison medical care. Prison doctors completed a questionnaire to elicit issues such as allocation of clinician's time, nurse and administrative support and resources available. Results There was wide variation in the standard of medical facilities and infrastructure provided across the IPS. The range of medical equipment available was generally below that of the equivalent general practice scheme in the community. There is inequality within the system with regard to the ratio of doctor-contracted time relative to the size of the prison population. There is limited administrative support, with the majority of prisons not having a medical secretary. There are few psychiatric or counselling sessions available. Conclusions People in prison have a wide range of medical care needs and there is evidence to suggest that these needs are being met inconsistently in Irish prisons.
Maheshwari, Amrat Kumar; Kumar, Pawan; Alam, Muhammad Tanveer; Aurangzeb, Muhammad; Parkash, Jai; Imran, Khalid; Masroor, Muhammad
To determine the frequency of hyperthermia in acute ischemic stroke patients visiting a tertiary care hospital in a developing country. Cross-sectional, observational study. Medical Wards of Civil Hospital, Karachi, from January to June 2013. Patients aged ≥18 years of either gender with acute ischemic stroke presenting within 24 hours of onset of symptoms were included. Written informed consent was obtained from all participants as well as approval of ethical review committee of the institute. Axillary temperature by mercury thermometer was monitored at the time of admission and after every 6 hours for 3 days. The data was analyzed using SPSS version 17.0 (SPSS Inc., IL, Chicago, USA). Atotal of 106 patients of ischemic stroke were included. The mean age of enrolled participants was 60.1 ±9.5 years. Among these, 61 (57.5%) were males and 45 (42.5%) females. Among all patients, 51.9% presented with loss of consciousness, 30.2% with slurred speech, 77.4% with limb weakness, and 9.4% with decrease vision. Atotal of 17 (16%) patients with ischemic stroke developed hyperthermia. When the prevalence of hyperthermia was stratified according to age, among patients of ischemic stroke was 16% and it should be looked for as it has significant impact on the outcome. The hyperthermia was significantly more common in younger adults as compared to older adults. However, gender had no influence on the prevalence rate of hyperthermia.
Full Text Available Background: Use of tobacco among alcohol dependent population is quite frequent. This co-morbidity increases the risk for various diseases. Understanding the pattern of tobacco use with co-morbid alcohol use may help in planning appropriate prevention/treatment strategies. The study aimed at examining the profile and pattern of nicotine use among alcohol dependent patients visiting a tertiary care treatment center in North India. Materials and Methods: Male patients fulfilling diagnostics and statistical manual of mental disorder fourth edition, criteria for nicotine and alcohol diagnostics and statistical dependence, attending the out-patient department of the tertiary care treatment center were recruited after obtaining informed consent. The socio-demographic profile, drug use history, nicotine associated health problems and general health problem were recorded. Motivation to stop tobacco use was assessed qualitatively using the direct questions about their interest and intentions to quit. Results: A total of 150 subjects were included in the study. The mean age of the study sample was 37.6 ± 10.44 years. Tobacco was reported as the gateway drug in 90% of the cases. Exclusive bidi use reported in 42% of the subjects. Mean duration of bidi and co-morbid alcohol use was higher than cigarette or smokeless tobacco use. Self-reported health problems associated with nicotine use and general health was reported by 41% and 39% of the subjects. Unsuccessful past quit attempts was present in 85% cases. More than 90% of subjects remained interested in quitting the tobacco use. An increased liver enzyme (aspartate transaminase, alanine transaminase and gamma-glutamyl transferase were observed in 43, 32 and 47% of the cases. Conclusion: The results suggest the nicotine and alcohol dependent patients represent a separate population requiring higher attention from the treating physician.
Asselin, J; Osunlana, A M; Ogunleye, A A; Sharma, A M; Campbell-Scherer, D
The 5As Team study was designed to create, implement and evaluate a flexible intervention to improve the quality and quantity of weight management visits in primary care. The objective of this portion of the study was to explore how primary care providers incorporate weight management in their practice. 5AsT is a randomized controlled trial (RCT) on the implementation of a 6-month 5 As Team (5AsT) intervention designed to operationalize the 5As of obesity management in primary care. Data for the qualitative portion of the study presented here included semi-structured interviews with 29 multidisciplinary team providers and field notes of intervention sessions. Thematic analysis was undertaken. A key pattern that emerged from the data was that healthcare providers usually do not address obesity as a primary focus for a visit. Rather, obesity is embedded in a wide range of primary care encounters for other conditions. Implications were it can take extra time to discuss weight, it can be inappropriate to bring up weight as a topic, and treating risk factors and root causes of obesity have indirect benefits to patient weight management. Our findings have implications for obesity treatment approaches and tools that assume a discreet weight management visit. The embedded nature of obesity management in primary care can be harnessed to leverage multiple opportunities for asking and assessing root causes of obesity, and working longitudinally towards individual health goals. © 2015 The Authors. Clinical Obesity published by John Wiley & Sons Ltd on behalf of World Obesity.
Introduction: The majority of the ICUs applies a restricted visiting policy, despite the fact that numerous research data support the beneficial impact of a flexible or an open visiting policy for the patients and their families. Aim: The aim of the present study was to explore the perceptions of the ICU nursing staff regarding the implementation of a flexible or an open visiting policy, as well as the impact of these perception on the patients, their families and the nurses themselves. Mater...
Full Text Available Abstract Background Scientific research has provided evidence on benefits of well developed primary care systems. The relevance of some of this research for the European situation is limited. There is currently a lack of up to date comprehensive and comparable information on variation in development of primary care, and a lack of knowledge of structures and strategies conducive to strengthening primary care in Europe. The EC funded project Primary Health Care Activity Monitor for Europe (PHAMEU aims to fill this gap by developing a Primary Care Monitoring System (PC Monitor for application in 31 European countries. This article describes the development of the indicators of the PC Monitor, which will make it possible to create an alternative model for holistic analyses of primary care. Methods A systematic review of the primary care literature published between 2003 and July 2008 was carried out. This resulted in an overview of: (1 the dimensions of primary care and their relevance to outcomes at (primary health system level; (2 essential features per dimension; (3 applied indicators to measure the features of primary care dimensions. The indicators were evaluated by the project team against criteria of relevance, precision, flexibility, and discriminating power. The resulting indicator set was evaluated on its suitability for Europe-wide comparison of primary care systems by a panel of primary care experts from various European countries (representing a variety of primary care systems. Results The developed PC Monitor approaches primary care in Europe as a multidimensional concept. It describes the key dimensions of primary care systems at three levels: structure, process, and outcome level. On structure level, it includes indicators for governance, economic conditions, and workforce development. On process level, indicators describe access, comprehensiveness, continuity, and coordination of primary care services. On outcome level, indicators
Pollyanna Kássia de Oliveira Borges
Full Text Available Objective: to check the profile of sensitive causes hospitalizations for primary care. Methods: this is an ecological, epidemiological study. Data was collected in the Hospital Information System at the Department of Health System Information, grouped according to the admissions list for Sensitive to Primary Causes of Health System. Results: there were 227,014 hospitalizations, 25.8% of them were sensitive to Primary care. The illnesses which caused sensitive admissions were pneumonia (n=19,832; 33.7%, heart failure (n=6,688, 11.3%, and gastroenteritis (n=6,287, 10.7%. Conclusion: sensitive hospitalizations for primary care have decreasing historical trend in the study area. Primary care services, with guidelines and principles, well conducted could minimize the risk of exacerbation of chronic conditions and also endorse lower rates of infection transmitted diseases.
The health promotion discourse is comprised of assumptions about health and health care that are compatible with primary health care. An examination of the health promotion discourse illustrates how assumptions of health can help to inform primary health care. Despite health promotion being a good fit for primary health care, this analysis demonstrates that the scope in which it is being implemented in primary health care settings is limited. The health promotion discourse appears largely compatible with primary health care-in theory and in the health care practices that follow. The aim of this article is to contribute to the advancement of theoretical understanding of the health promotion discourse, and the relevance of health promotion to primary health care.
Kriegel, J; Rebhandl, E; Reckwitz, N; Hockl, W
Current and projected general practitioner (GP) and primary care in Austria shows structural and process inadequacies in the quality as well as assurance of healthcare supply. The aim is therefore to develop solution- and patient-oriented measures that take patient-related requirements and medical perspectives into account. Using an effect matrix, subjective expert and user priorities were ascertained, cause and effect relationships were examined, and an expanded circle of success for the optimization of GP and primary care in Upper Austria was developed. Through this, the relevant levers for target-oriented development and optimization of the complex system of GP and primary care in Upper Austria were identified; these are training to become general practitioners, entrepreneurs as well as management and coordination. It is necessary to further adapt the identified levers conceptually and operationally in a targeted approach. This is to be achieved by means of the primary health care (PHC) concept as well as management tools and information and communication technologies (ICT) associated with it. © Georg Thieme Verlag KG Stuttgart · New York.
Shepardson, Robyn L; Funderburk, Jennifer S
Anxiety is common, but under-treated, in primary care. Behavioral health providers embedded in primary care can help address this treatment gap. Guidance on anxiety treatment preferences would help inform tailoring of clinical practice and new interventions to be more patient-centered and increase treatment engagement. We surveyed 144 non-treatment seeking Veteran primary care patients (82.6 % male, 85.4 % White, age M = 59.8 years, SD = 13.9) reporting current anxiety symptoms (M = 13.87, SD = 3.66, on the Generalized Anxiety Disorder-7 Questionnaire) on their likelihood of attending anxiety treatment featuring various levels of 11 attributes (modality, type, location, format, provider, visit frequency, visit length, treatment duration, type of psychotherapy, symptom focus, and topic/skill). Participants indicated clear preferences for individual, face-to-face treatment in primary care, occurring once a month for at least 30 min and lasting at least three sessions. They also tended to prefer a stress management approach focused on trouble sleeping or fatigue, but all topics/skills were rated equivalently. For most attributes, the highest rated options were consistent with characteristics of integrated care. Implications for research and practice are discussed.
Full Text Available The necessity is emphasized to distinguish between the traditional model of data acquisition reported by a patient in doctor’s office and the more valuable and desired model to become acquainted with the core of the problem by going to a patient’s domicile. In the desired model it is possible to come across various determinants of health during home visits. Family members can be approached and there is a possibility to evaluate the relationships between the patient and his loved ones. One can visually assess one’s living conditions and predictable environmental hazard. For several years, the desired model has been put into practice by general practitioners and home health care nurses. Recently this model is also promoted by “health care therapists” who are members of “teams of home health care”. The authors, being convinced of the merits of “home and environmental model” of practical medicine, have developed a method of recording and illustrating data collected during visits in patient’s home. The elaborated tool helps to communicate and exchange information among general practitioners, home health care nurses, social workers of primary health care centers and specialists. The method improves the formulation of the plan of further therapeutic steps and remedial interventions in psycho-social relations and living conditions of patients.
Mansfield Richard J
Full Text Available Abstract Background Although shoulder pain is a commonly encountered problem in primary care, there are few studies examining its presenting characteristics and clinical management in this setting. Methods We performed secondary data analysis of 692 office visits for shoulder pain collected through the National Ambulatory Medical Care Survey (Survey years 1993–2000. Information on demographic characteristics, history and place of injury, and clinical management (physician order of imaging, physiotherapy, and steroid intraarticular injection were examined. Results Shoulder pain was associated with an injury in one third (33.2% (230/692 of office visits in this population of US primary care physicians. Males, and younger adults (age ≤ 52 more often associated their shoulder pain with previous injury, but there were no racial differences in injury status. Injury-related shoulder pain was related to work in over one-fifth (21.3% (43/202 of visits. An x-ray was performed in 29.0% (164/566 of office visits, a finding that did not differ by gender, race, or by age status. Other imaging (CT scan, MRI, or ultrasound was infrequently performed (6.5%, 37/566. Physiotherapy was ordered in 23.9% (135/566 of visits for shoulder pain. Younger adults and patients with a history of injury more often had physiotherapy ordered, but there was no significant difference in the ordering of physiotherapy by gender or race. Examination of the use of intraarticular injection was not possible with this data set. Conclusion These data from the largest sample of patients with shoulder pain presenting to primary care settings offer insights into the presenting characteristics and clinical management of shoulder pain at the primary care level. The National Ambulatory Medical Care Survey is a useful resource for examining the clinical management of specific symptoms in U.S. primary care offices.
Full Text Available Iran is a large country with a total area of 1,645,000 square kilometers. The country’s population is estimated at about 31 millions. There is an uneven distribution of the population, varying from 2 to 50 per square kilometer. Sixty per cent of the total population (18 millions is living in nearly 66,000 small and large village’s scattered throughout the country. A total of 10,000 physicians provide the main source of medical manpower, however more than 40% of these physicians are located in the capital city of Teheran. The physician to population ratio for the country is about 1 per 3,000 and the figure reaches 100,000 in some rural areas. Each year a total of 600 graduates is added to the health manpower , but technical and socio-economic handicapping factors make the rural and low-income areas less attractive to the new graduates. In this paper the reconstruction of health services around the concept of Primary Medical Care has been reposed for the country’s health development. Taking into consideration the country’s special geographical and demographic features, two levels of primary care workers have been suggested; the first group with 4 year’s training in curative and preventive services, and the second group at grade 9 level in education. It is foreseen that the two afore-mentioned groups will form a network of auxiliaries to the physicians in extending health services to the remote areas of the country.
This is a retrospective report on the importance of Kark and Cassel's 1952 paper on community-oriented primary care (COPC). In 1978, WHO and UNICEF endorsed COPC. However, the ideas girding and framing this approach had first been given full expression in practice some four decades earlier. In Depression-Era South Africa, Sidney Kark, a leader of the National Department of Health, converted the emergent discipline of social medicine into a unique form of comprehensive practice and established the Pholela Health Center, which was the explicit model for COPC. COPC as founded and practiced by Kark was a community, family and personal practice; it also was a multidisciplinary and team practice. Furthermore, the innovations of COPC entailed monitoring, evaluation, and research. Evaluation is the essence of Kark and Kassel's paper, which offers a convincing demonstration of the effects of COPC. Its key findings include the following: 1) that there was a decline in the incidence of syphilis in the area served by the health center; 2) that diet and nutrition improved; and 3) that the crude mortality rate as well as the infant mortality rate--the standard marker--declined in Pholela. In the succeeding decades, OPC had an international legacy (through WHO and H. Jack Geiger's influence in the US Office of Economic Opportunity), which came full circle in the 1980s, when a young generation of South Africans began to search their history for models for their health care programs at the dawn of the post-Apartheid Era.
Young, Melodie; Aldredge, Lakshi; Parker, Patti
Primary care practitioners (PCPs) are playing an increasingly important role in the management and care of psoriasis. Thus, it is important for PCPs to be knowledgeable about the disease and to be able to differentiate between common myths and facts related to diagnosis and treatment. By building relationships with their patients and working collaboratively with dermatology health professionals and other specialists, PCPs can facilitate communication about the patient's treatment preferences and expectations for symptom relief, and they may be better able to work with the patient to optimize treatment adherence. This review aims to provide PCPs with a primer on psoriasis, its associated comorbidities, and its impact on patients' quality of life. Discussion topics include psoriasis epidemiology, triggering factors, clinical presentation, differential diagnosis, comorbidities, and approaches to treatment. This review also highlights the importance of staying abreast of advances in the understanding of psoriasis pathogenesis as well as emerging therapeutic treatment options, because these advances may change the treatment landscape and increase patients' expectations for skin clearance. ©2017 American Association of Nurse Practitioners.
Rost, K; Nutting, P A; Smith, J; Werner, J J
Complex interventions, which have been shown to improve primary care depression outcomes, are difficult to disseminate to routine practice settings. To address this problem, we developed a brief intervention to train primary care physicians and nurses employed by the practice to improve the detection and management of major depression. Before recruitment began, the research team conducted academic detailing conference calls with primary care physicians and nurses, and provided in-person training with nurses and administrative staff. Administrative staff screened over 11,000 patients before their visits to identify those with probable major depression. Primary care physicians delegated increased responsibility to office nurses, who educated over 90% of patients about effective depression treatment and systematically monitored their progress over time. Early results demonstrate that community primary care practices can rebundle traditional team roles over the short-term to provide more systematic mental health treatment without adding additional personnel. A rigorous evaluation of this effort will reduce time-consuming, expensive, and often unsuccessful efforts to "translate" research intervention findings into everyday practice.
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.
Mauksch, Larry B; Fogarty, Colleen T
The "perennial philosophy," a concept religious scholars have studied for centuries, represents a search for the values, themes, and constructs that transcend individual religions. Can we who develop and disseminate behavioral health integration in primary care step back from individual models to identify our perennial philosophy? If so, what are the components? What does the evidence tell us? What do we need to learn? Four case examples are presented which represent many patients seen by both of us-a family therapist and a family physician-over our combined 55 years of collaborative practice within integrated primary care settings. Can these patients be cared for in a primary care setting? Our experience provides a simple answer-yes. However, providing care for this range of patients requires variability in team configurations, frequency of visits, lengths of relationships, and interventional strategies. Is there a perennial philosophy of how to design and implement the integration of behavioral health in primary care? We think there should be. we highlight a recent publication from the Eugene S. Farley, Jr. Health Policy Center, entitled "Core Competencies For Behavioral Health Providers Working In Primary Care." The authors purposefully transcend models in delineating eight core competencies. Embedded within these competencies are common or perennial factors. These factors may guide our field going forward, helping us avoid "religious" divisions, seek to understand diverse designs, and embrace integration of models to meet the needs of the populations and teams we serve. (PsycINFO Database Record
Muhammad Ashraf Majrooh
Full Text Available BACKGROUND: Antenatal care is a very important component of maternal health services. It provides the opportunity to learn about risks associated with pregnancy and guides to plan the place of deliveries thereby preventing maternal and infant morbidity and mortality. In 'Pakistan' antenatal services to rural population are being provided through a network of primary health care facilities designated as 'Basic Health Units and Rural Health Centers. Pakistan is a developing country, consisting of four provinces and federally administered areas. Each province is administratively subdivided in to 'Divisions' and 'Districts'. By population 'Punjab' is the largest province of Pakistan having 36 districts. This study was conducted to assess the coverage and quality antenatal care in the primary health care facilities in 'Punjab' province of 'Pakistan'. METHODS: Quantitative and Qualitative methods were used to collect data. Using multistage sampling technique nine out of thirty six districts were selected and 19 primary health care facilities of public sector (seventeen Basic Health Units and two Rural Health Centers were randomly selected from each district. Focus group discussions and in-depth interviews were conducted with clients, providers and health managers. RESULTS: The overall enrollment for antenatal checkup was 55.9% and drop out was 32.9% in subsequent visits. The quality of services regarding assessment, treatment and counseling was extremely poor. The reasons for low coverage and quality were the distant location of facilities, deficiency of facility resources, indifferent attitude and non availability of the staff. Moreover, lack of client awareness about importance of antenatal care and self empowerment for decision making to seek care were also responsible for low coverage. CONCLUSION: The coverage and quality of the antenatal care services in 'Punjab' are extremely compromised. Only half of the expected pregnancies are enrolled and
Full Text Available Abstract Background Since 2000, Israel has had a national program for ongoing monitoring of the quality of the primary care services provided by the country's four competing non-profit health plans. Previous research has demonstrated that quality of care has improved substantially since the program's inception and that the program enjoys wide support among health plan managers. However, prior to this study there were anecdotal and journalistic reports of opposition to the program among primary care physicians engaged in direct service delivery; these raised serious questions about the extent of support among physicians nationally. Goals To assess how Israeli primary care physicians experience and rate health plan efforts to track and improve the quality of care. Method The study population consisted of primary care physicians employed by the health plans who have responsibility for the quality of care of a panel of adult patients. The study team randomly sampled 250 primary-care physicians from each of the four health plans. Of the 1,000 physicians sampled, 884 met the study criteria. Every physician could choose whether to participate in the survey by mail, e-mail, or telephone. The anonymous questionnaire was completed by 605 physicians – 69% of those eligible. The data were weighted to reflect differences in sampling and response rates across health plans. Main findings The vast majority of respondents (87% felt that the monitoring of quality was important and two-thirds (66% felt that the feedback and subsequent remedial interventions improved medical care to a great extent. Almost three-quarters (71% supported continuation of the program in an unqualified manner. The physicians with the most positive attitudes to the program were over age 44, independent contract physicians, and either board-certified in internal medicine or without any board-certification (i.e., residents or general practitioners. At the same time, support for the
Kringos, D.S.; Boerma, W.G.W.
Background: The investment in primary care (PC) reforms to improve the overall performance of health care systems has been substantial in Europe. There is however a lack of up to date comparable information to evaluate the development and strength of PC systems. This EU-funded Primary Health Care A
Eisenberg, John M.
The organization and curricula of internal medicine residencies programs that emphasize primary care are described and compared with traditional residencies in internal medicine. It is noted that primary care residents spend more time in ambulatory care and are allowed more electives in specialties outside of internal medicine. Out-of-hospital…
Maarsingh, O.R.; Dros, J.; Schellevis, F.G.; Weert, H.C. van; Windt, D.A. van der; Riet, G. ter; Horst, H.E. van der
PURPOSE: Although dizzy patients are predominantly seen in primary care, most diagnostic studies on dizziness have been performed among patients in secondary or tertiary care. Our objective was to describe subtypes of dizziness in elderly patients in primary care and to assess contributory causes of
Maarsingh, O.R.; Dros, J.; Schellevis, F.G.; van Weert, H.C.; van der Windt, D.A.; ter Riet, G.; van der Horst, H.E.
PURPOSE Although dizzy patients are predominantly seen in primary care, most diagnostic studies on dizziness have been performed among patients in secondary or tertiary care. Our objective was to describe subtypes of dizziness in elderly patients in primary care and to assess contributory causes of
Dinny H. de Bakker
Full Text Available
Background: Primary care in the Netherlands has a strong international reputation. However, this picture may be qualified in two respects. First of all, the Dutch primary care system is less cohesive than is sometimes suggested. Secondly, there are major challenges in the Dutch system (as is the case with other European health care systems, which have to be resolved in order to maintain and improve primary care. Methods: Description of primary care in the Netherlands based on nationally and internationally published sources. Identification of challenges and trends. Narrative review of the literature.
Results: GPs have a strong position in the Netherlands. Their numbers are relatively low; they have a gatekeeping position, and there is no cost-sharing for GP care (unlike other forms of care. The primary care system as a whole, however, is characterised by weak coherence. Individual primary care disciplines have their own separate modes of funding. Challenges include a growing and changing demand for primary care services, and changes in manpower and organisation, that affect the balance between demand and supply regarding primary care services.
Conclusions: Among the threats to strong primary care are the risk of increasing fragmentation of care, negative side effects of a transformation process from cottage industry to service industry, and reluctance to invest in integrated primary care. An opportunity lies in the consensus among stakeholders that integrated primary care has a future. Technological developments support this, especially the development of electronic patient records.
Montes de Oca M
Full Text Available Maria Montes de Oca,1 Carlos Aguirre,2 Maria Victorina Lopez Varela,3 Maria E Laucho-Contreras,1 Alejandro Casas,2 Filip Surmont4 1Service of Pneumology, Hospital Universitario de Caracas, Facultad de Medicina, Universidad Central de Venezuela, Caracas, Venezuela; 2Colombian Pneumological Foundation, Bogotá, Colombia; 3Universidad de la República, Facultad de Medicina, Hospital Maciel, Montevideo, Uruguay; 4Medical Affairs, AstraZeneca Latin America, Coral Gables, FL, USA Background: COPD, asthma, and asthma–COPD overlap increase health care resource consumption, predominantly because of hospitalization for exacerbations and also increased visits to general practitioners (GPs or specialists. Little information is available regarding this in the primary care setting. Objectives: To describe the prevalence and number of GP and specialist visits for any cause or due to exacerbations in patients with COPD, asthma, and asthma–COPD overlap. Methods: COPD was defined as post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC ratio <0.70; asthma was defined as prior medical diagnosis, wheezing in the last 12 months, or wheezing plus reversibility (post-bronchodilator FEV1 or FVC increase ≥200 mL and ≥12%; asthma–COPD overlap was defined as post-bronchodilator FEV1/FVC <0.70 plus prior asthma diagnosis. Health care utilization was evaluated as GP and/or specialist visits in the previous year. Results: Among the 1,743 individuals who completed the questionnaire, 1,540 performed acceptable spirometry. COPD patients had a higher prevalence of any medical visits to any physician versus those without COPD (37.2% vs 21.8%, respectively and exacerbations doubled the number of visits. The prevalence of any medical visits to any physician was also higher in asthma patients versus those without asthma (wheezing: 47.2% vs 22.7%; medical diagnosis: 54.6% vs 21.6%; wheezing plus reversibility: 46.2% vs 23.8%, respectively
Carmel, Amanda S; Steel, Peter; Tanouye, Robert; Novikov, Aleksey; Clark, Sunday; Sinha, Sanjai; Tung, Judy
Hospital admissions from the emergency department (ED) now account for approximately 50% of all admissions. Some patients admitted from the ED may not require inpatient care if outpatient care could be optimized. However, access to primary care especially immediately after ED discharge is challenging. Studies have not addressed the extent to which hospital admissions from the ED may be averted with access to rapid (next business day) primary care follow-up. We evaluated the impact of an ED-to-rapid-primary-care protocol on avoidance of hospitalizations in a large, urban medical center. We conducted a retrospective review of patients referred from the ED to primary care (Weill Cornell Internal Medicine Associates - WCIMA) through a rapid-access-to-primary-care program developed at New York-Presbyterian / Weill Cornell Medical Center. Referrals were classified as either an avoided admission or not, and classifications were performed by both emergency physician (EP) and internal medicine physician reviewers. We also collected outcome data on rapid visit completion, ED revisits, hospitalizations and primary care engagement. EPs classified 26 (16%) of referrals for rapid primary care follow-up as avoided admissions. Of the 162 patients referred for rapid follow-up, 118 (73%) arrived for their rapid appointment. There were no differences in rates of ED revisits or subsequent hospitalizations between those who attended the rapid follow-up and those who did not attend. Patients who attended the rapid appointment were significantly more likely to attend at least one subsequent appointment at WCIMA during the six months after the index ED visit [N=55 (47%) vs. N=8 (18%), P=0.001]. A rapid-ED-to-primary-care-access program may allow EPs to avoid admitting patients to the hospital without risking ED revisits or subsequent hospitalizations. This protocol has the potential to save costs over time. A program such as this can also provide a safe and reliable ED discharge option
Laing, Brian Yoshio; Ward, Lisa; Yeh, Thomas; Chen, Ellen; Bodenheimer, Thomas
The 15-minute office visit to primary care clinicians cannot meet the health care needs of patients. Innovation is needed to address this limitation, but practice redesign is challenging in clinical settings. Here we describe the implementation of a practice innovation, the teamlet model, in a San Francisco safety-net clinic. The teamlet consists of a clinician and "health coach" who expand the traditional medical visit into previsit, visit, postvisit, and between-visit care. Teamlet implementation is occurring in phases. Phase 1 is evaluated using plan-do-study-act improvement cycles and interviews with a few patients, clinicians, and coaches. Phase 2 is evaluated using a pre- and postevent questionnaire, focused interviews, and focus groups with patients, faculty, clinicians, and coaches. Phase 1: Plan-do-study-act cycles generate ideas to improve implementation. Phase 2 evaluation will query demographics, satisfaction, knowledge of self-management support, access, teamwork, and benefits/challenges of the teamlet model. Future research would measure objective clinical outcomes. Phase 1 of the teamlet project led to useful adaptations, with anecdotal evidence that patients and clinicians were satisfied overall with practice improvements. Logistic problems made implementation of the innovation challenging. Phase 2 is currently underway, with results expected in 2008. Primary care innovation requires multiple perspectives and constant revision. Traditional randomized controlled trials and quantitative evaluation designs are not appropriate for assessing practice-improvement pilot projects because projects must change and develop in their early stages. Despite numerous challenges, the teamlet practice redesign has the potential for improving on the traditional 15-minute physician's office visit.
Wrenn, Katherine; Catschegn, Sereina; Cruz, Marisa; Gleason, Nathaniel; Gonzales, Ralph
Introduction Electronic consultations (eConsults) increase access to specialty care, but little is known about the types of questions primary care providers (PCPs) ask through eConsults, and how they respond to specialist recommendations. Methods This is a retrospective descriptive analysis of the first 200 eConsults completed in the UCSF eConsult program. Participating PCPs were from eight adult primary care sites at the University of California, San Francisco (UCSF), USA. Medicine subspecialties participating were Cardiology, Endocrinology, Gastroenterology/hepatology, Hematology, Infectious diseases, Nephrology, Pulmonary medicine, Rheumatology, and Sleep medicine. We categorized eConsult questions into "diagnosis," "treatment," and/or "monitoring." We performed medical record reviews to determine the percentage of specialist recommendations PCPs implemented, and the proportion of patients with a specialist visit in the same specialty as the eConsult, emergency department visit, or hospital admission during the subsequent six months. Results PCP questions related to diagnosis in 71% of cases, treatment in 46%, and monitoring in 21%. Specialist responses related to diagnosis in 76% of cases, treatment in 64%, and monitoring in 40%. PCPs ordered 79% of all recommended laboratory tests, 86% of recommended imaging tests and procedures, 65% of recommended new medications, and 73% of recommended medication changes. In the six months after the eConsult, 14% of patients had a specialist visit within the UCSF system in the same specialty as the eConsult. Discussion eConsults provide guidance to PCPs across the spectrum of patient care. PCPs implement specialists' recommendations in the large majority of cases, and few patients subsequently require in-person specialty care related to the reason for the eConsult.
Sundler, Annelie J; Höglander, Jessica; Eklund, Jakob Håkansson; Eide, Hilde; Holmström, Inger K
This study aims to a) explore to what extent older persons express emotional cues and concerns during home care visits; b) describe what cues and concerns these older persons expressed, and c) explore who initiated these cues and concerns. A descriptive and cross-sectional study was conducted. Data consisted of 188 audio recorded home care visits with older persons and registered nurses or nurse assistants, coded with the Verona coding definitions on emotional sequences (VR-CoDES). Emotional expressions of cues and concerns occurred in 95 (51%) of the 188 recorded home care visits. Most frequent were implicit expressions of cues (n=292) rather than explicit concerns (n=24). Utterances with hints to hidden concerns (63,9%, n=202) were most prevalent, followed by vague or unspecific expressions of emotional worries (15,8%, n=50). Most of these were elicited by the nursing staff (63%, n=200). Emotional needs expressed by the older persons receiving home care were mainly communicated implicitly. To be attentive to such vaguely expressed emotions may demand nursing staff to be sensitive and open. The VR-CoDES can be applied on audio recorded home care visits to analyse verbal and emotional communication, and may allow comparative research. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Isabel Cristina Ramos Vieira Santos
Full Text Available This study aimed to describe the treatment of patients with wounds in the Primary Health Care. A descriptive research with quantitative approach. Ninety-three Family Health Units of the city of Recife-PE, Brazil, were selected, and 112 nurses were interviewed from July to December 2011. The record book of bandages and procedures and the dressing form were used as an additional source of data. Frequencies, measures of central tendency and dispersion, prevalence and, for continuous variables, the analysis of variance were estimated. The prevalence of patients with wounds was 1.9% of the estimated covered population. Vascular ulcers accounted for 74.1% of the treated wounds. The dressing was predominantly performed by Nursing technicians, and the products available for this procedure did not match the current technological development.
Dahrouge, Simone; Hogg, William; Younger, Jaime; Muggah, Elizabeth; Russell, Grant; Glazier, Richard H
The purpose of this study was to determine the relationship between the number of patients under a primary care physician's care (panel size) and primary care quality indicators. We conducted a cross-sectional, population-based study of fee-for-service and capitated interprofessional and non-interprofessional primary health care practices in Ontario, Canada between April 2008 and March 2010, encompassing 4,195 physicians with panel sizes ≥1,200 serving 8.3 million patients. Data was extracted from multiple linked, health-related administrative databases and covered 16 quality indicators spanning 5 dimensions of care: access, continuity, comprehensiveness, and evidence-based indicators of cancer screening and chronic disease management. The likelihood of being up-to-date on cervical, colorectal, and breast cancer screening showed relative decreases of 7.9% (P indicators (4 medication-based and 4 screening-based) showed no significant association with panel size. The likelihood of individuals with a new diagnosis of congestive heart failure having an echocardiogram, however, increased by a relative 8.1% (P hospitalization rates for ambulatory-care-sensitive conditions (P = .04) and a 10.8% decrease in non-urgent emergency department visits (P = .004). Continuity was highest with medium panel sizes (P management or access indicators. We found no panel size threshold above which quality of care suffered. © 2016 Annals of Family Medicine, Inc.
Trojahn, Melina Maria; Ruschel, Karen Brasil; Nogueira de Souza, Emiliane; Mussi, Cláudia Motta; Naomi Hirakata, Vânia; Nogueira Mello Lopes, Alexandra; Rabelo-Silva, Eneida Rejane
This study aimed to examine the predictors of better self-care behavior in patients with heart failure (HF) in a home visiting program. This is a longitudinal study nested in a randomized controlled trial (ISRCTN01213862) in which the home-based educational intervention consisted of a six-month followup that included four home visits by a nurse, interspersed with four telephone calls. The self-care score was measured at baseline and at six months using the Brazilian version of the European Heart Failure Self-Care Behaviour Scale. The associations included eight variables: age, sex, schooling, having received the intervention, social support, income, comorbidities, and symptom severity. A simple linear regression model was developed using significant variables (P ≤ 0.20), followed by a multivariate model to determine the predictors of better self-care. One hundred eighty-eight patients completed the study. A better self-care behavior was associated with patients who received intervention (P < 0.001), had more years of schooling (P = 0.016), and had more comorbidities (P = 0.008). Having received the intervention (P < 0.001) and having a greater number of comorbidities (P = 0.038) were predictors of better self-care. In the multivariate regression model, being in the intervention group and having more comorbidities were a predictor of better self-care. PMID:24083023
Davidson, Judith R; Dawson, Samantha; Krsmanovic, Adrijana
Primary care is where many patients with insomnia first ask for professional help. Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended treatment for chronic insomnia. Although CBT-I's efficacy is well established, its effectiveness in real-life primary care has seldom been investigated. We examined the effectiveness of CBT-I as routinely delivered in a Canadian primary care setting. The patients were 70 women and 11 men (mean age = 57.0 years, SD = 12.3); 83% had medical comorbidity. For the first 81 patients who took the six-session group program we compared initial and postprogram sleep diaries, sleep medication use, Insomnia Severity Index (ISI), the Hospital Anxiety and Depression Scale (HADS), and visits to the family physician. Sleep onset latency, wake after sleep onset, total sleep time, sleep efficiency, and ISI scores improved significantly (p sleep medication decreased (p 7). Wait-list data from 42 patients showed minimal sleep and mood improvements with the passage of time. Number of visits to the family physician six months postprogram decreased, although not significantly (p = .108). The CBT-I program was associated with improvement on all sleep and mood measures. Effect sizes were similar to, or larger than, those found in randomized controlled trials, demonstrating the real-world effectiveness of CBT-I in an interdisciplinary primary care setting.
Druss, Benjamin G; Mauer, Barbara J
The historic passage of the Patient Protection and Affordable Care Act in March 2010 offers the potential to address long-standing deficits in quality and integration of services at the interface between behavioral health and primary care. Many of the efforts to reform the care delivery system will come in the form of demonstration projects, which, if successful, will become models for the broader health system. This article reviews two of the programs that might have a particular impact on care on the two sides of that interface: Medicaid and Medicare patient-centered medical home demonstration projects and expansion of a Substance Abuse and Mental Health Services Administration program that colocates primary care services in community mental health settings. The authors provide an overview of key supporting factors, including new financing mechanisms, quality assessment metrics, information technology infrastructure, and technical support, that will be important for ensuring that initiatives achieve their potential for improving care.
Dempsey, Patrick P; Businger, Alexandra C; Whaley, Lauren E; Gagne, Joshua J; Linder, Jeffrey A
Clinicians prescribe antibiotics to over 65% of adults with acute bronchitis despite guidelines stating that antibiotics are not indicated. To identify and understand primary care clinician perceptions about antibiotic prescribing for acute bronchitis, we conducted semi-structured interviews with 13 primary care clinicians in Boston, Massachusetts and used thematic content analysis. All the participants agreed with guidelines that antibiotics are not indicated for acute bronchitis and felt that clinicians other than themselves were responsible for overprescribing. Barriers to guideline adherence included 6 themes: (1) perceived patient demand, which was the main barrier, although some clinicians perceived a recent decrease; (2) lack of accountability for antibiotic prescribing; (3) saving time and money; (4) other clinicians' misconceptions about acute bronchitis; (5) diagnostic uncertainty; and (6) clinician dissatisfaction in failing to meet patient expectations. Strategies to decrease inappropriate antibiotic prescribing included 5 themes: (1) patient educational materials; (2) quality reporting; (3) clinical decision support; (4) use of an over-the-counter prescription pad; and (5) pre-visit triage and education by nurses to prevent visits. Clinicians continued to cite patient demand as the main reason for antibiotic prescribing for acute bronchitis, though some clinicians perceived a recent decrease. Clinicians felt that other clinicians were responsible for inappropriate antibiotic prescribing and that better pre-visit triage by nurses could prevent visits and change patients' expectations.
Tedaldi, Ellen M.; Richardson, James T.; Debes, Rachel; Young, Benjamin; Chmiel, Joan S.; Durham, Marcus D.; Brooks, John T.; Buchacz, Kate
Biannual attendance at medical visits is an established measure of retention in HIV care. We examined factors associated with attending at least 2 clinic visits at least 90 days apart among HIV-infected, antiretroviral therapy (ART)-naive HIV Outpatient Study participants entering care during 2000 to 2011. Of 1441 patients, 85% were retained in care during the first year of observation. Starting ART during the year was the strongest correlate of retention (adjusted odds ratio [aOR] 6.4, 95% confidence interval [CI] 4.4–9.4). After adjusting for starting ART, publicly insured patients (aOR 0.6, 95% CI 0.4–1.0), and patients with baseline CD4 counts <200 cells/mm3 (aOR 0.5, 95% CI 0.3–0.9) or missing CD4 counts (aOR 0.3, 95% CI 0.2–0.6) were less likely to be retained in care. Although most patients had recommended biannual care visits, some ART-naive individuals may require additional interventions to remain in care. Promptly initiating ART may facilitate engagement in care. PMID:24493009
A primary health care approach is essential to contemporary nursing roles such as practice nursing. This paper examines the evolution of primary health care as a global strategy for responding to the social determinants of health. Primary health care roles require knowledge of, and a focus on social determinants of health, particularly the societal factors that allow and perpetuate inequities and disadvantage. They also require a depth and breadth of leadership skills that are responsive to health needs, appropriate in the social and regulatory context, and visionary in balancing both workforce and client needs. The key to succeeding in working with communities and groups under a primary health care umbrella is to balance the big picture of comprehensive primary health care with operational strategies for selective primary health care. The other essential element involves using leadership skills to promote inclusiveness, empowerment and health literacy, and ultimately, better health.
Smith, Michele S
Reviews the book, Integrated Psychological Services in Primary Care edited by William Scott Craig (see record 2016-01850-000). This book opens with an article by the editor, in which he outlines the behavioral health needs of primary care patients and the rationale behind integrating mental health services in primary care settings. Subsequent chapters address basic and practical information for a variety of practice locations, such as Patient Centered Medical Home clinics, the Veteran's Administration medical centers, and primary care settings where the concept of integrated health is new. This is an excellent primer for anyone planning to implement an integrated care program or for those considering moving from an independent practice, agency, or traditional health care/hospital environment into an integrated primary care environment. The authors' writing styles made difficult concepts easy to understand and their knowledge of the utility of integration was evident. (PsycINFO Database Record
Pinnock, Hilary; Ostrem, Anders; Roman Rodriguez, Miguel; Ryan, Dermot; Stallberg, Bjorn; Thomas, Mike; Tsiligianni, Ioanna; Williams, Sian; Yusuf, Osman
Background: Community-based care, underpinned by relevant primary care research, is an important component of the global fight against non-communicable diseases. The International Primary Care Research Group's (IPCRG's) Research Needs Statement identified 145 research questions within five domains (
Thomas, Paul; Graffy, Jonathan; Wallace, Paul; Kirby, Mike
PURPOSE Theory of effective network operation in primary care is underdeveloped. This study aimed to identify how primary care networks can best integrate academic and service initiatives. METHODS We performed a comparative case study of 4 primary care research networks in North London, England, for the years 1998–2002. Indicators were selected to assess changes in (1) research capacity, (2) multidisciplinary collaboration, and (3) research productivity. We compared the profiles of network outcome with descriptions of their contexts and organizational types from a previous evaluation. RESULTS Together, the networks supported 133 viable projects and 30 others; 399 practitioners, managers, and academics participated in the research teams. How the networks organized themselves was influenced by the circumstances in which they were formed. Different ways of organizing were associated with different outcome profiles. Shared projects and learning spaces helped participants to develop trusted relationships. A top-down, hierarchical approach based on institutional alliances and academic expertise attracted more funding and appeared to be stable. The bottom-up, individualistic network with research practices was good at reflecting on practical primary care concerns. Whole-system methods brought together stakeholder contributions from all parts of the system. CONCLUSIONS Networks can help integrate academic research and service development initiatives by facilitating interorganizational interactions and in shared leadership of projects. Researchers and practitioners stand to gain considerably from an integrated approach in both the short and the long term. Success requires agreement about a set of pathways, learning spaces, and feedback mechanisms to harness the insights and efforts of stakeholders throughout the whole system. PMID:16735525
Richards, S H; Pound, P; Dickens, A; Greco, M; Campbell, J L
Background Since 2000, out‐of‐hours primary medical care services in the UK have undergone major changes in the organisation and delivery of services in response to recommendations by the Carson Review and more recently, through the new General Medical Services Contract (GMS2). People calling their general practice in the evening or at weekends are redirected to the out‐of‐hours service which may offer telephone advice, a home visit or a visit to a treatment centre. Little is known about users' experiences under the new arrangements. Aim To explore users' experiences of out‐of‐hours primary medical care. Design of study A qualitative study employing focus groups and telephone interviews. Setting Three out‐of‐hours primary medical care service providers in England. Methods Focus groups and telephone interviews were conducted with 27 recent users of out‐of‐hours services. Results Key areas of concern included the urgency with which cases are handled, and delays when waiting for a call back or home visit. Users felt that providers were reluctant to do home visits. The service was regarded as under‐resourced and frequently misused. Many expressed anxiety about calling, feeling unsure about how appropriate their call was and many were uncertain about how the service operated. Conclusions Service users need clear information on how current out‐of‐hours services operate and how it should be used. Problems with triaging need to be addressed, users should be kept informed of any delays, and care needs to be taken to ensure that the new arrangements do not alienate older people or individuals with complex health needs. PMID:18055893
Healthcare professionals in primary care are gatekeepers to specialist services and are important in terms of ensuring access to community support and appropriate referral for the sizable number of older people with mental health problems. This literature review explores the role of primary care professionals, particularly GPs and practice nurses, in diagnosing and managing patients with dementia. It recommends that education and training are required to raise awareness of the importance of accurate diagnosis and management in primary care.
O'Flynn, Norma; Ridsdale, Leone
Headache is a common presentation in primary care. The classification of headache was overhauled by the International Headache Society (IHS) in 1988, and the past decade has seen rapid growth in the understanding of headache disorders. The IHS places particular importance on precise headache diagnosis. This paper discusses the relevance of such an approach to primary care. A review of the literature revealed a dearth of evidence regarding headache management in primary care settings. The evid...
MURTAUGH, PA; DICKSON, ER; VANDAM, GM; MALINCHOC, M; GRAMBSCH, PM; LANGWORTHY, AL; GIPS, CH
The progression of primary biliary cirrhosis was studied in 312 patients who were seen at the Mayo Clinic between January 1974 and May 1984. Follow-up was extended to April 30, 1988, by which time 140 of the patients had died and 29 had undergone orthotopic liver transplantation. These patients gene
Managing chronic conditions in a South African primary care context: ... is an approach to motivating behaviour change in general health care settings. ... They had mixed experiences with skills for agenda setting and reducing resistance.
Journal of Community Medicine and Primary Health Care. ... of research findings, reviews, theories and information on all aspects of public health. ... health planning and management, health policy, health care financing, public health nutrition, ...
Olivera Cañadas, G; Cañada Dorado, A; Drake Canela, M; Fernández-Martínez, B; Ordóñez León, G; Cimas Ballesteros, M
To identify and describe a list of sentinel events (SEs) for Primary Care (PC). A structured experts' consensus was obtained by using two online questionnaires. The participants were selected because of their expertise in PC and patient safety. The first questionnaire assessed the suitability of the hospital SEs established in the National Quality Forum 2006 for use in PC via responses of "yes", "no", or "yes but with modification". In the latter case, a re-wording of the SE was requested. Additionally, inclusion of new SEs was also allowed. The second questionnaire included those SEs with positive responses ("yes", "yes with modification"), so that the experts could choose between the original and alternative drafts, and evaluate the newly described SEs. The questionnaires were completed by 44 out of a total of the 47 experts asked to participate, and a total of 17 SEs were identified as suitable for PC. For the first questionnaire, 12 of the 28 hospital SEs were considered adaptable to PC, of which 11 were re-drafts. Thirty-seven experts proposed new SEs. These mainly concerned problems with medication and vaccines, delay, or lack of assistance, diagnostic delays, and problems with diagnostic tests, and were finally summarised in 5 SEs. In the second questionnaire, ≥65% of the experts chose the alternative wording against the original cases for the 11 SEs suitable for PC. The 5 newly included SEs were considered adequate with a positive response of 70-85%. Having a list of SEs available in PC will help to improve the management of health care risks. Copyright © 2017 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.
Rifkin, S B; Walt, G
What is the impact of technology on improving the life situations of people, especially the poor? How is this impact analyzed in terms of health improvements? These questions are paramount in the minds of health planners as they pursue national policies of primary health care, a policy popularized by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) and accepted by over 150 governments at Alma Ata in 1978. The purpose of this paper is to explore these questions in depth. It begins by giving the background to the debate, then examines the origins of two concepts which have dominated the field, those of 'primary health care' and 'selective primary health care.' On this basis it suggests areas of differences in the two concepts and discusses the policy and practical implications of confusing the two approaches. The paper suggests that the differences are firstly who controls the outcome of technological interventions and the perceived time frame in which plans can be carried out.
Full Text Available Objective. To develop a primary care assessment tool in Tibetan area and assess the primary care quality among different healthcare settings. Methods. Primary care assessment tool-Tibetan version (PCAT-T was developed to measure seven primary care domains. Data from a cross-sectional survey of 1386 patients was used to conduct validity and reliability analysis of PCAT-T. Analysis of variance was used to conduct comparison of primary care quality among different healthcare settings. Results. A 28-item PCAT-T was constructed which included seven multi-item scales and two single-item scales. All of multi-item scales achieved good internal consistency and item-total correlations. Scaling assumptions tests were well satisfied. The full range of possible scores was observed for all scales, except first contact and continuity. Compared with prefecture hospital (77.42 and county hospital (82.01, township health center achieved highest primary care quality total score (86.64. Conclusions. PCAT-T is a valid and reliable tool to measure patients' experience of primary care in the Tibet Autonomous Region. Township health center has the best primary care performance compared with other healthcare settings, and township health center should play a key role in providing primary care in Tibet.
Full Text Available Background Although the presence of an electronic health record (EHR alone does not ensure high quality, efficient care, few studies have focused on the work of those charged with optimising use of existing EHR functionality.Objective To examine the approaches used and challenges perceived by analysts supporting the optimisation of primary care teams’ EHR use at a large U.S. academic health care system.Methods A qualitative study was conducted. Optimisation analysts and their supervisor were interviewed and data were analysed for themes.Results Analysts needed to reconcile the tension created by organisational mandates focused on the standardisation of EHR processes with the primary care teams’ demand for EHR customisation. They gained an understanding of health information technology (HIT leadership’s and primary care team’s goals through attending meetings, reading meeting minutes and visiting with clinical teams. Within what was organisationally possible, EHR education could then be tailored to fit team needs. Major challenges were related to organisational attempts to standardise EHR use despite varied clinic contexts, personnel readiness and technical issues with the EHR platform. Forcing standardisation upon clinical needs that current EHR functionality could not satisfy was difficult.Conclusions Dedicated optimisation analysts can add value to health systems through playing a mediating role between HIT leadership and care teams. Our findings imply that EHR optimisation should be performed with an in-depth understanding of the workflow, cognitive and interactional activities in primary care.
In the current situation, an integrated health care system with primary eye care promoted by government of India is apparently the best answer. This model is both cost effective and practical for the prevention and control of blindness among the underprivileged population. Other models functioning with the newer technology of tele-ophthalmology or mobile clinics also add to the positive outcome in providing primary eye care services. This review highlights the strengths and weaknesses of various models presently functioning in the country with the idea of providing useful inputs for eye care providers and enabling them to identify and adopt an appropriate model for primary eye care services.
Pim P. Valentijn
Full Text Available Introduction: Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care.Methods: The search method involved a combination of electronic database searches, hand searches of reference lists (snowball method and contacting researchers in the field. The process of synthesizing the literature was iterative, to relate the concepts of primary care and integrated care. First, we identified the general principles of primary care and integrated care. Second, we connected the dimensions of integrated care and the principles of primary care. Finally, to improve content validity we held several meetings with researchers in the field to develop and refine our conceptual framework.Results: The conceptual framework combines the functions of primary care with the dimensions of integrated care. Person-focused and population-based care serve as guiding principles for achieving integration across the care continuum. Integration plays complementary roles on the micro (clinical integration, meso (professional and organisational integration and macro (system integration level. Functional and normative integration ensure connectivity between the levels.Discussion: The presented conceptual framework is a first step to achieve a better understanding of the inter-relationships among the dimensions of integrated care from a primary care perspective.
Katya Masae Kitajima Borges
Full Text Available A maioria dos hospitais estabelece idade mínima de 12 anos para a entrada de crianças nas unidades de terapia intensiva de adultos, porém, crianças menores participativas do processo de hospitalização têm manifestado, por meio de seus familiares, o desejo de visitar seus entes hospitalizados. Essa situação suscita diferentes opiniões entre os membros da equipe de saúde, principalmente no que diz respeito a pouca orientação sobre como manejar a entrada de criança na unidade de terapia intensiva sem causar danos psicológicos. Com objetivo de ampliar e fundamentar essa prática realizou-se revisão bibliográfica sobre o tema, alinhada ao estudo das fases do desenvolvimento cognitivo e emocional da criança em relação à compreensão da morte para, em seguida, sugerir proposta para rotina de entrada de crianças em unidade de terapia intensiva adulto.Most hospitals only allow children above 12 years-old to visit adult intensive care unit patients. However, younger children participating in the hospitalization process manifest, through their family members, their willingness to visit their hospitalized relatives. This raises different health care team members' opinions on how to manage their visits to the intensive care unit and prevent psychological harm. Aiming to expand and support this practice, a literature review was conducted, and the children's cognitive and emotional development phases related to understanding of death studied. From this, a routine for children's visits to adult intensive care unit is proposed.
Martins, Leonardo Fernandes; Laport, Tamires Jordão; Menezes, Vinicius de Paula; Medeiros, Priscila Bonfante; Ronzani, Telmo Mota
Burnout is characterized by emotional exhaustion, depersonalization and low occupational performance, which may occur among health professionals. This article evaluates burnout among workers in Primary Health Care (PHC) in three small towns in the Zona da Mata Mineira. The study analyzes associations by logistic regression between burnout, socioeconomic, and demographic aspects of work. A total of 149 professionals were selected, 107 of these responded to all questionnaires. To measure burnout, the Maslach Burnout Inventory (MBI) was used and to characterize the professional, a questionnaire assessing three different issues - namely individual and sociodemographic aspects and team area coverage - was used. 101 professionals were classified with positive indication for burnout. The variables present in the backward stepwise logistic regression model positively associated with indicative of burnout were: being younger than the population average (> 29.5 years) and use of drugs, including sedatives, tranquilizers and sleeping pills. The results contribute to the identification of factors associated with burnout and therefore highlight the need for more detailed investigation.
Over the last decade, I have put together a new theory of leadership. This paper describes its four propositions, which are consistent with the research literature but which lead to conclusions that are not commonly held and seldom put into practice. The first proposition is a model describing the territory of leadership that is different from either the Leadership Qualities Framework, 2006 or the Medical Leadership Competency Framework, 2010, both of which have been devised specifically for the NHS (National Health Service). The second proposition concerns the ill-advised attempt of individuals to become expert in all aspects of leadership: complete in themselves. The third suggests how personality and capability are related. The fourth embraces and recommends the notion of complementary differences among leaders. As the NHS seeks increasing leadership effectiveness, these propositions may need to be considered and their implications woven into the fabric of NHS leader selection and development. Primary Health Care research, like all fields of collective human endeavour, is eminently in need of sound leadership and the same principles that facilitate sound leadership in other fields is likely to be relevant to research teams.
Dowrick, Christopher; Kokanovic, Renata; Hegarty, Kelsey; Griffiths, Frances; Gunn, Jane
Resilience refers to the capacity for successful adaptation or change in the face of adversity. This concept has rarely been applied to the study of distress and depression. We propose two key elements of resilience - ordinary magic and personal medicine - which enable people to survive and flourish despite current experience of emotional distress. We investigate the extent to which these elements are considered important by a sample of 100 people, drawn from a longitudinal study of the management of depression in primary care in Victoria, Australia. We also assess how respondents rate personal resilience in comparison with help received from professional sources. Our data are obtained from semi-structured telephone interviews, and analysed inductively through refinement of our theoretical framework. We find substantial evidence of resilience both in terms of ordinary magic - drawing on existing social support and affectional bonds; and in terms of personal medicine - building on personal strengths and expanding positive emotions. There is a strong preference for personal over professional approaches to dealing with mental health problems. We conclude that personal resilience is important in the minds of our respondents, and that these elements should be actively considered in future research involving people with experience of mental health problems.
Chapel, Helen; Prevot, Johan; Gaspar, Hubert Bobby; Español, Teresa; Bonilla, Francisco A.; Solis, Leire; Drabwell, Josina
Primary immune deficiencies (PIDs) are a growing group of over 230 different disorders caused by ineffective, absent or an increasing number of gain of function mutations in immune components, mainly cells and proteins. Once recognized, these rare disorders are treatable and in some cases curable. Otherwise untreated PIDs are often chronic, serious, or even fatal. The diagnosis of PIDs can be difficult due to lack of awareness or facilities for diagnosis, and management of PIDs is complex. This document was prepared by a worldwide multi-disciplinary team of specialists; it aims to set out comprehensive principles of care for PIDs. These include the role of specialized centers, the importance of registries, the need for multinational research, the role of patient organizations, management and treatment options, the requirement for sustained access to all treatments including immunoglobulin therapies and hematopoietic stem cell transplantation, important considerations for developing countries and suggestions for implementation. A range of healthcare policies and services have to be put into place by government agencies and healthcare providers, to ensure that PID patients worldwide have access to appropriate and sustainable medical and support services. PMID:25566243
Full Text Available Primary Immune Deficiencies (PIDs are a growing group of over 230 different disorders caused by ineffective, absent or an increasing number of gain of function mutations in immune components (mainly cells and proteins. Once recognised, these rare disorders are treatable and in some cases curable. Otherwise untreated PIDs are often chronic, serious or even fatal. The diagnosis of PIDs can be difficult due to lack of awareness and facilities for diagnosis, and management of PIDs is complex. This document was prepared by a worldwide multi-disciplinary team of specialists; it aims to set out comprehensive principles of care for PIDs. These include the role of specialised centres, the importance of registries, the need for multinational research, the role of patient organisations, management and treatment options, the requirement for sustained access to all treatments including immunoglobulin (Ig therapies and HSCT, important considerations for developing countries and suggestions for implementation. A range of healthcare policies and services have to be put into place by government agencies and healthcare providers, to ensure that PID patients world-wide have access to appropriate and sustainable medical and support services.
The concept of primary care in the Kupat Holim Health Insurance Institution encompasses all the stages of health: the promotion of health, personal preventive care, curative care, and rehabilitation in the community. Primary care is, thus, the foundation of this nationwide comprehensive health insurance and health care delivery system; Kupat Holim covers 3.2 million people, close to 80 percent of Israel's total population in 1983. Primary care clinics in the community are the main focus of care and have undergone changes in the types of health care providers and functions as population characteristics change. In this system, the planning process allows constant review of changing needs and demands and the introduction of new functions. The main approaches to planning primary care that are presented deal with team members and the division of work in the community clinic, manpower training at undergraduate and postgraduate levels, and the content of primary care. Current trends include the extension of services provided to the patient in his home as well as the clinic and greater emphasis on preventive care. The interrelationship between policy and planning for primary care is strengthened by the linkage between financer, provider, and consumer in Kupat Holim. The planning process must make optimal use of this linkage to guide those responsible for health policy in implementing effective change.
Wong, Edwin S; Maciejewski, Matthew L; Hebert, Paul L; Batten, Adam; Nelson, Karin M; Fihn, Stephan D; Liu, Chuan-Fen
Massachusetts Health Reform (MHR), implemented in 2006, introduced new health insurance options that may have prompted some veterans already enrolled in the Veterans Affairs Healthcare System (VA) to reduce their reliance on VA health services. This study examined whether MHR was associated with changes in VA primary care (PC) use. Using VA administrative data, we identified 147,836 veterans residing in Massachusetts and neighboring New England (NE) states from October 2004 to September 2008. We applied difference-in-difference methods to compare pre-post changes in PC use among Massachusetts and other NE veterans. Among veterans not enrolled in Medicare, VA PC use was not significantly different following MHR for Massachusetts veterans relative to other NE veterans. Among VA-Medicare dual enrollees, MHR was associated with an increase of 24.5 PC visits per 1,000 veterans per quarter (p = .048). Despite new non-VA health options through MHR, VA enrollees continued to rely on VA PC. © The Author(s) 2016.
Iman Y. Alotaby
Aug 9, 2012 ... A self- administered questionnaire was used for data collection. Results: Barriers ... spite frequent visits to the health care centers, to disclose their experience of IPV .... domain dealing with the victim herself showed similar patterns ... Guidelines recommended that all adolescent and adult patients should be ...
Boerma, Wienke GW; Murante, Anna M; Sixma, Herman JM; Schellevis, François G; Groenewegen, Peter P
Abstract Objective To investigate patients’ perceptions of improvement potential in primary care in 34 countries. Methods We did a cross-sectional survey of 69 201 patients who had just visited general practitioners at primary-care facilities. Patients rated five features of person-focused primary care – accessibility/availability, continuity, comprehensiveness, patient involvement and doctor–patient communication. One tenth of the patients ranked the importance of each feature on a scale of one to four, and nine tenths of patients scored their experiences of care received. We calculated the potential for improvement by multiplying the proportion of negative patient experiences with the mean importance score in each country. Scores were divided into low, medium and high improvement potential. Pair-wise correlations were made between improvement scores and three dimensions of the structure of primary care – governance, economic conditions and workforce development. Findings In 26 countries, one or more features of primary care had medium or high improvement potentials. Comprehensiveness of care had medium to high improvement potential in 23 of 34 countries. In all countries, doctor–patient communication had low improvement potential. An overall stronger structure of primary care was correlated with a lower potential for improvement of continuity and comprehensiveness of care. In countries with stronger primary care governance patients perceived less potential to improve the continuity of care. Countries with better economic conditions for primary care had less potential for improvement of all features of person-focused care. Conclusion In countries with a stronger primary care structure, patients perceived that primary care had less potential for improvement. PMID:25883409
Lee, Linda; Hillier, Loretta M; Molnar, Frank; Borrie, Michael J
Increasingly, primary care collaborative memory clinics (PCCMCs) are being established to build capacity for person-centred dementia care. This paper reflects on the significance of PCCMCs within the system of care for older adults, supported with data from ongoing evaluation studies. Results highlight timelier access to assessment with a high proportion of patients being managed in primary care within a person-centred approach to care. Enhancing primary care capacity for dementia care with interprofessional and collaborative care will strengthen the system's ability to respond to increasing demands for service and mitigate the growth of wait times to access geriatric specialist assessment.
Hochman, Michael; Asch, Steven M
...; and coordinated care when it must be sought elsewhere.” As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives...
Full Text Available Introduction: The majority of the ICUs applies a restricted visiting policy, despite the fact that numerous research data support the beneficial impact of a flexible or an open visiting policy for the patients and their families. Aim: The aim of the present study was to explore the perceptions of the ICU nursing staff regarding the implementation of a flexible or an open visiting policy, as well as the impact of these perception on the patients, their families and the nurses themselves. Material – Method: The studied sample consisted of 105 nurses working in the ICUs of five Hospitals of Athens, Greece. The data collection was conducted through the use of a questionnaire, which included the demographic and professional data and questions regarding the nurses’ perceptions in relation to the types of visitation as well as their benefits or not for the patients, their families and the working conditions of the nursing staff. The statistical analysis was performed by the statistical package SPSS, ver. 17.Results: 90.5% of the studied sample was working in an ICU with a restricted type visitation policy and 57.2% was against changing the existing policy, though the participants did not appear to be totally against a flexible policy. There was no statistical correlation between the gender and the nurses’ perception. Working position, educational level and the years of working experience showed statistically significant correlation. Nurses with higher educational level and more experience had recognized the beneficial impact of visitation on patient and were in favor of the implementation of a more flexible policy, recognizing the increased satisfaction of the patients, their families and themselves. However, they are opposed letting the patients themselves or their families decide on the type of visitation to be implemented.Conclusions: The type of visitation in the ICUs affects the patients, their families and the nursing staff of the ICUs. The
Caban-Martinez, Alberto J; Davila, Evelyn P; Lam, Byron L; Arheart, Kristopher L; McCollister, Kathryn E; Fernandez, Cristina A; Ocasio, Manuel A; Lee, David J
Research has suggested that adults 40 years old and over are not following eye care visit recommendations. In the United States, the proportion of older adults is expected to increase drastically in the coming years. This has important implications for population ocular disease burden, given the relationship between older age and the development of many ocular diseases and conditions. Understanding individual level determinants of vision health could support the development of tailored vision health campaigns and interventions among our growing older population. Thus, we assessed correlates of eye care visits among participants of the Behavior Risk Factor Surveillance System (BRFSS) survey. We pooled and analyzed 2006-2009 BRFSS data from 16 States (N = 118,075). We assessed for the proportion of survey respondents 40 years of age and older reporting having visited an eye care provider within the past two years, two or more years ago, or never by socio-demographic characteristics. Nearly 80% of respondents reported an eye care visit within the previous two years. Using the 'never visits' as the referent category, the groups with greater odds of having an ocular visit within the past two years included those: greater than 70 years of age (OR = 6.8 [95% confidence interval = 3.7-12.6]), with college degree (5.2[3.0-8.8]), reporting an eye disease, (4.74[1.1-21.2]), diagnosed with diabetes (3.5[1.7-7.5]), of female gender (2.9[2.1-3.9]), with general health insurance (2.7[1.8-3.9]), with eye provider insurance coverage (2.1[1.5-3.0]), with high blood pressure (1.5[1.1-2.2]), and with moderate to extreme near vision difficulties (1.42[1.11-2.08]). We found significant variation by socio-demographic characteristics and some variation in state-level estimates in this study. The present findings suggest that there remains compliance gaps of screening guidelines among select socio-demographic sub-groups, as well as provide evidence and support to the CDC
Mold, James W
This seventh annual practice-based research theme issue of the Journal of the American Board of Family Medicine highlights primary care research conducted in practice-based research networks (PBRNs). The issue includes discussion of (1) theoretical and methodological research, (2) health care research (studies addressing primary care processes), (3) clinical research (studies addressing the impact of primary care on patients), and (4) health systems research (studies of health system issues impacting primary care including the quality improvement process). We had a noticeable increase in submissions from PBRN collaborations, that is, studies that involved multiple networks. As PBRNs cooperate to recruit larger and more diverse patient samples, greater generalizability and applicability of findings lead to improved primary care processes.
Full Text Available Purpose: The purpose of this study was to implement a continuous quality improvement project aimed at improving primary care provider recognition of depression. Materials and Methods: A randomized, blinded, pre- and post-test design was implemented with 92 adults attending an academic internal medicine clinic. Subjects were assigned to an intervention where healthcare technicians (HCT trained in the fundamentals of diabetes education delivered brief probing questions about self-care behavior and tailored talking points to encourage patients to talk to their primary care physician about their emotional health. The control group received a sham intervention that included only information on standards of diabetes care. Measures included both a paper-and-pencil screening of depression and the Primary Healthcare Questionnaire-8 (PHQ-8. Outcomes were evaluated for antidepressant and/or counseling treatment modalities once the possibility of depression was identified. Results: Both the control and intervention groups improved from pre-test to 3-month post-test scores on the PHQ-8 in clinically significant ways, but continued to have moderate to severe depression symptoms. There was a significant likelihood of receiving antidepressant therapy and/or counseling in those who scored high on the PHQ-8. Conclusion: HCT can be trained to talk to patients about emotional health issues during routine primary care visits. Depression screening measures can be administered as part of the triage routine at the start of a primary care visit, along with tasks such as vital signs. Answering a screening measure can help create awareness of symptoms and feelings that can prompt discussion during the patient-provider encounter that can result in the diagnosis and treatment of depression.
Full Text Available Abstract Background A strong and self confident primary care workforce can deliver the highest quality care and outcomes equitably and cost effectively. To meet the increasing demands being made of it, primary care needs its own thriving research culture and knowledge base. Methods Review of recent developments supporting primary care clinical research. Results Primary care research has benefited from a small group of passionate leaders and significant investment in recent decades in some countries. Emerging from this has been innovation in research design and focus, although less is known of the effect on research output. Conclusion Primary care research is now well placed to lead a broad re-vitalisation of academic medicine, answering questions of relevance to practitioners, patients, communities and Government. Key areas for future primary care research leaders to focus on include exposing undergraduates early to primary care research, integrating this early exposure with doctoral and postdoctoral research career support, further expanding cross disciplinary approaches, and developing useful measures of output for future primary care research investment.
Full Text Available Jesús Favela,1 Luis A Castro,2 Francisco Franco-Marina,3 Sergio Sánchez-García,4 Teresa Juárez-Cedillo,4 Claudia Espinel Bermudez,4 Julia Mora-Altamirano,4 Marcela D Rodriguez,5 Carmen García-Peña41Center for Scientific Research and Higher Education of Ensenada, Ensenada, Baja California, Mexico; 2Sonora Institute of Technology, Ciudad Obregon, Mexico; 3National Institute of Respiratory Diseases, Mexican Ministry of Health, Mexico City, Mexico; 4Epidemiologic and Health Service Research Unit, Aging Area, XXI Century National Medical Center, Mexican Institute of Social Security, Mexico City, Mexico; 5School of Engineering, MyDCI, Autonomous University of Baja California, Mexicali, MexicoObjective: To assess whether an intervention based on nurse home visits including alert buttons (NV+AB is effective in reducing frailty compared to nurse home visits alone (NV-only and usual care (control group for older adults.Design: Unblinded, randomized, controlled trial.Setting: Insured population covered by the Mexican Social Security Institute living in the city of Ensenada, Baja California, Mexico.Participants: Patients were aged over 60 years with a frailty index score higher than 0.14.Intervention: After screening and informed consent, participants were allocated randomly to the control, NV+AB, or NV-only groups.Measurements: The primary outcome was the frailty score 9 months later. Quality of life, depression, comorbidities, health status, and health service utilization were also considered.Results: The framing sample included 819 patients. Of those, 591 were not located because they did not have a landline/telephone (341 patients, they had died (107, they were ill (50, or they were not currently living in the city (28. A screening interview was applied to 228 participants, and 57 had a score ≤0.14, 171 had ≥0.14, and 16 refused to complete the baseline questionnaire. A home visit was scheduled for 155 patients. However, 22 did not complete
Hegarty, Kelsey; Tarzia, Laura; Hooker, Leesa; Taft, Angela
Experiences of domestic and sexual violence are common in patients attending primary care. Most often they are not identified due to barriers to asking by health practitioners and disclosure by patients. Women are more likely than men to experience such violence and present with mental and physical health symptoms to health practitioners. If identified through screening or case finding as experiencing violence they need to be supported to recover from these traumas. This paper draws on systematic reviews published in 2013-2015 and a further literature search undertaken to identify recent intervention studies relevant to recovery from domestic and sexual violence in primary care. There is limited evidence as to what interventions in primary care assist with recovery from domestic violence; however, they can be categorized into the following areas: first line response and referral, psychological treatments, safety planning and advocacy, including through home visitation and peer support programmes, and parenting and mother-child interventions. Sexual violence interventions usually include trauma informed care and models to support recovery. The most promising results have been from nurse home visiting advocacy programmes, mother-child psychotherapeutic interventions, and specific psychological treatments (Cognitive Behaviour Therapy, Trauma informed Cognitive Behaviour Therapy and, for sexual assault, Exposure and Eye Movement Desensitization and Reprocessing Interventions). Holistic healing models have not been formally tested by randomized controlled trials, but show some promise. Further research into what supports women and their children on their trajectory of recovery from domestic and sexual violence is urgently needed.
Shrank, William H
Americans are increasingly demanding the same level of service in healthcare that they receive in other services and products that they buy. This rise in consumerism poses challenges for primary care physicians as they attempt to transform their practices to succeed in a value-based reimbursement landscape, where they are rewarded for managing costs and improving the health of populations. In this paper, three examples of consumer-riven trends are described: retail healthcare, direct and concierge care, and home-based diagnostics and care. For each, the intersection of consumer-driven care and the goals of value-based primary care are explored. If the correct payment and connectivity enablers are in place, some examples of consumer-driven care are well-positioned to support primary care physicians in their mission to deliver high-quality, efficient care for the populations they serve. However, concerns about access and equity make other trends less consistent with that mission.
Sibbald, B.; Laurant, M.G.H.; Reeves, D.
Nurses increasingly work as substitutes for, or to complement, general practitioners in the care of minor illness and the management of chronic diseases. Available research suggests that nurses can provide as high quality care as GPs in the provision of first contact and ongoing care for unselected
Sibbald, B.; Laurant, M.G.H.; Reeves, D.
Nurses increasingly work as substitutes for, or to complement, general practitioners in the care of minor illness and the management of chronic diseases. Available research suggests that nurses can provide as high quality care as GPs in the provision of first contact and ongoing care for unselected
Belhocine, Z; Mahiout, B; Laraba, A; Grangaud, J P
This article reports the experiences of a primary health care unit located in Algeria's Zeralda district in the control of diarrhea. Curative and preventive care is provided to the adult and child populations of the district by a medical and paramedical team. The overall goal of the diarrheal control program, initiated in 1980, is to combat mortality from diarrhea in children under 2 years of age. Intermediate goals include improvement of care provided to infants with diarrhea, early hospitalization of cases of diarrhea, improvement of contacts between the primary care unit and the hospital, and prevention of diarrhea. Children in the target group are located through use of a register of children living in the district, and their families are sent cards containing information on diarrhea and its control. Children are followed from the 1st day of consultation for diarrhea until the 30th day after the episode. Record keeping and careful follow-up are stressed. In 1983, 335 children 18 months of age or younger (47% of the target population) consulted health structures in Zeralda for diarrhea. About 1/3 of children fail to return for follow-up visits. This is attributed both to long waits in the clinic and the fact that children are usually cured by the time of this visit. The number of children hospitalized for acute dehydration has declined from 33 in 1980 to 18 in 1983; the number of deaths from dehydration declined from 16 to 8 in this same period.
Patrizia Gallo MD
Full Text Available Background: Epidemiologic evidences suggest a strong association between low birth weight and some diseases in adult life ( hypertension, diabetes, cardiovascular diseases.Aim of this study was to evaluate the obesity/overweight prevalence in a population of children born small for gestation age, SGA children 400, 208 males and 192 females compared to a population of children born appropriate for gestational age 6818 AGA children, 3502 males and 3316 females, during childhood. Our intention was also to build the natural history of weight gain during prepubertal age in children born SGA and AGA. Design and Methods: Observational prospective longitudinal study. We followed our patients from January2001 up to December 2010; weight, height and body mass index (BMI were evaluated in all the SGA and AGA children. BMI z-score range for defining overweight and obesity was, respectively, 1.13 to 1.7 and >1.7 according to CDC growth charts. Results: In transversal evaluation, we prove that 10-year-old SGA females are twice obese and more overweight compared to equal age AGA females. In longitudinal evaluation, we highlight different observations: SGA children obese at 2 years are still obese at 10 years; the number of obese SGA children increases gradually until the age of 10; AGA children, appear to be less obese than SGA children at 10 years. Conclusion: SGA males and females are more obese at 5 and 10 years compared to the AGA population. Primary care pediatricians, through early detection of the children at risk, can carry out an effective obesity prevention project in SGA children.
Pandhi, Nancy; Yang, Wan-Lin; Karp, Zaher; Young, Alexander; Beasley, John W.; Kraft, Sally; Carayon, Pascale
Background Although the presence of an electronic health record (EHR) alone does not ensure high quality, efficient care, few studies have focused on the work of those charged with optimizing use of existing EHR functionality. Objective To examine the approaches used and challenges perceived by analysts supporting the optimization of primary care teams’ EHR use at a large U.S. academic healthcare system. Methods A qualitative study was conducted. Optimization analysts and their supervisor were interviewed and data was analyzed for themes. Results Analysts needed to reconcile the tension created by organizational mandates focused on the standardization of EHR processes with the primary care teams’ demand for EHR customization. They gained an understanding of health information technology (HIT) leadership’s and primary care team’s goals through attending meetings, reading meeting minutes, and visiting with clinical teams. Within what was organizationally possible, EHR education could then be tailored to fit team needs. Major challenges were related to organizational attempts to standardize EHR use despite varied clinic contexts, personnel readiness, and technical issues with the EHR platform. Forcing standardization upon clinical needs that current EHR functionality could not satisfy was difficult. Conclusions Dedicated optimization analysts can add value to health systems through playing a mediating role between HIT leadership and care teams. Our findings imply that EHR optimization should be performed with an in-depth understanding of the workflow, cognitive, and interactional activities in primary care. PMID:25207618
Rolnick, S J; Jackson, J M; DeFor, T A; Flottemesch, T J
The study objectives were twofold: 1. To examine how an intervention to apply fluoride varnish (FV) in a primary health setting to all young, low-income children was implemented and sustained and 2. To assess the feasibility of tracking medical care utilization in this population. The study included children age 1-5, insured through a government program, seen (7/1/2010-4/30/2012). Data on age, race, sex, clinic encounter, eligibility for and receipt of FV was obtained. The level of data in primary care, specialty care, urgent care and hospitalizations to assess feasibility of future patient tracking was also acquired.. Of 12,067 children, 85% received FV. Differences were found by age (youngest had highest rates). Small differences by race (81%-88%, highest in Blacks.) was found. No differences were found by sex. Ability to track over time was mixed. Approximately 50% had comprehensive data. However, primary care visit and hospitalization data was available on a larger percentage. FV programs can be introduced in the primary care setting and sustained. Further, long-term follow up is possible. Future study of such cohorts capturing health and cost benefits of oral health prevention efforts is needed.
Warman, Karen; Silver, Ellen
To examine whether a primary care-based asthma program that applies the Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-2007 criteria to classify asthma severity increases detection of persistent asthma in inner-city children and affects "step of care" compared to routine care. A retrospective chart review was conducted of 97 consecutive children referred to the asthma program from 2011-2013. Asthma severity documented during routine health care maintenance visits was compared to the asthma severity assessed during the asthma program visit using five standardized questions and spirometry. Medication plan "step of care" was compared pre- and post- the asthma program visit. 79 children, ages 5-19 years old (mean = 9.6), had spirometry tracings meeting American Thoracic Society criteria and were included in this study. 53% were male. The majority of children were Latino (45.6%) or African American (35.4%). At the asthma program visit, more children were identified with moderate or severe persistent asthma based upon clinical questions (47.9%), spirometry (56.9%) or combined criteria (75.3%) than had been identified during routine care (15.2%); all p asthma program visit, more children were prescribed controller medications (82.3% vs 63.3%; p children, asthma severity was under-recognized and undertreated during routine care. A primary care based asthma program, which formalized applying EPR-3 criteria, increased detection of persistent asthma and led to "step-ups" in treatment plans.
Full Text Available Problem statement: Health care delivery in Germany is highly fragmented, resulting in poor vertical and horizontal integration and a system that is focused on curing acute illness or single diseases instead of managing patients with more complex or chronic conditions, or managing the health of determined populations. While it is now widely accepted that a strong primary care system can help improve coordination and responsiveness in health care, primary care has so far not played this role in the German system. Primary care physicians traditionally do not have a gatekeeper function; patients can freely choose and directly access both primary and secondary care providers, making coordination and cooperation within and across sectors difficult. Description of policy development: Since 2000, driven by the political leadership and initiative of the Federal Ministry of Health, the German Bundestag has passed several laws enabling new forms of care aimed to improve care coordination and to strengthen primary care as a key function in the German health care system. These include on the contractual side integrated care contracts, and on the delivery side disease management programmes, medical care centres, gatekeeping and ‘community medicine nurses’. Conclusion and discussion: Recent policy reforms improved framework conditions for new forms of care. There is a clear commitment by the government and the introduction of selective contracting and financial incentives for stronger cooperation constitute major drivers for change. First evaluations, especially of disease management programmes, indicate that the new forms of care improve coordination and outcomes. Yet the process of strengthening primary care as a lever for better care coordination has only just begun. Future reforms need to address other structural barriers for change such as fragmented funding streams, inadequate payment systems, the lack of standardized IT systems and trans
Poulsen, Erik; Overgaard, Søren; Vestergaard, Jacob T
BACKGROUND: Hip osteoarthritis (OA) is the most common diagnosis in primary care adult patients presenting with hip pain but pain location and pain distribution in primary care patients with hip OA have been reported inadequately. OBJECTIVE: To describe pain location and pain distribution...
Schreiter, Elizabeth A. Zeidler; Pandhi, Nancy; Fondow, Meghan D. M.; Thomas, Chantelle; Vonk, Jantina; Reardon, Claudia L.; Serrano, Neftali
Summary After implementation of an integrated consulting psychiatry model and psychology services within primary care at a federally qualified health center, patients have increased access to needed mental health services, and primary care clinicians receive the support and collaboration needed to meet the psychiatric needs of the population. PMID:24185149
Verbakel, N.J.; Melle, M. van; Langelaan, M.; Verheij, T.J.M.; Wagner, C.; Zwart, D.L.M.
Objective: To explore perceptions of safety culture in nine different types of primary care professions and to study possible differences. Design Cross-sectional survey: Setting: Three hundred and thirteen practices from nine types of primary care profession groups in the Netherlands. Participants:
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.
Oort, M. van; Devillé, W.; Bakker, D. de
In 2000 policymakers decided that primary care for asylum seekers should be organized as it is for Dutch residents. Nurses of the Community Health Services organize selection and referral to primary care. General practitioners have practice in the different Centres of Asylum Seekers or in their own
Oort, M. van; Devillé, W.; Bakker, D. de
In 2000 policymakers decided that primary care for asylum seekers should be organized as it is for Dutch residents. Nurses of the Community Health Services organize selection and referral to primary care. General practitioners have practice in the different Centres of Asylum Seekers or in their own
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.
The primary care psychologist (PCP) in the Netherlands has 30 years of experience. The PCP is a generalist who, in close cooperation with the family physician and other providers of primary health care, has a mindset and manner of working that is largely determined by the context in which the PCP
2NIHR School for Primary Care Research, Centre for Primary Care, Institute of ... patient evaluation of PHC and draw implications for the Nigerian practice setting. Design: A systematic review .... The data analysis that followed the extraction was .... survey. Here the length of the questionnaire and the response pattern were ...
Faber, M.J.; Burgers, J.S.; Westert, G.P.
The Dutch primary care system has drawn international attention, because of its high performance at low cost. Primary care practices are easily accessible during office hours and collaborate in a unique out-of-hours system. After the reforms in 2006, there are no copayments for patients receiving ca
Florentinus, S.R.; Heerdink, R.; Dijk, L. van; Griens, F.A.M.G.; Groenewegen, P.P.; Leufkens, H.G.M
Background: Medical specialists are often seen as the first prescribers of new drugs. However, the extent to which specialists influence new drug prescribing in primary care is largely unknown. Methods: This study estimates the influence of medical specialists on new drug prescribing in primary care
Florentinus, S.R.; Heerdink, E.R.; Dijk, L. van; Griens, F.; Groenewegen, P.P.; Leufkens, H.G.M.
BACKGROUND: Medical specialists are often seen as the first prescribers of new drugs. However, the extent to which specialists influence new drug prescribing in primary care is largely unknown. METHODS: This study estimates the influence of medical specialists on new drug prescribing in primary care
The primary care psychologist (PCP) in the Netherlands has 30 years of experience. The PCP is a generalist who, in close cooperation with the family physician and other providers of primary health care, has a mindset and manner of working that is largely determined by the context in which the PCP wo
Meyer, William J.; Morrison, Patrick; Lombardero, Anayansi; Swingle, Kelsey; Campbell, Duncan G.
Unwillingness to share depression experiences with primary care physicians contributes to the undertreatment of depression. This project examined college students' reasons for depression nondisclosure to primary care providers (PCPs). Undergraduate participants read a vignette describing someone with depression and completed measures of disclosure…
Branch, William T., Jr.; And Others
The problems encountered, diagnostic procedures performed, and treatments prescribed in dermatology were studied in a primary care practice and in a dermatology clinic. It is proposed that the findings of this study be the basis for designing a curriculum in dermatology for residents in primary care medicine. (Author/MLW)
Bakker, D.H. de; Groenewegen, P.P.
Background: Primary care in the Netherlands has a strong international reputation. However, this picture may be qualified in two respects. First of all, the Dutch primary care system is less cohesive than is sometimes suggested. Secondly, there are major challenges in the Dutch system (as is the
In this thesis, the primary aim was to gain insight into management of obstetric emergencies occurring in primary midwifery care in the Netherlands. Secondly, we aimed to develop preventative strategies and tools to optimise care in case of an obstetric emergency. From 2008-2010, a unique dataset of
Mundt, Marlon P.; Agneessens, Filip; Tuan, Wen-Jan; Zakletskaia, Larissa I.; Kamnetz, Sandra A.; Gilchrist, Valerie J.
Background Primary care teams play an important role in providing the best quality of care to patients with diabetes. Little evidence is available on how team communication networks and team climate contribute to high quality diabetes care. Objective To determine whether primary care team communication and team climate are associated with health outcomes, health care utilization, and associated costs for patients with diabetes. Methods A cross-sectional survey of primary care team members collected information on frequency of communication with other care team members about patient care and on team climate. Patient outcomes (glycemic, cholesterol, and blood pressure control, urgent care visits, emergency department visits, hospital visit days, medical costs) in the past 12 months for team diabetes patient panels were extracted from the electronic health record. The data were analyzed using nested (clinic/team/patient) generalized linear mixed modeling. Participants 155 health professionals at 6 U.S. primary care clinics participated from May through December 2013. Results Primary care teams with a greater number of daily face-to-face communication ties among team members were associated with 52% (Rate Ratio=0.48, 95% CI: 0.22, 0.94) fewer hospital days and US$1220 (95% CI: -US$2416, -US$24) lower health-care costs per team diabetes patient in the past 12 months. In contrast, for each additional registered nurse (RN) who reported frequent daily face-to-face communication about patient care with the primary care practitioner (PCP), team diabetes patients had less-controlled HbA1c (Odds Ratio=0.83, 95% CI: 0.66, 0.99), increased hospital days (RR=1.57, 95% CI: 1.10, 2.03), and higher healthcare costs (β=US$877, 95% CI: US$42, US$1713). Shared team vision, a measure of team climate, significantly mediated the relationship between team communication and patient outcomes. Conclusions Primary care teams which relied on frequent daily face-to-face communication among more
Kathryn M. Magruder
Full Text Available Background and Objectives: Research in the last decade has acknowledged that primary care plays a pivotal role in the delivery of mental health services. The aim of this paper is to review major accomplishments, emerging trends, and continuing gaps concerning mental health problems in primary care in North America. Methods: Literature from North America was reviewed and synthesized. Results: Major accomplishments include: the development and adoption of a number of clinical guidelines specifically for mental health conditions in primary care, the acceptance of the chronic care model as a framework for treating depression in primary care, and the clear adoption of pharmacologic approaches as the predominant mode for treating depression and anxiety. Emerging trends include: the use of non-physician facilitators as care managers in the treatment of depression in primary care, increasing use of technology in the assessment and treatment of mental health conditions in primary care, and dissemination and implementation of integrated mental health treatment approaches. Lingering issues include: the difficulty in moving beyond problem identification and initiation of treatment to sustaining evidence-based treatments, agreement on a common metric to evaluate outcomes, and the stigma still associated with mental illness. Conclusion: Though there now exists a solid and growing evidence base for the delivery of mental health services in primary care, there are still significant challenges which must be overcome in order to make further advances.
Max Moura de Oliveira
Full Text Available The scope of this study was to analyze the socio-demographic profile, morbidity and frequency of seeking of adult men enrolled in a Family Doctor Program for health care in Niterói in the State of Rio de Janeiro. It is a cross-sectional study using secondary data, files and records of the first care visit in November 2003 through August 2009. The frequencies of the variables studied and the prevalence rates among those who sought and those who did not seek attention were calculated. Among the 323 men registered, 56% sought attendance. The main reason given for the first visit was a routine appointment. It was observed that 43 men were overweight, 26 were obese and 44 had abnormal blood pressure. The profile of the men who sought and those who did not seek care presented statistically significant differences (p
Eiser, A R; Eiser, B J
The congruence model is a framework used to analyze organizational strengths and weaknesses and pinpoint specific areas for improving effectiveness. This article provides an overview of organizations as open systems, with examples in the primary care arena. It explains and applies the congruence model in the context of primary care issues and functions, including methods by which the model can be used to diagnose organizational problems and generate solutions. Changes needed in primary care due to the managed care environment, and areas of potential problems and sensitivities requiring organizational changes to meet market and regulatory demands now placed on PCOs are examined.
Full Text Available Abstract Background Chronic disease management requires input from multiple health professionals, both specialist and primary care providers. This study sought to assess the impact of co-ordinated multidisciplinary care in primary care, represented by the delivery of formal care planning by primary care teams or shared across primary-secondary teams, on outcomes in stroke, relative to usual care. Methods A Systematic review of Medline, EMBASE, CINAHL (all 1990–2006, Cochrane Library (Issue 1 2006, and grey literature from web based searching of web sites listed in the CCOHA Health Technology Assessment List Analysis used narrative analysis of findings of randomised and non-randomised trials, and observational and qualitative studies of patients with completed stroke in the primary care setting where care planning was undertaken by 1 a multi-disciplinary primary care team or 2 through shared care by primary and secondary providers. Results One thousand and forty-five citations were retrieved. Eighteen papers were included for analysis. Most care planning took part in the context of multidisciplinary team care based in hospitals with outreach to community patients. Mortality rates are not impacted by multidisciplinary care planning. Functional outcomes of the studies were inconsistent. It is uncertain whether the active engagement of GPs and other primary care professionals in the multidisciplinary care planning contributed to the outcomes in the studies showing a positive effect. There may be process benefits from multidisciplinary care planning that includes primary care professionals and GPs. Few studies actually described the tasks and roles GPs fulfilled and whether this matched what was presumed to be provided. Conclusion While multidisciplinary care planning may not unequivocally improve the care of patients with completed stroke, there may be process benefits such as improved task allocation between providers. Further study on the impact
O. A. Shtegman
Full Text Available Aim. To evaluate primary care efficacy in patients with chronic heart failure (CHF.Material and methods. Outpatients (n=139 with CHF and 35 primary care physicians were included into the study. The evaluation of drug therapy and patient awareness of the principles of non-drug CHF treatment were performed. An anonymous survey among doctors in terms of current CHF guidelines knowledge, patient information provided by physicians, and doctors’ burnout status was also carried out.Results. Only 39% and 10% of CHF outpatients received target doses of ACE inhibitors/sartans and beta-blockers, respectively. Majority of CHF outpatients and their doctors need in additional education/training. 56% of primary care physicians demonstrated an emotional burnout.Conclusion. Author considers it essential to distribute short pocket-guidelines on CHF management among primary care physicians, and to reduce the load on primary care physicians with simultaneous strengthening of their performance control.
O. A. Shtegman
Full Text Available Aim. To evaluate primary care efficacy in patients with chronic heart failure (CHF.Material and methods. Outpatients (n=139 with CHF and 35 primary care physicians were included into the study. The evaluation of drug therapy and patient awareness of the principles of non-drug CHF treatment were performed. An anonymous survey among doctors in terms of current CHF guidelines knowledge, patient information provided by physicians, and doctors’ burnout status was also carried out.Results. Only 39% and 10% of CHF outpatients received target doses of ACE inhibitors/sartans and beta-blockers, respectively. Majority of CHF outpatients and their doctors need in additional education/training. 56% of primary care physicians demonstrated an emotional burnout.Conclusion. Author considers it essential to distribute short pocket-guidelines on CHF management among primary care physicians, and to reduce the load on primary care physicians with simultaneous strengthening of their performance control.
Baena-Cañada, José M; Ramírez-Daffós, Patricia; Cortés-Carmona, Cristina; Rosado-Varela, Petra; Nieto-Vera, Juan; Benítez-Rodríguez, Encarnación
Hospitals have traditionally been the place where the follow-up of breast cancer patients occurs in Spain. To describe the evolution of long-term survivors of breast cancer according to type of follow-up received (in primary or specialist/hospital care), measuring impact of care type on health, cost, health-related quality of life (HRQL) and satisfaction results. Retrospective study of cohorts with disease-free patients followed up for at least 5 years in Oncology. Using personal questionnaires, the type and cost of the follow-up, events, HRQL and satisfaction were analysed. Ninety-eight women were surveyed, 60 in primary and 38 in specialist care. There were no differences between groups in diagnosis of metastasis or new primary tumours. The number of annual visits per patient was 0.98 (0.48) in primary and 1.11 (0.38) in specialist care (P = 0.19). In primary, 44.6% were programmed and 55.4% on demand; in specialist, 94.6% were programmed and 5.4% on demand (P = 0.0001). The costs of follow-up in primary care were lower--€112.86 (77.54) versus €184.61 (85.87) per patient and year (P = 0.0001). No differences were reported in HRQL. Preference for specialist care was expressed by 80%, versus 10% for primary, with 10% indifferent. Patients showed greater satisfaction with specialist care in all questionnaire dimensions. Compliance with follow-up protocol was high in both groups. In specialist care nearly all the visits were programmed and in primary almost half were on demand. In our locality, primary is more cost-effective than specialist care, but patients express greater satisfaction with specialist follow-up and hence prefer it.
primary care provider and support staff—a nurse care manager, clinical associate, and administrative clerk. Letter Page 2 GAO-16-328...Health Eligibility Center, VHA central office—VHA’s Health Resource Center, Office of Primary Care, and Access and Clinical Administration Program ...newly enrolled veterans were able to access primary care from the Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA), and others
Marques, Ana Gabriela B; Záchia, Suzana A; Schmidt, Maria Luiza S; Heldt, Elizeth
The aim of the work was to identify characteristics of pregnant women cared for by an obstetric nurse in a visit to the prenatal outpatient nursing service and compare these over the period from 1972 to 2009. Sociodemographic and obstetric data were collected from the forms completed by the pregnant patients during their visit to the nursing service. A total of 1245 forms were analyzed 208 (16.7%) being from the 1970s, 323 (25.9%) from the 1980s, 329 (26.4%) from the 1990s, and 385 (30.0%) from year 2000. A significant difference was found between the previous decades and year 9000 in relation to the greater number of high-risk pregnancies, number of nursing consultations and obstetric ultrasounds performed during the prenatal exam. The characteristics of pregnant women were observed to change over time, as well as the care provided by the obstetric nurse during visits to the outpatient nursing service, remaining associated with the demands of patients and legal resolutions.
Stange, Kurt C; Etz, Rebecca S; Gullett, Heidi; Sweeney, Sarah A; Miller, William L; Jaén, Carlos Roberto; Crabtree, Benjamin F; Nutting, Paul A; Glasgow, Russell E
Metrics focus attention on what is important. Balanced metrics of primary health care inform purpose and aspiration as well as performance. Purpose in primary health care is about improving the health of people and populations in their community contexts. It is informed by metrics that include long-term, meaning- and relationship-focused perspectives. Aspirational uses of metrics inspire evolving insights and iterative improvement, using a collaborative, developmental perspective. Performance metrics assess the complex interactions among primary care tenets of accessibility, a whole-person focus, integration and coordination of care, and ongoing relationships with individuals, families, and communities; primary health care principles of inclusion and equity, a focus on people's needs, multilevel integration of health, collaborative policy dialogue, and stakeholder participation; basic and goal-directed health care, prioritization, development, and multilevel health outcomes. Environments that support reflection, development, and collaborative action are necessary for metrics to advance health and minimize unintended consequences.
Adler, Kenneth G
Background Online Web communication between physician and patient has been proposed by leading primary care organizations as a way to enhance physician-patient communication, but lack of payment for this service has acted as a significant barrier to implementation. Objective This study evaluates current patient readiness and willingness to pay for online services in a fairly typical urban family medicine practice. Methods All patients that visited the author for medical care during a one-mont...
Caban-Martinez Alberto J
Full Text Available Abstract Background Research has suggested that adults 40 years old and over are not following eye care visit recommendations. In the United States, the proportion of older adults is expected to increase drastically in the coming years. This has important implications for population ocular disease burden, given the relationship between older age and the development of many ocular diseases and conditions. Understanding individual level determinants of vision health could support the development of tailored vision health campaigns and interventions among our growing older population. Thus, we assessed correlates of eye care visits among participants of the Behavior Risk Factor Surveillance System (BRFSS survey. We pooled and analyzed 2006–2009 BRFSS data from 16 States (N = 118,075. We assessed for the proportion of survey respondents 40 years of age and older reporting having visited an eye care provider within the past two years, two or more years ago, or never by socio-demographic characteristics. Results Nearly 80% of respondents reported an eye care visit within the previous two years. Using the ‘never visits’ as the referent category, the groups with greater odds of having an ocular visit within the past two years included those: greater than 70 years of age (OR = 6.8 [95% confidence interval = 3.7–12.6], with college degree (5.2[3.0–8.8], reporting an eye disease, (4.74[1.1–21.2], diagnosed with diabetes (3.5[1.7–7.5], of female gender (2.9[2.1–3.9], with general health insurance (2.7[1.8–3.9], with eye provider insurance coverage (2.1[1.5–3.0], with high blood pressure (1.5[1.1–2.2], and with moderate to extreme near vision difficulties (1.42[1.11–2.08]. Conclusion We found significant variation by socio-demographic characteristics and some variation in state-level estimates in this study. The present findings suggest that there remains compliance gaps of screening guidelines among select socio
Kringos, D.S.; Bolibar, Y.; Bourgueil, T.; Cartier, T.; Dedeum, T.; Hasvold, A.; Hutchinson, M.; Lember, M.; Oleszczyk, D.; Rotar Pavlick, I.; Svab, P.; Tedeschi, A.; Wilson, S.; Wilm, A.; Windak, A.; Boerma, W.
Background: A strong primary care (PC) system provides accessible, comprehensive care in an ambulatory setting on a continuous basis and by coordinated care processes. These features give PC the opportunity to play a key role in providing public health (PH) services to their practice population. Th
Kringos, D.S.; Bolibar, Y.; Bourgueil, T.; Cartier, T.; Dedeum, T.; Hasvold, A.; Hutchinson, M.; Lember, M.; Oleszczyk, D.; Rotar Pavlick, I.; Svab, P.; Tedeschi, A.; Wilson, S.; Wilm, A.; Windak, A.; Boerma, W.
Background: A strong primary care (PC) system provides accessible, comprehensive care in an ambulatory setting on a continuous basis and by coordinated care processes. These features give PC the opportunity to play a key role in providing public health (PH) services to their practice population. Th
Smits, M.; Francissen, O.; Weerts, M.; Janssen, K.; Grunsven, P. van; Giesen, P.
OBJECTIVE: To examine patient and care characteristics of emergency ambulance call-outs and to determine how many of them were, in retrospect, effectively providing primary care. DESIGN: Retrospective cross-sectional study. METHOD: We charted patient and care characteristics of 598 emergency
McColl, Mary Ann; Shortt, Samuel; Godwin, Marshall; Smith, Karen; Rowe, Kirby; O'Brien, Patti; Donnelly, Catherine
To describe the scope and breadth of knowledge currently available regarding the integration of rehabilitation and primary care services. Peer-reviewed journals were searched using CINAHL, MEDLINE, and EBM Reviews for the years 1995 through 2007. This process identified 172 items. To be considered for the subsequent review, the article had to describe a service delivery program that offered primary care and rehabilitation, or services specifically designed for people with chronic conditions/disabilities. Further, it had to be available in English or French. No methodological limitations were applied to screen for levels of evidence. Based on these criteria, 38 articles remained that pertained to both primary care and rehabilitation. These were reviewed, sorted, and categorized to discover commonalities and differences among the approaches used to integrating rehabilitation into primary care. In consultation with the team of investigators, it was determined that there were 6 different models for providing primary health care and rehabilitation services in an integrated approach: clinic, outreach, self-management, community-based rehabilitation, shared care, and case management. In addition, a number of themes were identified across models that may act as either supports or impediments to the integration of rehabilitation services into primary care settings: team approach, interprofessional trust, leadership, communication, compensation, accountability, referrals, and population-based approach. Rehabilitation providers interested in working in the primary care sector may be assisted in conceptualizing the benefits that they bring to the setting by considering these models and issues.
Misra, Vasundhra; Vashist, Praveen; Malhotra, Sumit; Gupta, Sanjeev K
Blindness and visual impairment continues to be a major public health problem in India. Availability and easy access to primary eye care services is essential for elimination of avoidable blindness. 'Vision 2020: The Right to Sight - India' envisaged the need for establishing primary eye care units named vision centers for every 50,000 population in the country by the year 2020. The government of India has given priority to develop vision centers at the level of community health centers and primary health centers under the 'National Program for Control of Blindness'. NGOs and the private sector have also initiated some models for primary eye care services. In the current situation, an integrated health care system with primary eye care promoted by government of India is apparently the best answer. This model is both cost effective and practical for the prevention and control of blindness among the underprivileged population. Other models functioning with the newer technology of tele-ophthalmology or mobile clinics also add to the positive outcome in providing primary eye care services. This review highlights the strengths and weaknesses of various models presently functioning in the country with the idea of providing useful inputs for eye care providers and enabling them to identify and adopt an appropriate model for primary eye care services.
Walley, John; Lawn, Joy E; Tinker, Anne; de Francisco, Andres; Chopra, Mickey; Rudan, Igor; Bhutta, Zulfiqar A; Black, Robert E
The principles agreed at Alma-Ata 30 years ago apply just as much now as they did then. "Health for all" by the year 2000 was not achieved, and the Millennium Development Goals (MDGs) for 2015 will not be met in most low-income countries without substantial acceleration of primary health care. Factors have included insufficient political prioritisation of health, structural adjustment policies, poor governance, population growth, inadequate health systems, and scarce research and assessment on primary health care. We propose the following priorities for revitalising primary health care. Health-service infrastructure, including human resources and essential drugs, needs strengthening, and user fees should be removed for primary health-care services to improve use. A continuum of care for maternal, newborn, and child health services, including family planning, is needed. Evidence-based, integrated packages of community and primary curative and preventive care should be adapted to country contexts, assessed, and scaled up. Community participation and community health workers linked to strengthened primary-care facilities and first-referral services are needed. Furthermore, intersectoral action linking health and development is necessary, including that for better water, sanitation, nutrition, food security, and HIV control. Chronic diseases, mental health, and child development should be addressed. Progress should be measured and accountability assured. We prioritise research questions and suggest actions and measures for stakeholders both locally and globally, which are required to revitalise primary health care.
Pascale, Alisa; Beal, Margaret W; Fitzgerald, Thérèse
The annual pap smear for cervical cancer screening, once a mainstay of the well woman visit (WWV), is no longer recommended for most low-risk women. This change has led many women and their health care providers to wonder if they should abandon this annual preventive health visit altogether. Changing guidelines coinciding with expanded WWV coverage for millions of American women under the Patient Protection and Affordable Care Act have created confusion for health care consumers and care givers alike. Is there evidence to support continued routine preventive health visits for women and, if so, what would ideally constitute the WWV of today? A scoping review of the literature was undertaken to appraise the current state of evidence regarding a wide range of possible elements to identify priority areas for the WWV. A population health perspective taking into consideration the reproductive health needs of women as well as the preventable and modifiable leading causes of death and disability was used to identify eight domains for the WWV of today: 1) reproductive life planning and sexual health, 2) cardiovascular disease and stroke, 3) prevention, screening, and early detection of cancers, 4) unintended injury, 5) anxiety, depression, substance abuse, and suicidal intent, 6) intimate partner violence, assault, and homicide, 7) lower respiratory disease, and 8) arthritis and other musculoskeletal problems. The WWV remains a very important opportunity for prevention, health education, screening, and early detection and should not be abandoned. Copyright © 2016 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.
Okoli Ugo; Eze-Ajoku Ezinne; Oludipe Modupe; Spieker Nicole; Ekezie Winifred; Ohiri Kelechi
Background: Nigeria has a high population density but a weak health-care system. To improve the quality of care, 3 organizations carried out a quality improvement pilot intervention at the primary health-care level in selected rural areas. Objective: To assess the change in quality of care in primary health-care facilities in rural Nigeria following the provision of technical governance support and to document the successes and challenges encountered. Method: A total of 6 states were selected...
Heide, I. van der; Heijmans, M.; Schuit, A.J.; Uiters, E.; Rademakers, J.
Introduction: In chronic care, patients are expected to exert a certain degree of control over the care for their condition, for instance by fulfilling care tasks in their home environment. Health literacy is considered relevant in this regard, especially critical health literacy. The aim of this st
Lebovics, Edward; Torres, Richard; Porter, Lucinda K
-up HCV RNA test, and every effort must be made to overcome the challenge of losing patients between these two steps. Good communication between the physician, the physician's office staff, and the patient is necessary. In addition, point-of-care tests and PCR reflex testing can alleviate the need for HCV antibody positive patients to arrange subsequent office visits to undergo confirmatory HCV RNA testing. Physician and patient perspectives are presented throughout this roundtable discussion to obtain a complete picture of the management barriers encountered prior to initiation of therapy. Physician perspectives are provided by Edward Lebovics, the Upham Professor of Gastroenterology and Director of the Sarah C. Upham Division of Gastroenterology and Hepatobiliary Diseases at New York Medical College and Westchester Medical Center in Valhalla, New York, and Richard Torres, Chief Medical Officer at Optimus Health Care and an Associate Professor of Medicine at Yale School of Medicine. Torres has been a primary care provider for 29 years, working at the largest federally qualified community health center in Southwestern CT, which provides over 240,000 patient visits annually primarily to populations that are underserved and suffering from healthcare disparities. Patient perspectives in this roundtable are provided by Lucinda K. Porter, RN, who is the author of two books for hepatitis C patients, and is a former hepatology nurse and hepatitis C patient. She has been advocating for others since 1997, and writes for the HCV Advocate. Lucinda is a contributing editor of HEP magazine, and she blogs at www.LucindaPorterRN.com. The overall goal of this video roundtable discussion is to demonstrate that when provided with appropriate clinical knowledge, and aided by supportive collaborations with appropriate specialists, primary care clinicians should be able to effectively screen, diagnose, and link patients with hepatitis C to appropriate care. While patients need to be educated
Srivastava, Anita; Kahan, Meldon; Nader, Maya
Abstract Objective To advise physicians on which treatment options to recommend for specific patient populations: abstinence-based treatment, buprenorphine-naloxone maintenance, or methadone maintenance. Sources of information PubMed was searched and literature was reviewed on the effectiveness, safety, and side effect profiles of abstinence-based treatment, buprenorphine-naloxone treatment, and methadone treatment. Both observational and interventional studies were included. Main message Both methadone and buprenorphine-naloxone are substantially more effective than abstinence-based treatment. Methadone has higher treatment retention rates than buprenorphine-naloxone does, while buprenorphine-naloxone has a lower risk of overdose. For all patient groups, physicians should recommend methadone or buprenorphine-naloxone treatment over abstinence-based treatment (level I evidence). Methadone is preferred over buprenorphine-naloxone for patients at higher risk of treatment dropout, such as injection opioid users (level I evidence). Youth and pregnant women who inject opioids should also receive methadone first (level III evidence). If buprenorphine-naloxone is prescribed first, the patient should be promptly switched to methadone if withdrawal symptoms, cravings, or opioid use persist despite an optimal buprenorphine-naloxone dose (level II evidence). Buprenorphine-naloxone is recommended for socially stable prescription oral opioid users, particularly if their work or family commitments make it difficult for them to attend the pharmacy daily, if they have a medical or psychiatric condition requiring regular primary care (level IV evidence), or if their jobs require higher levels of cognitive functioning or psychomotor performance (level III evidence). Buprenorphine-naloxone is also recommended for patients at high risk of methadone toxicity, such as the elderly, those taking high doses of benzodiazepines or other sedating drugs, heavy drinkers, those with a lower
Full Text Available Stephen Thielke1, Alexander Thompson2, Richard Stuart31Psychiatry and Behavioral Sciences, University of Washington, Geriatric Research, Education, and Clinical Center, Puget Sound VA Medical Center, Seattle, WA, USA; 2Group Health Cooperative, Seattle, WA, USA; 3Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USAAbstract: Over the last decade, research about health psychology in primary care has reiterated its contributions to mental and physical health promotion, and its role in addressing gaps in mental health service delivery. Recent meta-analyses have generated mixed results about the effectiveness and cost-effectiveness of health psychology interventions. There have been few studies of health psychology interventions in real-world treatment settings. Several key challenges exist: determining the degree of penetration of health psychology into primary care settings; clarifying the specific roles of health psychologists in integrated care; resolving reimbursement issues; and adapting to the increased prescription of psychotropic medications. Identifying and exploring these issues can help health psychologists and primary care providers to develop the most effective ways of applying psychological principles in primary care settings. In a changing health care landscape, health psychologists must continue to articulate the theories and techniques of health psychology and integrated care, to put their beliefs into practice, and to measure the outcomes of their work.Keywords: health psychology, primary care, integrated care, collaborative care, referral, colocation
... Administration Lists of Designated Primary Medical Care, Mental Health, and Dental Health Professional Shortage... designated as primary medical care, mental health, and dental health professional shortage areas (HPSAs) as... seven health professional types (primary medical care, dental, psychiatric, vision care,...
Castillo-Arenas, E; Garrido, V; Serrano-Ortega, S
Skin conditions are among the main reasons for seeking primary health care. Primary care physicians (PCPs) must diagnose skin conditions and determine their impact, and must therefore incorporate the relevant knowledge and skills into their education. The present study analyzes the reasons for primary care referral to dermatology (referral demand) as well as diagnostic agreement between PCPs and dermatologists informed by pathology where appropriate. Data were collected for 755 patients and 882 initial dermatology appointments from February 1, 2012 through April 30, 2012 following primary care referral. Data obtained included age, sex, occupation, reason for referral, primary care diagnosis, and dermatologic diagnosis. Statistical analysis of the data for each diagnosed condition identified frequency, reasons for referral, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the κ statistic for diagnostic agreement. The most common diagnoses were seborrheic keratosis, melanocytic nevus, actinic keratosis, and acne. The main reason for referral was diagnostic assessment (52.5%). For skin tumors, sensitivity of primary care diagnosis was 22.4%, specificity 94.7%, PPV 40.7%, and NPV 88.3%, with a κ of 0.211. For the more common diagnoses, primary care sensitivity was generally low and specificity high. According to our results, primary care physicians are better qualified to rule out a given skin condition in a patient (high specificity) than to establish an accurate clinical diagnosis (poor sensitivity). This suggests that knowledge and skills training should be organized for primary care physicians to improve management of skin conditions-especially skin cancer, because of its impact. A more responsive system would ensue, with shorter waiting lists and better health care. Copyright © 2013 Elsevier España, S.L. and AEDV. All rights reserved.
Josyula, Lakshmi K; Lyle, Roseann M
Barriers encountered in implementing a physical activity intervention in primary health care settings, and ways to address them, are described in this paper. A randomized comparison trial was designed to examine the impact of health care providers' written prescriptions for physical activity, with or without additional physical activity resources, to adult, nonpregnant patients on preventive care or chronic disease monitoring visits. Following abysmal recruitment outcomes, the research protocol was altered to make it more appealing to all the participants, i.e., health care providers, office personnel, and patients. Various barriers--financial, motivational, and executive--to the implementation of health promotion interventions in primary health care settings were experienced and identified. These barriers have been classified by the different participants in the research process, viz., healthcare providers, administrative personnel, researchers, and patients. Some of the barriers identified were lack of time and reimbursement for health promotion activities, and inadequate practice capacity, for health care providers; increased time and labor demands for administrative personnel; constrained access to participants, and limited funding, for researchers; and superseding commitments, and inaccurate comprehension of the research protocol, for patients. Solutions suggested to overcome these barriers include financial support, e.g., funding for researchers, remuneration for health care organization personnel, reimbursement for providers, payment for participants, and free or subsidized postage, and use of health facilities; motivational strategies such as inspirational leadership, and contests within health care organizations; and partnerships, with other expert technical and creative entities, to improve the quality, efficiency, and acceptability of health promotion interventions.
Bouman, A.; Rossum, E. van; Evers, S.; Ambergen, T.; Kempen, G.; Knipschild, P.
BACKGROUND: Home visiting programs have been developed to improve the functional abilities of older people and subsequently to reduce the use of institutional care services. The results of trials have been inconsistent and their cost-effectiveness uncertain. Home visits for a high-risk population ra
Boerma, W.G.W.; Kringos, D.S.; Verschuuren, M.; Pellny, M.; Bulc, M.
Of all GPs in Slovenia 86% are not interested in activities to systematically improve care. A clear national quality policy, further education for care managers and financial incentives for GPs could change the picture, as NIVEL research – done on the initiative of the World Health Organisation (WHO
Judith M. Myers
Full Text Available Advance directives (ADs provide patients with the opportunity to indicate their preferences for medical care while they still maintain the capacity to express their wishes, thus retaining autonomy. ADs increase the likelihood that patients will receive the care they desire, as their family members and physicians will better understand the level of care desired. Despite this, the AD completion rate by elderly patients continues to be low, especially for patients not facing serious illnesses. Primary care physicians (PCPs are uniquely positioned to engage patients in discussions about ADs before a health crisis arises yet often do not due to time constraints. Using assets associated with the PCP relationship to and longitudinal care for patients, findings reveal that PCPs who emphasize the importance of ADs and who normalize the discussion during office visits by asking questions to understand patients' health goals and holding short conversations over several visits can improve AD completion rates.
Wound care is expensive and can cause immeasurable stress and inconvenience to patients and their significant others. It is therefore in the best interest of the patient, their significant others and the NHS as a whole that wounds are expertly assessed, managed and healed in the quickest timeframe possible. Nurses play a pivotal role in the process of accurate holistic wound assessment, evaluation and treatment. This article aims to help further develop and enhance both professional and clinical wound care assessment and evaluation skills. Pertinent wound care literature is critically reviewed and the crucial nature and important components of comprehensive wound assessment for facilitating the highest possible quality wound care to patients are presented alongside recommendations regarding how the enhanced knowledge and skills could be applied into everyday wound care practice.
Selby, Joe V; Slutsky, Jean R
In their article in this issue, Mazur and colleagues analyze the characteristics of early recipients of funding from the Patient-Centered Outcomes Research Institute (PCORI). Mazur and colleagues note correctly that PCORI has a unique purpose and mission and suggest that it should therefore have a distinct portfolio of researchers and departments when compared with other funders such as the National Institutes of Health (NIH). Responding on behalf of PCORI, the authors of this Commentary agree with the characterization of PCORI's mission as distinct from that of NIH and others. They agree too that data found on PCORI's Web site demonstrate that PCORI's portfolio of researchers and departments is more diverse and more heavily populated with clinician researchers, as would be expected. The authors take issue with Mazur and colleagues' suggestion that because half of clinical visits occur within primary care settings, half of PCORI's funded research should be based in primary care departments. PCORI's portfolio reflects what patients and others tell PCORI are the critical questions. Many of these do, in fact, occur with more complex conditions in specialty care. The authors question whether the research of primary care departments is too narrowly focused and whether it sufficiently considers study of these complex conditions. Research on more complex conditions including heart failure, coronary artery disease, and multiple comorbid conditions could be highly valuable when approached from the primary care perspective, where many of the comparative effectiveness questions first arise.
Joo, Min J; Sharp, Lisa K; Au, David H; Lee, Todd A; Fitzgibbon, Marian L
Guidelines that recommend spirometry to confirm airflow obstruction among patients with suspected COPD are not routinely followed. We conducted a qualitative study to identify attitudes and barriers of primary care physicians to performing spirometry for patients with possible COPD. We conducted four focus groups, each with three primary care physicians (PCPs) who practice in an urban, academic medical center. In general, PCPs believed that spirometry was not necessary to confirm the diagnosis of COPD. Compared to other co-morbid conditions, in a patient with a diagnosis of COPD without self-reported symptoms, COPD was not a priority during a clinic visit. This was in part due to the belief that there was lack of evidence that medication used in COPD lead to improved outcomes and that there was no point of care measure for COPD compared to other co-morbid conditions such as diabetes mellitus or hypertension. Health system barriers specific to spirometry use was not identified. In conclusion, in our sample of PCPs, there was skepticism that spirometry is warranted to diagnose and manage COPD. Availability of spirometry was not a perceived barrier. Our results explain, in part, why previous interventions to improve access to spirometry and diagnosis of COPD in primary care settings have been difficult to conduct and/or have had marginal success. Our findings strongly suggest that a first step toward increasing the use of spirometry among primary care physicians is to have them believe in its utility in the diagnosis of COPD.
SIMON, G; ORMEL, J; VONKORFF, M; BARLOW, W
Objective: The authors examined the overall health care costs associated with depression and anxiety among primary care patients. Method: Of 2,110 consecutive primary care patients in a health maintenance organization, 1,962 were screened with the 12-item General Health Questionnaire. A stratified
Burke, Triona; O'Neill, Catherine
Primary care health services in the Irish Republic have undergone fundamental transformation with the establishment of multidisciplinary primary care teams nationwide. Primary care teams provide a community-based health service delivered through a range of health professionals in an integrated way. As part of this initiative ten pilot teams were established in 2003. This research was undertaken in order to gain an understanding of nurse's experiences of working in a piloted primary care team. The methodology used was a focus group approach. The findings from this study illustrated how community nurse's roles and responsibilities have expanded within the team. The findings also highlighted the benefits and challenges of working as a team with various other community-based health-care disciplines.
Primary care health services in the Irish Republic have undergone fundamental transformation with the establishment of multidisciplinary primary care teams nationwide. Primary care teams provide a community-based health service delivered through a range of health professionals in an integrated way. As part of this initiative ten pilot teams were established in 2003. This research was undertaken in order to gain an understanding of nurse\\'s experiences of working in a piloted primary care team. The methodology used was a focus group approach. The findings from this study illustrated how community nurse\\'s roles and responsibilities have expanded within the team. The findings also highlighted the benefits and challenges of working as a team with various other community-based health-care disciplines.
Bennett, Alice L; Munkholm, Pia; Andrews, Jane M
are helpful but they are not designed for the primary care setting. Few non-expert IBD management tools or guidelines exist compared with those used for other chronic diseases such as asthma and scant data have been published regarding the usefulness of such tools including IBD action plans and associated......Healthcare systems throughout the world continue to face emerging challenges associated with chronic disease management. Due to the likely increase in chronic conditions in the future it is now vital that cooperation and support between specialists, generalists and primary health care physicians...... affected by IBD in their caseload, the proportion of patients with IBD-related healthcare issues cared for in the primary care setting appears to be widespread. Data suggests however, that primary care physician's IBD knowledge and comfort in management is suboptimal. Current treatment guidelines for IBD...
Licskai, Christopher; Sands, Todd; Ong, Michael; Paolatto, Lisa; Nicoletti, Ivan
Quality problem International guidelines establish evidence-based standards for asthma care; however, recommendations are often not implemented and many patients do not meet control targets. Initial assessment Regional pilot data demonstrated a knowledge-to-practice gap. Choice of solutions We engineered health system change in a multi-step approach described by the Canadian Institutes of Health Research knowledge translation framework. Implementation Knowledge translation occurred at multiple levels: patient, practice and local health system. A regional administrative infrastructure and inter-disciplinary care teams were developed. The key project deliverable was a guideline-based interdisciplinary asthma management program. Six community organizations, 33 primary care physicians and 519 patients participated. The program operating cost was $290/patient. Evaluation Six guideline-based care elements were implemented, including spirometry measurement, asthma controller therapy, a written self-management action plan and general asthma education, including the inhaler device technique, role of medications and environmental control strategies in 93, 95, 86, 100, 97 and 87% of patients, respectively. Of the total patients 66% were adults, 61% were female, the mean age was 35.7 (SD = ± 24.2) years. At baseline 42% had two or more symptoms beyond acceptable limits vs. 17% (P< 0.001) post-intervention; 71% reported urgent/emergent healthcare visits at baseline (2.94 visits/year) vs. 45% (1.45 visits/year) (P< 0.001); 39% reported absenteeism (5.0 days/year) vs. 19% (3.0 days/year) (P< 0.001). The mean follow-up interval was 22 (SD = ± 7) months. Lessons learned A knowledge-translation framework can guide multi-level organizational change, facilitate asthma guideline implementation, and improve health outcomes in community primary care practices. Program costs are similar to those of diabetes programs. Program savings offset costs in a ratio of 2.1:1.
Anderson, Daren R; St Hilaire, Daniel; Flinter, Margaret
Care coordination is a core element of the Patient-Centered Medical Home and requires an effective, well educated nursing staff. A greater understanding of roles and tasks currently being carried out by nurses in primary care is needed to help practices determine how best to implement care coordination and transform into PCMHs. We conducted an observational study of primary care nursing in a Community Health Center by creating a classification schema for nursing responsibilities, directly observing and tracking nurses' work, and categorizing their activities. Ten nurses in eight different practice sites were observed for a total of 61 hours. The vast majority of nursing time was spent in vaccine and medication administration; telephone work; and charting and paper work, while only 15% of their time was spent in activity that was classified broadly as care coordination. Care coordination work appeared to be subsumed by other daily tasks, many of which could have been accomplished by other, lesser trained members of the health care team. Practices looking to implement care coordination need a detailed look at work flow, task assignments, and a critical assessment of staffing, adhering to the principal of each team member working to the highest level of his or her education and license. Care coordination represents a distinct responsibility that requires dedicated nursing time, separate from the day to day tasks in a busy practice. To fully support these new functions, reimbursement models are needed that support such non visit-based work and provide incentives to coordinate and manage complex cases, achieve improved clinical outcomes and enhance efficiency of the health system. This article describes our study methods, data collection, and analysis, results, and discussion about reorganizing nursing roles to promote care coordination.
Barry, Arden R; Pammett, Robert T
In 2013, Jorgenson et al. published guidelines for pharmacists integrating into primary care teams. These guidelines outlined 10 evidence-based recommendations designed to support pharmacists in successfully establishing practices in primary care environments. The aim of this review is to provide a detailed, practical approach to implementing these recommendations in real life, thereby aiding to validate their effectiveness. Both authors reviewed the guidelines independently and ranked the importance of each recommendation respective to their practice. Each author then provided feedback for each recommendation regarding the successes and challenges they encountered through implementation. This feedback was then consolidated into agreed upon statements for each recommendation. Focusing on building relationships (with an emphasis on face time) and demonstrating value to both primary care providers and patients were identified as key aspects in developing these new roles. Ensuring that the environment supports the practice, along with strategic positioning within the clinic, improves uptake and can maximize the usefulness of a pharmacist in primary care. Demonstrating consistent and competent clinical and documentation skills builds on the foundation of the other recommendations to allow for the effective provision of clinical pharmacy services. Additional recommendations include developing efficient ways (potentially provider specific) to communicate with primary care providers and addressing potential preconceived notions about the role of the pharmacist in primary care. We believe these guidelines hold up to real-life integration and emphatically recommend their use for new and existing primary care pharmacists.
Sandra C Thompson
Full Text Available Background: The Aboriginal people of Australia have much poorer health and social indicators and a substantial life expectancy gap compared to other Australians, with premature cardiovascular disease a major contributor to poorer health. This article draws on research undertaken to examine cardiovascular disparities and focuses on ways in which primary care practitioners can contribute to reducing cardiovascular disparities and improving Aboriginal health. Methods: The overall research utilised mixed methods and included data analysis, interviews and group processes which included Aboriginal people, service providers and policymakers. Workshop discussions to identify barriers and what works were recorded by notes and on whiteboards, then distilled and circulated to participants and other stakeholders to refine and validate information. Additional engagement occurred through circulation of draft material and further discussions. This report distils the lessons for primary care practitioners to improve outcomes through management that is attentive to the needs of Aboriginal people. Results: Aspects of primordial, primary and secondary prevention are identified, with practical strategies for intervention summarised. The premature onset and high incidence of Aboriginal cardiovascular disease make prevention imperative and require that primary care practitioners understand and work to address the social underpinnings of poor health. Doctors are well placed to reinforce the importance of healthy lifestyle at all visits to involve the family and to reduce barriers which impede early care seeking. Ensuring better information for Aboriginal patients and better integrated care for patients who frequently have complex needs and multi-morbidities will also improve care outcomes. Conclusion: Primary care practitioners have an important role in improving Aboriginal cardiovascular care outcomes. It is essential that they recognise the special needs of their
Esteban Giner, M J; Giner Galvañ, V; Prats Hernández, J L; Llopis Martínez, F; Cortés i Pérez, P J; Castejón Esteban, J
To evaluate the efficacy and efficiency of a system set up to overcome the current disparity between primary and specialist health care and with the capacity to detect patients with significant diseases. To describe the activity of the Unit for Connection with Primary Care Centres (UCPCC) in the Alcoy Health Area (Alicante) during its first year. A total of 450 visits were made, with 6.5 (95% CI 5.7-7.3) first visits, and 3.9 (95% CI 3.1-4.8) successive ones per day. There were more than 50 reasons for consultation, and more than 60 final diagnoses (65.6% non-significant, 14% undefined and 12.4% significant). Digestive (31%) and functional (14.4%) diseases were the most frequently defined diagnoses, with neoplasic and autoimmune diseases among those defined as significant ones. The great majority (86.9%) of patients required 1-2 visits, with 40% diagnosed by just reviewing the hospital files. More than 20 different complementary examinations were performed, with 38.8%, 34.4%, 21.6%, and 5.2% of patients requiring 0, 1, 2, or ≥ 3, respectively. Patients with a significant pathology were diagnosed more quickly (12.4 ± 19.4 vs. 45.3 ± 52.8 days; P = .001), with less complementary examinations (0,5 ± 0,7 vs. 0,9 ± 0,9 per patient; P = .032. 58.6% vs. 39.6% patients without complementary examinations; P = .052), and were more frequently referred to specialised medicine (58.6% vs. 18.3%, P < .0001). The demonstrated differential management of patients with potentially significant pathology using existing resources, make the UCPCC with internists an efficient model for the connection between health care levels. Copyright © 2012 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España. All rights reserved.
Full Text Available Objectives: The aim of follow-up visits by the general practitioner and district nurse (within a week after discharge from hospital is to reduce hospital readmissions and improve the overall wellbeing of the patient. There is strong evidence that these programmes are effective, but are difficult to implement because of a number of organizational obstacles, including co-ordination between the organizations involved in the process. In this paper we look at the factors that affect motivation to participate in a cross-sectoral programme in Copenhagen, Denmark, implementing follow-up home visits to elderly persons. Theory and methods: The analysis is based on inter-organisational network theory in an attempt to explain the role of motivation in network formation between organizational systems. The empirical findings are based on focus groups and in-depth interviews with hospital staff, general practitioners, and district nurses. Results: Care providers are motivated to collaborate by a number of factors. The focus of collaboration needs to be clearly defined and agreed upon, there needs to be a high degree of equality between the professionals involved, and there has to be a will to co-operate based on a shared understanding of values and learning potentials. Conclusions: The study concludes that we need to focus on specific care fields and actors to reduce complexity in the area and more fully understand what motivates care providers to participate in cross-sectoral activities such as a follow-up home visit programme. One lesson for current policy is that motivational factors need to be addressed in future collaborative programs in order to fully exploit the potential health benefits.
Full Text Available Objectives: The aim of follow-up visits by the general practitioner and district nurse (within a week after discharge from hospital is to reduce hospital readmissions and improve the overall wellbeing of the patient. There is strong evidence that these programmes are effective, but are difficult to implement because of a number of organizational obstacles, including co-ordination between the organizations involved in the process. In this paper we look at the factors that affect motivation to participate in a cross-sectoral programme in Copenhagen, Denmark, implementing follow-up home visits to elderly persons.Theory and methods: The analysis is based on inter-organisational network theory in an attempt to explain the role of motivation in network formation between organizational systems. The empirical findings are based on focus groups and in-depth interviews with hospital staff, general practitioners, and district nurses.Results: Care providers are motivated to collaborate by a number of factors. The focus of collaboration needs to be clearly defined and agreed upon, there needs to be a high degree of equality between the professionals involved, and there has to be a will to co-operate based on a shared understanding of values and learning potentials.Conclusions: The study concludes that we need to focus on specific care fields and actors to reduce complexity in the area and more fully understand what motivates care providers to participate in cross-sectoral activities such as a follow-up home visit programme. One lesson for current policy is that motivational factors need to be addressed in future collaborative programs in order to fully exploit the potential health benefits.
Hjelmar, Ulf; Hendriksen, Carsten; Hansen, Kirsten
The aim of follow-up visits by the general practitioner and district nurse (within a week after discharge from hospital) is to reduce hospital readmissions and improve the overall wellbeing of the patient. There is strong evidence that these programmes are effective, but are difficult to implement because of a number of organizational obstacles, including co-ordination between the organizations involved in the process. In this paper we look at the factors that affect motivation to participate in a cross-sectoral programme in Copenhagen, Denmark, implementing follow-up home visits to elderly persons. The analysis is based on inter-organizational network theory in an attempt to explain the role of motivation in network formation between organizational systems. The empirical findings are based on focus groups and in-depth interviews with hospital staff, general practitioners, and district nurses. Care providers are motivated to collaborate by a number of factors. The focus of collaboration needs to be clearly defined and agreed upon, there needs to be a high degree of equality between the professionals involved, and there has to be a will to co-operate based on a shared understanding of values and learning potentials. The study concludes that we need to focus on specific care fields and actors to reduce complexity in the area and more fully understand what motivates care providers to participate in cross-sectoral activities, such as a follow-up home visit programme. One lesson for current policy is that motivational factors need to be addressed in future collaborative programmes in order to fully exploit the potential health benefits.
Hochman, Michael; Asch, Steven M
Starfield and colleagues have suggested four overarching attributes of good primary care: "first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere." As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for high-needs, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.
O'Malley, Denalee; Hudson, Shawna V; Nekhlyudov, Larissa; Howard, Jenna; Rubinstein, Ellen; Lee, Heather S; Overholser, Linda S; Shaw, Amy; Givens, Sarah; Burton, Jay S; Grunfeld, Eva; Parry, Carly; Crabtree, Benjamin F
This study describes the experiences of early implementers of primary care-focused cancer survivorship delivery models. Snowball sampling was used to identify innovators. Twelve participants (five cancer survivorship primary care innovators and seven content experts) attended a working conference focused on cancer survivorship population strategies and primary care transformation. Data included meeting discussion transcripts/field notes, transcribed in-depth innovator interviews, and innovators' summaries of care models. We used a multistep immersion/crystallization analytic approach, guided by a primary care organizational change model. Innovative practice models included: (1) a consultative model in a primary care setting; (2) a primary care physician (PCP)-led, blended consultative/panel-based model in an oncology setting; (3) an oncology nurse navigator in a primary care practice; and (4) two subspecialty models where PCPs in a general medical practice dedicated part of their patient panel to cancer survivors. Implementation challenges included (1) lack of key stakeholder buy-in; (2) practice resources allocated to competing (non-survivorship) change efforts; and (3) competition with higher priority initiatives incentivized by payers. Cancer survivorship delivery models are potentially feasible in primary care; however, significant barriers to widespread implementation exist. Implementation efforts would benefit from increasing the awareness and potential value-add of primary care-focused strategies to address survivors' needs. Current models of primary care-based cancer survivorship care may not be sustainable. Innovative strategies to provide quality care to this growing population of survivors need to be developed and integrated into primary care settings.
Hjelmar, U; Hendriksen, Carsten; Hansen, K
Objectives: The aim of follow-up visits by the general practitioner and district nurse (within a week after discharge from hospital) is to reduce hospital readmissions and improve the overall wellbeing of the patient. There is strong evidence that these programmes are effective, but are difficult......, and district nurses. Results: Care providers are motivated to collaborate by a number of factors. The focus of collaboration needs to be clearly defined and agreed upon, there needs to be a high degree of equality between the professionals involved, and there has to be a will to co-operate based on a shared...
Boeringa, F.H.; Sluijs, E.M.
This bibliography contains literature about certification- and recertification of health care professionals. Certification and recertification are increasingly being used as quality assurance systems for professionals. As such (re)certification does fit in with the current developments towards quali
Goodrich, David E; Kilbourne, Amy M; Nord, Kristina M; Bauer, Mark S
Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems, as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims underhealth care reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components.
Valderrama-Martínez, José Arturo; Dávalos-Díaz, Guillermina
To know factors related to job satisfaction among primary care Physicians from the Mexican Social Security Institute. Cross-sectional survey applied to physicians of outpatient visit areas in four Family Medicine Units in Leon, Guanajuato, from February to May 2007. The survey explored six areas. We used 95% confidence intervals and One-Way ANOVA to compare means among clinics and Chi square and OR'95% confidence intervals to compare proportions. One hundred sixty physicians participated (response rate 88.9%), three were excluded. Most physicians were satisfied with their work (86%). Half of the doctors feel satisfied with their economic benefits (48%), non-economic benefits (52%), and those from the collective bargaining agreement (53%), as well as with the labor union (46%) and their actual insurances (45%). Only one third or less of participants refer to receive incentives (31%) or recognitions for their work (33%), were satisfied with the opportunities for training (31%), the economic incentives (29%), or the salary (24%). The satisfaction's means of work, benefits, insurances, labor union and collective bargaining agreement were significantly higher than the means of salary and economic incentives. Satisfaction means were significantly higher in Clinic #53 than in Clinic #51 for job satisfaction and opportunities for training, as well as percentages of response in institutional support, incentives and recognitions for their work, were higher in Clinic 53 compared to all other clinics; however, it's the smallest clinic in this study. Family doctors find satisfaction in their practice, and factors such as institutional support, recognition and incentives may improve their general job satisfaction.
Monguillon, Dominique; Gracia, Pierre-Benjamin
Nurse home visits in France. More and more nurses carry out home visits, either as freelance nurses or employees of a nurse home visits service, a home hospital care structure or a nursing care centre. These home visits are both demanded by patients and encouraged by the health authorities. As a consequence, the service is expanding every year.
Adams, Eike; Boulton, Mary; Rose, Peter; Lund, Susi; Richardson, Alison; Wilson, Sue; Watson, Eila
Background The Quality and Outcomes Framework (QOF) provides an incentive for practices to establish a cancer register and conduct a review with cancer patients within 6 months of diagnosis, but implementation is unknown. Aim To describe: (1) implementation of the QOF cancer care review; (2) patients' experiences of primary care over the first 3 years following a cancer diagnosis; (3) patients' views on optimal care; and (4) the views of primary care professionals regarding their cancer care. Design of study Qualitative study using thematic analysis and a framework approach. Setting Six general practices in the Thames Valley area. Method Semi-structured interviews with cancer patients and focus groups with primary care teams. Results Thirty-eight adults with 12 different cancer types were interviewed. Seventy-one primary care team members took part in focus groups. Most cancer care reviews are conducted opportunistically. Thirty-five patients had had a review; only two could recall this. Patients saw acknowledgement of their diagnosis and provision of general support as important and not always adequately provided. An active approach and specific review appointment would legitimise the raising of concerns. Primary care teams considered cancer care to be part of their role. GPs emphasised the importance of being able to respond to individual patients' needs and closer links with secondary care to facilitate a more involved role. Conclusion Patients and primary care teams believe primary care has an important role to play in cancer care. Cancer care reviews in their current format are not helpful, with considerable scope for improving practice in this area. An invitation to attend a specific appointment at the end of active treatment may aid transition from secondary care and improve satisfaction with follow-up in primary care. PMID:21439175
Rocha, Thiago Augusto Hernandes; da Silva, Núbia Cristina; Thomaz, Erika Bárbara Abreu Fonseca; Queiroz, Rejane Christine de Sousa; de Souza, Marta Rovery; Lein, Adriana; Alvares, Viviane; de Almeida, Dante Grapiuna; Barbosa, Allan Claudius Queiroz; Thumé, Elaine; Staton, Catherine; Vissoci, João Ricardo Nickenig; Facchini, Luiz Augusto
Cervical cancer is a common neoplasm that is responsible for nearly 230 000 deaths annually in Brazil. Despite this burden, cervical cancer is considered preventable with appropriate care. We conducted a longitudinal ecological study from 2002 to 2012 to examine the relationship between the delivery of preventive primary care and cervical cancer mortality rates in Brazil. Brazilian states and the federal district were the unit of analysis (N = 27). Results suggest that primary health care has contributed to reducing cervical cancer mortality rates in Brazil; however, the full potential of preventive care has yet to be realized. PMID:28252500
Sheridan, Bethany; Chien, Alyna T; Peters, Antoinette S; Rosenthal, Meredith B; Brooks, Joanna Veazey; Singer, Sara J
Team-based care has the potential to improve primary care quality and efficiency. In this model, medical assistants (MAs) take a more central role in patient care and population health management. MAs' traditionally low status may give them a unique view on changing organizational dynamics and teamwork. However, little empirical work exists on how team-based organizational designs affect the experiences of low-status health care workers like MAs. The aim of this study was to describe how team-based primary care affects the experiences of MAs. A secondary aim was to explore variation in these experiences. In late 2014, the authors interviewed 30 MAs from nine primary care practices transitioning to team-based care. Interviews addressed job responsibilities, teamwork, implementation, job satisfaction, and learning. Data were analyzed using a thematic networks approach. Interviews also included closed-ended questions about workload and job satisfaction. Most MAs reported both a higher workload (73%) and a greater job satisfaction (86%) under team-based primary care. Interview data surfaced four mechanisms for these results, which suggested more fulfilling work and greater respect for the MA role: (a) relationships with colleagues, (b) involvement with patients, (c) sense of control, and (d) sense of efficacy. Facilitators and barriers to these positive changes also emerged. Team-based care can provide low-status health care workers with more fulfilling work and strengthen relationships across status lines. The extent of this positive impact may depend on supporting factors at the organization, team, and individual worker levels. To maximize the benefits of team-based care, primary care leaders should recognize the larger role that MAs play under this model and support them as increasingly valuable team members. Contingent on organizational conditions, practices may find MAs who are willing to manage the increased workload that often accompanies team-based care.
Pérez-Vico-Díaz de Rada, Lucía; González-Suárez, Miriam; Duarte-Clíments, Gonzalo; Brito-Brito, Pedro Ruymán
A case is presented of a 52 year-old male seen in a Primary Care nursing clinic for a type 2 diabetes mellitus metabolic control. The frequency of the visits increased due to perceived difficulties caused by changing the medical treatment. A focused interview was conducted under functional health patterns framework. The patient was unable to write or read, had not worked for the last 25 years, and expressed a lack of control over his self-care. An action plan was prepared, prioritizing Ineffective Health Maintenance, Powerlessness, and Impaired Social Interaction NANDA-I nursing diagnoses. The goals were set at improving knowledge and control over his disease and participating in leisure activities. To achieve these, the social health resources in the area were contacted, and agreed that the patient could attend activities that could improve his self-care and his quality of life. An improvement in his diabetes control was observed in the following evaluations, with an increase in his level of knowledge and self-care. The Primary Health care nurse should consider available community resources by using a comprehensive approach to chronic diseases for their therapeutic benefit and management, especially in those patients with adverse sociocultural conditions.
da Silva, Andréa Tenório Correia; Lopes, Claudia de Souza; Susser, Ezra; Menezes, Paulo Rossi
To identify work-related factors associated with depressive symptoms and probable major depression in primary care teams. Cross-sectional study among primary care teams (community health workers, nursing assistants, nurses, and physicians) in the city of São Paulo, Brazil (2011-2012; n = 2940), to assess depressive symptoms and probable major depression and their associations with job strain and other work-related conditions. Community health workers presented higher prevalence of probable major depression (18%) than other primary care workers. Higher odds ratios for depressive symptoms or probable major depression were associated with longer duration of employment in primary care; having a passive, active, or high-strain job; lack of supervisor feedback regarding performance; and low social support from colleagues and supervisors. Observed levels of job-related depression can endanger the sustainability of primary care programs. Public Health implications. Strategies are needed to deliver care to primary care workers with depression, facilitating diagnosis and access to treatment, particularly in low- and middle-income countries. Preventive interventions can include training managers to provide feedback and creating strategies to increase job autonomy and social support at work.
Stephanie Giulianne Silva Morelli
Full Text Available Objectives: to analyze the associations between burnout syndrome and individual and work-related characteristics among primary care physicians. Methods: a systematic review was performed using the Medline (PubMed, SciELO, Lilacs and Cochrane databases. In November, 2013, we ran a search based on the descriptors: “professional burnout”, “health personnel”, and “primary care”. We assessed 2,416 titles and 18 studies were selected. Results: the prevalence of burnout was high among primary care physicians. Burnout was associated with physical illnesses, mental disorders, and alcohol and substance abuse. Physicians who had higher levels of emotional exhaustion were more likely to be absent from work, and to change their job. Physicians suffering from burnout were also more likely to increase pharmaceutical expenditure per patient. The work-related characteristics associated with burnout were: length of employment in primary care, number of working hours per week, number of patients attended, type of employment contract, teaching activity, holiday period, and difficulties in dealing with other staff. Conclusion: the high prevalence of burnout among primary care physicians is a major concern for policy makers, since primary care is the cornerstone of health systems, and burnout syndrome can jeopardize the quality of care provided to populations, and the effectiveness of the entire health care system. Understanding the factors associated with burnout allows the development of strategies for intervention and prevention.
Acharya, Bibhav; Tenpa, Jasmine; Thapa, Poshan; Gauchan, Bikash; Citrin, David; Ekstrand, Maria
Globally, access to mental healthcare is often lacking in rural, low-resource settings. Mental healthcare services integration in primary care settings is a key intervention to address this gap. A common strategy includes embedding mental healthcare workers on-site, and receiving consultation from an off-site psychiatrist. Primary care provider perspectives are important for successful program implementation. We conducted three focus groups with all 24 primary care providers at a district-level hospital in rural Nepal. We asked participants about their concerns and recommendations for an integrated mental healthcare delivery program. They were also asked about current practices in seeking referral for patients with mental illness. We collected data using structured notes and analyzed the data by template coding to develop themes around concerns and recommendations for an integrated program. Participants noted that the current referral system included sending patients to the nearest psychiatrist who is 14 h away. Participants did not think this was effective, and stated that integrating mental health into the existing primary care setting would be ideal. Their major concerns about a proposed program included workplace hierarchies between mental healthcare workers and other clinicians, impact of staff turnover on patients, reliability of an off-site consultant psychiatrist, and ability of on-site primary care providers to screen patients and follow recommendations from an off-site psychiatrist. Their suggestions included training a few existing primary care providers as dedicated mental healthcare workers, recruiting both senior and junior mental healthcare workers to ensure retention, recruiting academic psychiatrists for reliability, and training all primary care providers to appropriately screen for mental illness and follow recommendations from the psychiatrist. Primary care providers in rural Nepal reported the failure of the current system of referral, which
Tillison, Ashley Simone; Avery, Ann Keltner
Since 2006, numerous testing initiatives have been launched across the United States to increase the number of individuals who know their HIV status. These initiatives are often venue based and reported in a variety of settings. However, the effectiveness of these initiatives has not been evaluated to determine if patients were identified earlier in the course of disease or would not have been otherwise tested. In 2010, a publicly funded teaching hospital implemented an electronic medical record prompt to improve the rate of routine HIV screening and diagnosis, focusing on primary care office visits. Both sex and CD4 count were found to be significantly related to being newly diagnosed after the intervention. Routine testing in primary care is an effective strategy to diagnose patients earlier in disease progression, particularly men who might otherwise not be tested and thus would remain undiagnosed until developing symptoms from advanced disease.
Cubic, Barbara; Mance, Janette; Turgesen, Jeri N; Lamanna, Jennifer D
Rapidly occurring changes in the healthcare arena mean time is of the essence for psychology to formalize a strategic plan for training in primary care settings. The current article articulates factors affecting models of integrated care in Academic Health Centers (AHCs) and describes ways to identify and utilize resources at AHCs to develop interprofessional educational and clinical integrated care opportunities. The paper asserts that interprofessional educational experiences between psychology and other healthcare providers are vital to insure professionals value one another's disciplines in health care reform endeavors, most notably the patient-centered initiatives. The paper highlights ways to create shared values and common goals between primary care providers and psychologists, which are needed for trainee internalization of integrated care precepts. A developmental perspective to training from pre-doctoral, internship and postdoctoral levels for psychologists in integrated care is described. Lastly, a call to action is given for the field to develop more opportunities for psychology trainees to receive education and training within practica, internships and postdoctoral fellowships in primary care settings to address the reality that most patients seek their mental health treatment in primary care settings.
Marco Antonio Zapata Sampedro
Full Text Available Out-patients undergoing anticoagulant treatment are attended by nursing staff, working with doctors.To be able to provide adequate medical care, nurses must have the minimum knowledge and skills needed to work with the programme described in this article. These include basic and specific knowledge of anticoagulation. The correct functioning of the service will help provide an optimum control of the INR (International Normalized Ratio and reduce the complications of bleeding, both of which are the main objectives of the nursing care of these patients.
Ab Rahman, Norazida; Sivasampu, Sheamini; Mohamad Noh, Kamaliah; Khoo, Ee Ming
.... Little is known about the health profiles of foreign population in Malaysia. The aim of this study was to provide a detailed description of the health problems presented by foreigners attending primary care clinics in Malaysia...
and physical examination usually suffice. This contrasts with back pain ... pain in primary care have a neoplasm, 4% have fractures and 1-3% have a prolapsed ... Pharmacological therapy may be initiated once baseline pain, and the potential ...
among primary health care providers toward mental illness and those who suffer from it. These findings ... measures that tend to restrict civil rights and freedoms of people .... Mental Health Nurse is basically a Registered Nurse who undergoes ...
Holm, Anne; Aabenhus, Rune
in primary care. The aim of this study was to determine the accuracy of urine culture from different sampling-techniques in symptomatic non-pregnant women in primary care. Methods: A systematic review was conducted by searching Medline and Embase for clinical studies conducted in primary care using......Background: Choice of urine sampling technique in urinary tract infection may impact diagnostic accuracy and thus lead to possible over- or undertreatment. Currently no evidencebased consensus exists regarding correct sampling technique of urine from women with symptoms of urinary tract infection...... seven studies investigating urine sampling technique in 1062 symptomatic patients in primary care. Mid-stream-clean-catch had a positive predictive value of 0.79 to 0.95 and a negative predictive value close to 1 compared to sterile techniques. Two randomized controlled trials found no difference...
Full Text Available Abstract Background The aim of our study was to validate a Greek translation of the Berlin Questionnaire (BQ for obstructive sleep apnoea syndrome (OSAS and to explore whether this screening questionnaire could be used to help identify primary care patients at greater risk of having OSAS. Methods We recruited 189 patients visiting a primary health care setting on the island of Crete, Greece. They all completed the Greek Version of the BQ. Patients were then referred to a Sleep Disorders Unit for evaluation of suspected sleep-disordered breathing. Results A PSG study was performed in 129 of the 189 subjects (68.3%. BQ identified 74.4% (n = 96 of the patients as high-risk for OSAS and the remaining 25.6% (n = 33 as low-risk. The sensitivity and specificity of BQ for OSAS diagnosis were 76% and 40%, respectively, for an apnoea–hypopnoea index (AHI ≥5 per hour but 30 per hour. Conclusions In conclusion, the Greek Version of the BQ is a useful instrument for identifying patients at risk for OSAS in primary health care in Greece. The findings of our study confirm that such screening tools should be used by primary care clinicians for OSAS prediction.
Cates, Carolyn Brockmeyer; Weisleder, Adriana; Mendelsohn, Alan L
Poverty related disparities in early child development and school readiness are a major public health crisis, the prevention of which has emerged in recent years as a national priority. Interventions targeting parenting and the quality of the early home language environment are at the forefront of efforts to address these disparities. In this article we discuss the innovative use of the pediatric primary care platform as part of a comprehensive public health strategy to prevent adverse child development outcomes through the promotion of parenting. Models of interventions in the pediatric primary care setting are discussed with evidence of effectiveness reviewed. Taken together, a review of this significant body of work shows the tremendous potential to deliver evidence-based preventive interventions to families at risk for poverty related disparities in child development and school readiness at the time of pediatric primary care visits. We also addresss considerations related to scaling and maximizing the effect of pediatric primary care parenting interventions and provide key policy recommendations.
Full Text Available Abstract Background In recent years out-of-hours primary care in the Netherlands has changed from practice-based to large-scale cooperatives. The purpose of this study is to determine patient satisfaction with current out-of-hours care organised in general practitioner (GP cooperatives, and gain insight in factors associated with this satisfaction. Methods From March to June 2003, 2805 questionnaires were sent to patients within three weeks after they had contacted the GP cooperative in their region. The study was conducted in the province of Limburg in the South of the Netherlands. One-third of these questionnaires was sent to patients who had only received telephone advice, one-third to patients who attended the GP cooperative for consultation, and one-third to patients who received a home visit. Four weeks after the first reminder, a non-respondents telephone interview was performed among a random sample of 100 patients. Analyses were performed with respect to the type of consultation. Results The total response was 42.4% (1160/2733. Sixty-seven percent of patients who received telephone advice only reported to be satisfied with out-of-hours care. About 80% of patients who went to the GP cooperative for consultation or those receiving a home visit, reported to be satisfied. Factors that were strongly associated with overall satisfaction included, the doctor's assistant's attitude on the phone, opinion on GP's treatment, and waiting time. Conclusion Patients seem generally satisfied with out-of-hours primary care as organised in GP cooperatives. However, patients who received telephone advice only are less satisfied compared to those who attended the GP cooperative or those who received a home visit.
Sudhanthar, Sathyanarayan; Thakur, Kripa; Sigal, Yakov; Turner, Jane; Gold, Jonathan
Asthma is the most commonly encountered chronic disease in children. Periodic assessment of asthma severity and control is an integral part of asthma management, but patients with uncontrolled asthma don't always schedule routine asthma care visits. The aim of this project was to improve asthma control and severity screening in a primary care setting by using a validated tool for all visits for patients with a diagnosis of asthma aged 4-21 years. Our QI team developed a protocol to administer the Asthma Control Test (TM), a validated questionnaire to assess asthma control. The stakeholders involved were the physicians, nursing staff, and the Health Information Team (HIT). All patients who had a prior diagnosis of asthma or with an asthma medication in their chart, who presented for any clinical visit including asthma were administered ACT. The staff scored the ACT and included the form in the encounter sheet so that the physicians can review the scores, address the asthma control, severity, and document in the chart. The number of patients whose asthma control was assessed improved from 10% per year to 85% after the three PDSA cycles. Administration of the tool did not impact the flow of the patients in a busy primary care practice. Screening asthma severity and control for patients diagnosed with asthma with a validated questionnaire when presenting for any chief complaint including asthma will help the provider address the severity and control of asthma symptoms in a timely manner and would potentially help prevent unwanted emergency department or urgent care usage.