Understanding the process of patient satisfaction with nurse-led chronic disease management in general practice.

PubMed

Mahomed, Rosemary; St John, Winsome; Patterson, Elizabeth

2012-11-01

  To investigate the process of patient satisfaction with nurse-led chronic disease management in Australian general practice.   Nurses working in the primary care context of general practice, referred to as practice nurses, are expanding their role in chronic disease management; this is relatively new to Australia. Therefore, determining patient satisfaction with this trend is pragmatically and ethically important. However, the concept of patient satisfaction is not well understood particularly in relation to care provided by practice nurses.   A grounded theory study underpinned by a relativist ontological position and a relativist epistemology.   Grounded theory was used to develop a theory from data collected through in-depth interviews with 38 participants between November 2007-April 2009. Participants were drawn from a larger project that trialled a practice nurse-led, collaborative model of chronic disease management in three Australian general practices. Theoretical sampling, data collection, and analysis were conducted concurrently consistent with grounded theory methods.   Patients undergo a cyclical process of Navigating Care involving three stages, Determining Care Needs, Forming Relationship, and Having Confidence. The latter two processes are inter-related and a feedback loop from them informs subsequent cycles of Determining Care Needs. If any of these steps fails to develop adequately, patients are likely to opt out of nurse-led care.   Navigating Care explains how and why time, communication, continuity, and trust in general practitioners and nurses are important to patient satisfaction. It can be used in identifying suitable patients for practice nurse-led care and to inform the practice and organization of practice nurse-led care to enhance patient satisfaction. © 2012 Blackwell Publishing Ltd.

How do Australian patients rate their general practitioner? A descriptive study using the General Practice Assessment Questionnaire.

PubMed

Potiriadis, Maria; Chondros, Patty; Gilchrist, Gail; Hegarty, Kelsey; Blashki, Grant; Gunn, Jane M

2008-08-18

To report patient responses to the General Practice Assessment Questionnaire (GPAQ) as a measure of satisfaction with health care received from Australian general practitioners. A clustered cross-sectional study involving general practice patients from 30 randomly selected general practices in Victoria. Between January and December 2005, a screening survey, including a postal version of the GPAQ, was mailed to 17 780 eligible patients. Scores on the six GPAQ items. We analysed data from 7130 patients who completed the screening survey and fulfilled our eligibility criteria. Levels of patient satisfaction with general practice care were generally high: mean GPAQ scores ranged from 68.6 (95% CI, 66.1-71.0) for satisfaction with access to the practice to 84.0 (95% CI, 82.2-85.4) for satisfaction with communication. Intracluster correlations for the GPAQ items ranged from 0.016 for overall satisfaction with the practice to 0.163 for satisfaction with access to the practice. Compared with national benchmarks in the United Kingdom, the GPs and practices participating in our study were rated higher on all six GPAQ items. Multivariable mixed effects linear regression showed that patients who were older, rated their health more highly, visited their GP more frequently and saw the same GP each time tended to express greater satisfaction with their care. Generally patients reported high levels of satisfaction with GP care. Greater satisfaction with care was associated with older patients, good health, more frequent contact with the GP, and seeing the one GP consistently.

A nurse led model of chronic disease care - an interim report.

PubMed

Eley, Diann S; Del Mar, Chris B; Patterson, Elizabeth; Synnott, Robyn L; Baker, Peter G; Hegney, Desley

2008-12-01

Chronic condition management in general practice is projected to account for 50% of all consultations by 2051. General practices under present workforce conditions will be unable to meet this demand. Nurse led collaborative care models of chronic disease management have been successful overseas and are proposed as one solution. This article provides an interim report on a prospective randomised trial to investigate the acceptability, cost effectiveness and feasibility of a nurse led model of care for chronic conditions in Australian general practice. A qualitative study focused on the impact of this model of care through the perceptions of practice staff from one urban and one regional practice in Queensland, and one Victorian rural practice. Primary benefits of the collaborative care model focused on increased efficiency and communication between practice staff and patients. The increased degree of patient self responsibility was noted by all and highlights the motivational aspect of chronic disease management.

Individualized population care: linking personal care to population care in general practice.

PubMed

Buetow, Stephen; Getz, Linn; Adams, Peter

2008-10-01

General practice is increasingly expected to deliver population care to individual patients. The feasibility and ethics of this policy shift have been challenged. Our aim is to suggest how to deliver population care while protecting personal care. We outline and discuss concepts of these types of care, their relation to the prevailing discourse regarding intervention benefits, and arguments for individualized population care. Individualized population care can enable general practice to meet the health targets of individual patients in the light of population-based goals. It unifies the concepts of personal care and whole population care. Personal care focuses on the individual good in particular consultations. Whole population care focuses on the overall health good of a population without reference to the individuality of each population member. These types of care constitute elements of a continuum that varies in purpose and objects of focus. The limitations of a crude dichotomy of personal care and population care are made explicit in a series of five arguments that lend support to the concept of individualized population care. We advocate a constructive but critical attitude towards the idea of population-based interventions in everyday general practice. Traditional personal care and whole population care can theoretically be integrated into individualized population care. However, this presupposes clinical-epidemiological expertise and moral awareness in practising clinicians.

Family medicine outpatient encounters are more complex than those of cardiology and psychiatry.

PubMed

Katerndahl, David; Wood, Robert; Jaén, Carlos Roberto

2011-01-01

comparison studies suggest that the guideline-concordant care provided for specific medical conditions is less optimal in primary care compared with cardiology and psychiatry settings. The purpose of this study is to estimate the relative complexity of patient encounters in general/family practice, cardiology, and psychiatry settings. secondary analysis of the 2000 National Ambulatory Medical Care Survey data for ambulatory patients seen in general/family practice, cardiology, and psychiatry settings was performed. The complexity for each variable was estimated as the quantity weighted by variability and diversity. there is minimal difference in the unadjusted input and total encounter complexity of general/family practice and cardiology; psychiatry's input is less complex. Cardiology encounters involved more input quantitatively, but the diversity of general/family practice input eliminated the difference. Cardiology also involved more complex output. However, when the duration of visit is factored in, the complexity of care provided per hour in general/family practice is 33% more relative to cardiology and 5 times more relative to psychiatry. care during family physician visits is more complex per hour than the care during visits to cardiologists or psychiatrists. This may account for a lower rate of completion of process items measured for quality of care.

A qualitative study of the barriers and enablers to fertility-awareness education in general practice.

PubMed

Hampton, Kerry D; Newton, Jennifer M; Parker, Rhian; Mazza, Danielle

2016-07-01

To understand the barriers and enablers to fertility-awareness education in general practice. Most women along with their primary care practitioners - general practitioners and practice nurses - believe that women should be educated about fertility-awareness when first reporting trouble conceiving. To date, no in-depth study has examined the enablers and challenges of this type of education in general practice. A descriptive exploratory qualitative study using deductive content analysis. General practitioners (N = 11) and practice nurses (N = 20) were recruited from general practices in three socioculturally diverse areas in Victoria, Australia. Data were collected through semistructured interviews based on the 12 domains of a theoretical behaviour change framework from April-August 2012. The participants' responses were organized into themes that fall under the framework domains. The biggest barriers to fertility-awareness education in general practice were short consultations and time constraints faced by general practitioners together with a lack of patient educational materials and remuneration to support its delivery. The biggest enablers were a greater use of nurses trained in fertility-awareness in a collaborative team care arrangement with general practitioners. This study has identified several important barriers and enablers to fertility-awareness education in general practice. Translation into practice of our findings is imperative as the first step in establishing a primary care model in fertility-awareness. This would fill an important gap in the primary care of infertile women and build capacity in general practice to reduce infertility through women's enhanced fertility knowledge. © 2016 John Wiley & Sons Ltd.

Systems for the management of respiratory disease in primary care - an international series: Australia.

PubMed

Glasgow, Nicholas

2008-03-01

Australia has a complex health system with policy and funding responsibilities divided across federal and state/territory boundaries and service provision split between public and private providers. General practice is largely funded through the federal government. Other primary health care services are provided by state/territory public entities and private allied health practitioners. Indigenous health services are specifically funded by the federal government through a series of Aboriginal Community Controlled Organisations. NATIONAL POLICY AND MODELS: The dominant primary health care model is federally-funded private "small business" general practices. Medicare reimbursement items have incrementally changed over the last decade to include increasing support for chronic disease care with both generic and disease specific items as incentives. Asthma has received a large amount of national policy attention. Other respiratory diseases have not had similar policy emphasis. Australia has a high prevalence of asthma. Respiratory-related encounters in general practice, including acute and chronic respiratory illness and influenza immunisations, account for 20.6% of general practice activity. Lung cancer is a rare disease in general practice. Tuberculosis is uncommon and most often found in people born outside of Australia. Aboriginal and Torres Strait Islanders have higher rates of asthma, smoking and tuberculosis. Access to care is positively influenced by substantial public funding underpinning both the private and public sectors through Medicare. Access to general practice care is negatively influenced by workforce shortages, the ongoing demands of acute care, and the incremental way in which system redesign is occurring in general practice. Most general practice operates from privately-owned rooms. The Australian Government requires general practice facilities to be accredited against certain standards in order for the practice to receive income from a number of government programs. These standards require GPs to have ready access to spirometry, but do not require every practice to have a spirometer. The initial assessment and management of acute respiratory illnesses currently seen in primary health care settings will continue, but for this to occur the sector may have to adapt traditional workforce roles because of workforce shortages. In the longer term, climate change and migration patterns may result in changes in the epidemiology of regions and populations. The health system will continue to reform incrementally in order to deliver improved chronic disease care, including care of people with asthma and COPD. The incoming Labor Government's National Primary Health Care Strategy provides the high level policy opportunity to drive reform. Australia's complex primary health care system is incrementally changing from one of exclusive acute- and episodic-care orientation in both the public and private sectors to a system that delivers effective anticipatory chronic disease care as well. From a national policy perspective, asthma has received most attention. COPD and possibly other respiratory diseases may now receive focus.

Patients' evaluations of European general practice--revisited after 11 years.

PubMed

Petek, Davorina; Künzi, Beat; Kersnik, Janko; Szecsenyi, Joachim; Wensing, Michel

2011-12-01

In the last decade many things have changed in healthcare systems, primary care practices and populations. To describe evaluations of general practice care by patients with a chronic illness in 2009 and compare these with a previous study done in 1998. A descriptive analysis of patients' evaluations, using data from the European practice assessment Cardio study on cardiovascular patients in eight European countries in 2009. We compared these evaluations with a subgroup of patients with self-defined chronic illness from the study in 1998, using a linear regression model. Patients' evaluation of general practice using the EUROPEP questionnaire. The EUROPEP is a 23-item validated measure of patient evaluations of general practice care. In 2009, 7472 patients from 251 practices participated in the study with an overall response rate of 49.6%. The percentage of patients with positive evaluations (good/excellent) was 80% or higher for all items, except for the waiting time. More positive evaluations were found in older patients, patients with a longer attachment to the practice, patients with a higher self-evaluation of their health, patients with fewer mental health problems and less pain/discomfort. The comparison between 1998 and 2009 showed no overall trends for all countries combined. Whereas English patients became fairly more positive about general practice in 2009, German patients became slightly less positive, although still more positive than English patients. Overall, the patients' evaluations of general practice were very positive in family practice care in the years 1998 and 2009. The trends over the years need to be carefully interpreted over time.

Early detection of health problems in potentially frail community-dwelling older people by general practices--project [G]OLD: design of a longitudinal, quasi-experimental study.

PubMed

Stijnen, Mandy M N; Duimel-Peeters, Inge G P; Jansen, Maria W J; Vrijhoef, Hubertus J M

2013-01-18

Due to the ageing of the population, the number of frail older people who suffer from multiple, complex health complaints increases and this ultimately threatens their ability to function independently. Many interventions for frail older people attempt to prevent or delay functional decline, but they show contradicting results. Recent studies emphasise the importance of embedding these interventions into existing primary care systems and tailoring care to older people's needs and wishes. This article presents the design of an evaluation study, aiming to investigate the effects and feasibility of the early detection of health problems among community-dwelling older people and their subsequent referral to appropriate care and/or well-being facilities by general practices. A longitudinal, quasi-experimental study is designed comparing 13 intervention practices with 11 control practices. General practices select eligible community-dwelling older people (≥ 75 years). Practice nurses from intervention practices (1) visit older people at home for a comprehensive assessment of their health and well-being; (2) discuss results with the GP; (3) formulate - if required - a care and treatment plan together with the patient; (4) refer patient to care and/or well-being facilities; and (5) monitor and coordinate care and follow-up. Control practices provide usual care and match the intervention practices on the presence of different primary care professionals within the practice. Primary outcome measures are health-related quality of life and disability. Additionally, attitude towards ageing, care satisfaction, health care utilisation, nursing home admission and mortality are measured. Some outcomes are assessed by means of a postal questionnaire (at baseline and after 6, 12, and 18 months follow-up), others through continuous registration over the 18-month period. A profound process evaluation will provide insight into barriers and facilitators for implementing the intervention protocol within general practices from both the patient and caregiver perspective. The proposed approach requires redesigning care delivery within general practices for accomplishing appropriate care for older people. A quasi-experimental design is chosen to closely resemble a real-life situation, which is desirable for future implementation after this innovation proves to be successful. Results of the effect and process evaluation will become available in 2013. The Netherlands National Trial Register NTR2737.

Postgraduate training for general practice in the United Kingdom.

PubMed

Eisenberg, J M

1979-04-01

Although the role of general practice is well established in the United Kingdom's National Health Service, formal postgraduate training for primary care practice is a recent development. Trainees may enter three-year programs of coordinated inpatient and outpatient training or may select a series of independent posts. Programs have been developed to train general practitioners as teachers, and innovative courses have been established. Nevertheless, there is a curious emphasis on inpatient experiences, especially since British general practitioners seldom treat patients in the hospital. In their outpatient experiences trainees are provided with little variety in their instructors, practice settings, and medical problems. The demands on this already strained system will soon be increased due to recent legislation requiring postgraduate training for all new general practitioners. With a better understanding of training for primary care in the National Health Service, those planning American primary care training may avoid the problems and incorporate the attributes of British training for general practice.

Management of asthma in Australian general practice: care is still not in line with clinical practice guidelines.

PubMed

Barton, Christopher; Proudfoot, Judith; Amoroso, Cheryl; Ramsay, Emmae; Holton, Christine; Bubner, Tanya; Harris, Mark; Beilby, Justin

2009-06-01

We investigated the quality of primary care asthma management in a sample of Australian general practices. 247 general practitioners (GPs) from 97 practices completed a structured interview about management of asthma, diabetes and hypertension/heart disease. A further structured interview with the senior practice principal and practice manager was used to collect information about practice capacity for chronic disease management. Just under half of GPs (47%) had access to an asthma register and the majority (76%) had access to spirometry in their practice. In terms of routine management of asthma, 12% of GPs reported using spirometry routinely, 13% routinely reviewed written asthma action plans, 27% routinely provided education about trigger factors, 30% routinely reviewed inhaler technique, 24% routinely assessed asthma severity, and 29% routinely assessed physical activity. Practice characteristics such as practice size (p=1.0) and locality (rural/metropolitan) (p=0.7) did not predict quality of asthma management nor did indicators of practice capacity including Business maturity, IT/IM maturity, Multidisciplinary teamwork, and Clinical linkages. Gaps remain in the provision of evidence-based care for patients with asthma in general practice. Markers of practice capacity measured here were not associated with guideline-based respiratory care within practices.

Systems and complexity thinking in the general practice literature: an integrative, historical narrative review.

PubMed

Sturmberg, Joachim P; Martin, Carmel M; Katerndahl, David A

2014-01-01

Over the past 7 decades, theories in the systems and complexity sciences have had a major influence on academic thinking and research. We assessed the impact of complexity science on general practice/family medicine. We performed a historical integrative review using the following systematic search strategy: medical subject heading [humans] combined in turn with the terms complex adaptive systems, nonlinear dynamics, systems biology, and systems theory, limited to general practice/family medicine and published before December 2010. A total of 16,242 articles were retrieved, of which 49 were published in general practice/family medicine journals. Hand searches and snowballing retrieved another 35. After a full-text review, we included 56 articles dealing specifically with systems sciences and general/family practice. General practice/family medicine engaged with the emerging systems and complexity theories in 4 stages. Before 1995, articles tended to explore common phenomenologic general practice/family medicine experiences. Between 1995 and 2000, articles described the complex adaptive nature of this discipline. Those published between 2000 and 2005 focused on describing the system dynamics of medical practice. After 2005, articles increasingly applied the breadth of complex science theories to health care, health care reform, and the future of medicine. This historical review describes the development of general practice/family medicine in relation to complex adaptive systems theories, and shows how systems sciences more accurately reflect the discipline's philosophy and identity. Analysis suggests that general practice/family medicine first embraced systems theories through conscious reorganization of its boundaries and scope, before applying empirical tools. Future research should concentrate on applying nonlinear dynamics and empirical modeling to patient care, and to organizing and developing local practices, engaging in community development, and influencing health care reform.

Systems and Complexity Thinking in the General Practice Literature: An Integrative, Historical Narrative Review

PubMed Central

Sturmberg, Joachim P.; Martin, Carmel M.; Katerndahl, David A.

2014-01-01

PURPOSE Over the past 7 decades, theories in the systems and complexity sciences have had a major influence on academic thinking and research. We assessed the impact of complexity science on general practice/family medicine. METHODS We performed a historical integrative review using the following systematic search strategy: medical subject heading [humans] combined in turn with the terms complex adaptive systems, nonlinear dynamics, systems biology, and systems theory, limited to general practice/family medicine and published before December 2010. A total of 16,242 articles were retrieved, of which 49 were published in general practice/family medicine journals. Hand searches and snowballing retrieved another 35. After a full-text review, we included 56 articles dealing specifically with systems sciences and general/family practice. RESULTS General practice/family medicine engaged with the emerging systems and complexity theories in 4 stages. Before 1995, articles tended to explore common phenomenologic general practice/family medicine experiences. Between 1995 and 2000, articles described the complex adaptive nature of this discipline. Those published between 2000 and 2005 focused on describing the system dynamics of medical practice. After 2005, articles increasingly applied the breadth of complex science theories to health care, health care reform, and the future of medicine. CONCLUSIONS This historical review describes the development of general practice/family medicine in relation to complex adaptive systems theories, and shows how systems sciences more accurately reflect the discipline’s philosophy and identity. Analysis suggests that general practice/family medicine first embraced systems theories through conscious reorganization of its boundaries and scope, before applying empirical tools. Future research should concentrate on applying nonlinear dynamics and empirical modeling to patient care, and to organizing and developing local practices, engaging in community development, and influencing health care reform. PMID:24445105

The work and challenges of care managers in the implementation of collaborative care: A qualitative study.

PubMed

Overbeck, G; Kousgaard, M B; Davidsen, A S

2018-04-01

WHAT IS KNOWN ON THE SUBJECT?: In collaborative care models between psychiatry and general practice, mental health nurses are used as care managers who carry out the treatment of patients with anxiety or depression in general practice and establish a collaborating relationship with the general practitioner. Although the care manager is the key person in the collaborative care model, there is little knowledge about this role and the challenges involved in it. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study shows that before the CMs could start treating patients in a routine collaborative relationship with GPs, they needed to carry out an extensive amount of implementation work. This included solving practical problems of location and logistics, engaging GPs in the intervention, and tailoring collaboration to meet the GP's particular preferences. Implementing the role requires high commitment and an enterprising approach on the part of the care managers. The very experienced mental health nurses of this study had these skills. However, the same expertise cannot be presumed in a disseminated model. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When introducing new collaborative care interventions, the care manager role should be well defined and be well prepared, especially as regards the arrival of the care manager in general practice, and supported during implementation by a coordinated leadership established in collaboration between hospital psychiatry and representatives from general practice. Introduction In collaborative care models for anxiety and depression, the care manager (CM), often a mental health nurse, has a key role. However, the work and challenges related to this role remain poorly investigated. Aim To explore CMs' experiences of their work and the challenges they face when implementing their role in a collaborative care intervention in the Capital Region of Denmark. Methods Interviews with eight CMs, a group interview with five CMs and a recording of one supervision session were analysed by thematic analysis. Results The CM carried out considerable implementation work. This included finding suitable locations; initiating and sustaining communication with the GPs and maintaining their engagement in the model; adapting to the patient population in general practice; dealing with personal security issues, and developing supportive peer relations and meaningful supervision. Discussion We compare our findings to previous studies of collaborative care and advanced nursing roles in general practice. The importance of organizational leadership to support the CM's bridge-building role is emphasized. Implications for practice The planners of new collaborative care interventions should not only focus on the CM's clinical tasks but also on ensuring the sufficient organizational conditions for carrying out the role. © 2017 John Wiley & Sons Ltd.

I don't think general practice should be the front line: Experiences of general practitioners working with refugees in South Australia

PubMed Central

Johnson, David R; Ziersch, Anna M; Burgess, Teresa

2008-01-01

Introduction Many refugees arrive in Australia with complex health needs. In South Australia (SA), providing initial health care to refugees is the responsibility of General Practitioners (GPs) in private practice. Their capacity to perform this work effectively for current newly arrived refugees is uncertain. The aim of this study was to document the challenges faced by GPs in private practice in SA when providing initial care to refugees and to discuss the implications of this for policy relating to optimising health care services for refugees. Methods Semi-structured interviews with twelve GPs in private practice and three Medical Directors of Divisions of General Practice. Using a template analysis approach the interviews were coded and analysed thematically. Results Multiple challenges providing care to refugees were found including those related to: (1) refugee health issues; (2) the GP-refugee interaction; and (3) the structure of general practice. The Divisions also reported challenges assisting GPs to provide effective care related to a lack of funding and awareness of which GPs required support. Although respondents suggested a number of ways that GPs could be assisted to provide better initial care to refugees, strong support was voiced for the initial care of refugees to be provided via a specialist refugee health service. Conclusion GPs in this study were under-resourced, at both an individual GP level as well as a structural level, to provide effective initial care for refugees. In SA, there are likely to be a number of challenges attempting to increase the capacity of GPs in private practice to provide initial care. An alternative model is for refugees with multiple and complex health care needs as well as those with significant resettlement challenges to receive initial health care via the existing specialist refugee health service in Adelaide. PMID:18687150

Getting the most out of your practice--the Practice Health Atlas and business modelling opportunities.

PubMed

Del Fante, Peter; Allan, Don; Babidge, Elizabeth

2006-01-01

The Practice Health Atlas (PHA) is a decision support tool for general practice, designed by the Adelaide Western Division of General Practice (AWDGP). This article describes the features of the PHA and its potential role in enhancing health care. In developing the PHA, the AWDGP utilises a range of software tools and consults with a practice to understand its clinical data management approach. The PHA comprises three sections: epidemiology, business and clinical modelling systems, access to services. The objectives include developing a professional culture around quality health data and synthesis of aggregated de-identified general practice data at both practice and divisional level (and beyond) to assist with local health needs assessment, planning, and funding. Evaluation occurs through group feedback sessions and from the general practitioners and staff. It has demonstrated its potential to fulfill the objectives in outcome areas such as data quality and management, team based care, pro-active practice population health care, and business systems development, thereby contributing to improved patient health outcomes.

Role of the registered nurse in primary health care: meeting health care needs in the 21st century.

PubMed

Smolowitz, Janice; Speakman, Elizabeth; Wojnar, Danuta; Whelan, Ellen-Marie; Ulrich, Suzan; Hayes, Carolyn; Wood, Laura

2015-01-01

There is widespread interest in the redesign of primary health care practice models to increase access to quality health care. Registered nurses (RNs) are well positioned to assume direct care and leadership roles based on their understanding of patient, family, and system priorities. This project identified 16 exemplar primary health care practices that used RNs to the full extent of their scope of practice in team-based care. Interviews were conducted with practice representatives. RN activities were performed within three general contexts: episodic and preventive care, chronic disease management, and practice operations. RNs performed nine general functions in these contexts including telephone triage, assessment and documentation of health status, chronic illness case management, hospital transition management, delegated care for episodic illness, health coaching, medication reconciliation, staff supervision, and quality improvement leadership. These functions improved quality and efficiency and decreased cost. Implications for policy, practice, and RN education are considered. Copyright © 2015 Elsevier Inc. All rights reserved.

A pragmatic cluster randomized controlled trial of early intervention for chronic obstructive pulmonary disease by practice nurse-general practitioner teams: Study Protocol

PubMed Central

2012-01-01

Background Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of disability, hospitalization, and premature mortality. General practice is well placed to diagnose and manage COPD, but there is a significant gap between evidence and current practice, with a low level of awareness and implementation of clinical practice guidelines. Under-diagnosis of COPD is a world-wide problem, limiting the benefit that could potentially be achieved through early intervention strategies such as smoking cessation, dietary advice, and exercise. General practice is moving towards more structured chronic disease management, and the increasing involvement of practice nurses in delivering chronic care. Design A pragmatic cluster randomised trial will test the hypothesis that intervention by a practice nurse-general practitioner (GP) team leads to improved health-related quality of life and greater adherence with clinical practice guidelines for patients with newly-diagnosed COPD, compared with usual care. Forty general practices in greater metropolitan Sydney Australia will be recruited to identify patients at risk of COPD and invite them to attend a case finding appointment. Practices will be randomised to deliver either practice nurse-GP partnership care, or usual care, to patients newly-diagnosed with COPD. The active intervention will involve the practice nurse and GP working in partnership with the patient in developing and implementing a care plan involving (as appropriate), smoking cessation, immunisation, pulmonary rehabilitation, medication review, assessment and correction of inhaler technique, nutritional advice, management of psycho-social issues, patient education, and management of co-morbidities. The primary outcome measure is health-related quality of life, assessed with the St George’s Respiratory Questionnaire 12 months after diagnosis. Secondary outcome measures include validated disease-specific and general health related quality of life measures, smoking and immunisation status, medications, inhaler technique, and lung function. Outcomes will be assessed by project officers blinded to patients’ randomization groups. Discussion This study will use proven case-finding methods to identify patients with undiagnosed COPD in general practice, where improved care has the potential for substantial benefit in health and healthcare utilization. The study provides the capacity to trial a new model of team-based assessment and management of newly diagnosed COPD in Australian primary care. Trial registration ACTRN12610000592044\\ PMID:22958678

Relationship of respiratory care bundle with incentive spirometry to reduced pulmonary complications in a medical general practice unit.

PubMed

Lamar, Joanne

2012-01-01

To address an increase in patient transfers to the intensive care unit because of respiratory distress, a respiratory care bundle utilizing incentive spirometry was developed for a medical general practice unit. This resulted in decreased respiratory complications over 12 months.

Performance of new alternative providers of primary care services in England: an observational study

PubMed Central

Greaves, Felix; Laverty, Anthony A; Pape, Utz; Ratneswaren, Anenta; Majeed, Azeem

2015-01-01

Summary Objectives Health system reforms in England are opening broad areas of clinical practice to new providers of care. As part of these reforms, new entrants – including private companies – have been allowed into the primary care market under ‘alternative provider of medical services’ contracting mechanisms since 2004. The characteristics and performance of general practices working under new alternative provider contracts are not well described. We sought to compare the quality of care provided by new entrant providers to that provided by the traditional model of general practice. Design Open cohort study of English general practices. We used linear regression in cross-sectional and time series analyses, adjusting for practice and population characteristics, to compare quality in practices using alternative provider contracts to traditional practices. We created regression models using practice fixed effects to estimate the impact of practices changing to the new contract type. Setting The English National Health Service. Participants All general practices open from 2008/2009 to 2012/2013. Main outcome measures Seventeen established quality indicators – covering clinical effectiveness, efficiency, access and patient experience. Results In total, 4.1% (347 of 8300) of general practices in England were run by alternative contract providers. These practices tended to be smaller, and serve younger, more diverse and more deprived populations than traditional providers. Practices run by alternative providers performed worse than traditional providers on 15 of 17 indicators after adjusting for practice and population characteristics (p < 0.01 for all). Switching to a new alternative provider contract did not result in improved performance. Conclusions The introduction of new alternative providers to deliver primary care services in England has not led to improvements in quality and may have resulted in worse care. Regulators should ensure that new entrants to clinical provider markets are performing to adequate standards and at least as well as traditional providers. PMID:25908312

Performance of new alternative providers of primary care services in England: an observational study.

PubMed

Greaves, Felix; Laverty, Anthony A; Pape, Utz; Ratneswaren, Anenta; Majeed, Azeem; Millett, Christopher

2015-05-01

Health system reforms in England are opening broad areas of clinical practice to new providers of care. As part of these reforms, new entrants--including private companies--have been allowed into the primary care market under 'alternative provider of medical services' contracting mechanisms since 2004. The characteristics and performance of general practices working under new alternative provider contracts are not well described. We sought to compare the quality of care provided by new entrant providers to that provided by the traditional model of general practice. Open cohort study of English general practices. We used linear regression in cross-sectional and time series analyses, adjusting for practice and population characteristics, to compare quality in practices using alternative provider contracts to traditional practices. We created regression models using practice fixed effects to estimate the impact of practices changing to the new contract type. The English National Health Service. All general practices open from 2008/2009 to 2012/2013. Seventeen established quality indicators--covering clinical effectiveness, efficiency, access and patient experience. In total, 4.1% (347 of 8300) of general practices in England were run by alternative contract providers. These practices tended to be smaller, and serve younger, more diverse and more deprived populations than traditional providers. Practices run by alternative providers performed worse than traditional providers on 15 of 17 indicators after adjusting for practice and population characteristics (p < 0.01 for all). Switching to a new alternative provider contract did not result in improved performance. The introduction of new alternative providers to deliver primary care services in England has not led to improvements in quality and may have resulted in worse care. Regulators should ensure that new entrants to clinical provider markets are performing to adequate standards and at least as well as traditional providers. © The Royal Society of Medicine.

General practice and specialist palliative care teams: an exploration of their working relationship from the perspective of clinical staff working in New Zealand.

PubMed

Keane, Barry; Bellamy, Gary; Gott, Merryn

2017-01-01

With the future focus on palliative and end-of-life care provision in the community, the role of the general practice team and their relationship with specialist palliative care providers is key to responding effectively to the projected increase in palliative care need. Studies have highlighted the potential to improve co-ordination and minimise fragmentation of care for people living with palliative care need through a partnership between generalist services and specialist palliative care. However, to date, the exact nature of this partnership approach has not been well defined and debate exists about how to make such partnerships work successfully. The aim of this study was to explore how general practice and specialist palliative care team (SPCT) members view their relationship in terms of partnership working. Five focus group discussions with general practices and SPCT members (n = 35) were conducted in 2012 in two different regions of New Zealand and analysed using a general inductive approach. The findings indicate that participants' understanding of partnership working was informed by their identity as a generalist or specialist, their existing rules of engagement and the approach they took towards sustaining the partnership. Considerable commitment to partnership working was shown by all participating teams. However, their working relationship was based primarily on trust and personal liaison, with limited formal systems in place to enable partnership working. Tensions between the cultures of 'generalism' and 'specialism' also provided challenges for those endeavouring to meet palliative care need collaboratively in the community. Further research is required to better understand the factors associated with successful partnership working between general practices and specialist palliative care in order to develop robust strategies to support a more sustainable model of community palliative care. © 2015 John Wiley & Sons Ltd.

Managing high-risk patients: the Mass General care management programme

PubMed Central

Kodner, Dennis L.

2015-01-01

The Massachusetts General Care Management Program (Mass General CMP or CMP) was designed as a federally supported demonstration to test the impact of intensive, practice-based care management on high-cost Medicare fee-for-service (FFS) beneficiaries—primarily older persons—with multiple hospitalisations and multiple chronic conditions. The Massachusetts General Care Management Program operated over a 6-year period in two phases (3 years each). It started during the first phase at Massachusetts General Hospital, a major academic medical centre in Boston, Massachusetts in collaboration with Massachusetts General Physicians Organisation. During the second phase, the programme expanded to two more affiliated sites in and around the Boston area, including a community hospital, as well as incorporated several modifications primarily focused on the management of transitions to post-acute care in skilled nursing facilities. At the close of the demonstration in July 2012, Mass General Massachusetts General Care Management Program became a component of a new Pioneer accountable care organisation (ACO). The Massachusetts General Care Management Program is focused on individuals meeting defined eligibility criteria who are offered care that is integrated by a case manager embedded in a primary care practice. The demonstration project showed substantial cost savings compared to fee-for-service patients served in the traditional Medicare system but no impact on hospital readmissions. The Massachusetts General Care Management Program does not rest upon a “whole systems” approach to integrated care. It is an excellent example of how an innovative care co-ordination programme can be implemented in an existing health-care organisation without making fundamental changes in its underlying structure or the way in which direct patient care services are paid for. The accountable care organisation version of the Massachusetts General Care Management Program includes the staffing structure, standards of practice, collaborative approach to care transitions and information technology tools that were used in the original demonstration project. PMID:26417211

Primary care access for mental illness in Australia: Patterns of access to general practice from 2006 to 2016.

PubMed

Farrer, Louise M; Walker, Jennie; Harrison, Christopher; Banfield, Michelle

2018-01-01

General practice has an important role within the Australian healthcare system to provide access to care and effective management of chronic health conditions. However, people with serious mental illness experience challenges associated with service access. The current paper seeks to examine drivers of access to general practice for people with common and serious mental disorders, compared with people who access care for type II diabetes, a common physical health problem managed in general practice. The Bettering the Evaluation and Care of Health (BEACH) programme provides the most comprehensive and objective measurement of general practitioner activity in Australia. Using BEACH data, this study compared general practice encounters for depression, anxiety, bipolar disorder, schizophrenia, and type II diabetes during a 10-year period between 2006 and 2016. Analysis revealed more frequent encounters for depression compared to anxiety, and a higher representation of women in encounters for bipolar disorder compared to men. The relationship between number of encounters and patient age was strongly associated with the life course and mortality characteristics associated with each disorder. The findings highlight specific challenges associated with access to primary care for people with serious mental illness, and suggest areas of focus to improve the ability of these patients to access and navigate the health system.

Information in general medical practices: the information processing model.

PubMed

Crowe, Sarah; Tully, Mary P; Cantrill, Judith A

2010-04-01

The need for effective communication and handling of secondary care information in general practices is paramount. To explore practice processes on receiving secondary care correspondence in a way that integrates the information needs and perceptions of practice staff both clinical and administrative. Qualitative study using semi-structured interviews with a wide range of practice staff (n = 36) in nine practices in the Northwest of England. Analysis was based on the framework approach using N-Vivo software and involved transcription, familiarization, coding, charting, mapping and interpretation. The 'information processing model' was developed to describe the six stages involved in practice processing of secondary care information. These included the amendment or updating of practice records whilst simultaneously or separately actioning secondary care recommendations, using either a 'one-step' or 'two-step' approach, respectively. Many factors were found to influence each stage and impact on the continuum of patient care. The primary purpose of processing secondary care information is to support patient care; this study raises the profile of information flow and usage within practices as an issue requiring further consideration.

Attitudes to the public release of comparative information on the quality of general practice care: qualitative study.

PubMed

Marshall, Martin N; Hiscock, Julia; Sibbald, Bonnie

2002-11-30

To examine the attitudes of service users, general practitioners, and clinical governance leads based in primary care trusts to the public dissemination of comparative reports on quality of care in general practice, to guide the policy and practice of public disclosure of information in primary care. Qualitative focus group study using mock quality report cards as prompts for discussion. 12 focus groups held in an urban area in north west England and a semirural area in the south of England. 35 service users, 24 general practitioners, and 18 clinical governance leads. There was general support for the principle of publishing comparative information, but all three stakeholder groups expressed concerns about the practical implications. Attitudes were strongly influenced by experience of comparative reports from other sectors-for example, school league tables. Service users distrusted what they saw as the political motivation driving the initiative, expressed a desire to "protect" their practices from political and managerial interference, and were uneasy about practices being encouraged to compete against each other. General practitioners focused on the unfairness of drawing comparisons from current data and the risks of "gaming" the results. Clinical governance leads thought that public disclosure would damage their developmental approach to implementing clinical governance. The initial negative response to the quality reports seemed to diminish on reflection. Despite support for the principle of greater openness, the planned publication of information about quality of care in general practice is likely to face considerable opposition, not only from professional groups but also from the public. A greater understanding of the practical implications of public reporting is required before the potential benefits can be realised.

Multicomponent Program to Reduce Functional Decline in Frail Elderly People: A Cluster Controlled Trial.

PubMed

Ruikes, Franca G H; Zuidema, Sytse U; Akkermans, Reinier P; Assendelft, Willem J J; Schers, Henk J; Koopmans, Raymond T C M

2016-01-01

The increasing number of community-dwelling frail elderly people poses a challenge to general practice. We evaluated the effectiveness of a general practitioner-led extensive, multicomponent program integrating cure, care, and welfare for the prevention of functional decline. We performed a cluster controlled trial in 12 general practices in Nijmegen, the Netherlands. Community-dwelling frail elderly people aged ≥70 years were identified with the EASY-Care two-step older persons screening instrument. In 6 general practices, 287 frail elderly received care according to the CareWell primary care program. This consisted of proactive care planning, case management, medication reviews, and multidisciplinary team meetings with a general practitioner, practice and/or community nurse, elderly care physician, and social worker. In another 6 general practices, 249 participants received care as usual. The primary outcome was independence in functioning during (instrumental) activities of daily living (Katz-15 index). Secondary outcomes were quality of life [EuroQol (EQ5D+C) instrument], mental health and health-related social functioning (36-item RAND Short Form survey instrument), institutionalization, hospitalization, and mortality. Outcomes were assessed at baseline and at 12 months, and were analyzed with linear mixed-model analyses. A total of 204 participants (71.1%) in the intervention group and 165 participants (66.3%) in the control group completed the study. No differences between groups regarding independence in functioning and secondary outcomes were found. We found no evidence for the effectiveness of a multifaceted integrated care program in the prevention of adverse outcomes in community-dwelling frail elderly people. Large-scale implementation of this program is not advocated. © Copyright 2016 by the American Board of Family Medicine.

Are "part-time" general practitioners workforce idlers or committed professionals?

PubMed

Dwan, Kathryn M; Douglas, Kirsty A; Forrest, Laura E

2014-09-19

The traditional view of general practice holds that only general practitioners (GPs) in full-time clinical practice can provide quality patient care. Nevertheless, increasing numbers of GPs are choosing to work sessionally, that is, ostensibly "part-time". There are concerns about the health workforce's ability to meet demand and also fears that patient care may be compromised. We sought answers to a) what activities do GPs undertake when not consulting patients, b) why do they choose to work sessionally, and c) does sessional general practice reflect a lack of commitment to patients and the profession? Semi-structured interviews were conducted with GPs who worked sessionally, (i.e. six or fewer sessions a week in clinical general practice, where a session comprises four consecutive hours of patient care). These data were analysed qualitatively and saturation was reached. The majority of participants were in full-time paid employment, while part-time in clinical general practice. They reported that consultations increasingly required the management of patients with complex, chronic conditions who also required psychological management. Coupled with unrealistic patient expectations, these factors led GPs to be concerned about maintaining the quality patient care they considered professionally desirable. Many diversified their work activities to ensure that they retained their professional standards. "Part-time" general practice is a misnomer that masks the contribution these GPs make as part of the health workforce. Sessional practice more accurately describes the nature of our participants' clinical work. Their choice of sessional work is a professional response to the increasing demands within the consultation. It enables GPs to maintain their commitment to quality patient care and their profession, while attenuating the challenges of demanding consultations. Sessional general practitioners demonstrate strong commitment to their patients and the profession.

Models of clinical reasoning with a focus on general practice: A critical review.

PubMed

Yazdani, Shahram; Hosseinzadeh, Mohammad; Hosseini, Fakhrolsadat

2017-10-01

Diagnosis lies at the heart of general practice. Every day general practitioners (GPs) visit patients with a wide variety of complaints and concerns, with often minor but sometimes serious symptoms. General practice has many features which differentiate it from specialty care setting, but during the last four decades little attention was paid to clinical reasoning in general practice. Therefore, we aimed to critically review the clinical reasoning models with a focus on the clinical reasoning in general practice or clinical reasoning of general practitioners to find out to what extent the existing models explain the clinical reasoning specially in primary care and also identity the gaps of the model for use in primary care settings. A systematic search to find models of clinical reasoning were performed. To have more precision, we excluded the studies that focused on neurobiological aspects of reasoning, reasoning in disciplines other than medicine decision making or decision analysis on treatment or management plan. All the articles and documents were first scanned to see whether they include important relevant contents or any models. The selected studies which described a model of clinical reasoning in general practitioners or with a focus on general practice were then reviewed and appraisal or critics of other authors on these models were included. The reviewed documents on the model were synthesized. Six models of clinical reasoning were identified including hypothetic-deductive model, pattern recognition, a dual process diagnostic reasoning model, pathway for clinical reasoning, an integrative model of clinical reasoning, and model of diagnostic reasoning strategies in primary care. Only one model had specifically focused on general practitioners reasoning. A Model of clinical reasoning that included specific features of general practice to better help the general practitioners with the difficulties of clinical reasoning in this setting is needed.

The Readiness for Integrated Care Questionnaire (RICQ): An instrument to assess readiness to integrate behavioral health and primary care.

PubMed

Scott, Victoria C; Kenworthy, Tara; Godly-Reynolds, Erin; Bastien, Gilberte; Scaccia, Jonathan; McMickens, Courtney; Rachel, Sharon; Cooper, Sayon; Wrenn, Glenda; Wandersman, Abraham

2017-01-01

Integration of behavioral health and primary care services is a promising approach for reducing health disparities. The growing national emphasis on care coordination has mobilized efforts to integrate behavioral health and primary care services across the United States. These efforts align with broader health care system goals of improving health care quality, health equity, utilization efficiency, and patient outcomes. Drawing from our work on a multiyear integrated care initiative (Integrated Care Leadership Program; ICLP) and an implementation science heuristic for organizational readiness (Readiness = Motivation x General Capacity and Innovation-Specific Capacity; R = MC2), this article describes the development and implementation of a tool to assess organizational readiness for integrated care, referred to as the Readiness for Integrated Care Questionnaire (RICQ). The tool was piloted with 11 health care practices that serve vulnerable, underprivileged populations. Initial results from the RICQ revealed that participating practices were generally high in motivation, innovation-specific capacities, and general capacities at the start of ICLP. Additionally, analyses indicated that practices particularly needed support with increasing staff capacities (general knowledge and skills), improving access to and use of resources, and simplifying the steps in integrating care so the effort appears less daunting and difficult to health care team members. We discuss insights from the initial use of RICQ and practical implications of the new tool for driving integrated care efforts that can contribute to health equity. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Morbidity and process of care in urban Malaysian general practice: the impact of payment system.

PubMed

Teng, C L; Aljunid, S M; Cheah, Molly; Leong, K C; Kwa, S K

2003-08-01

The majority of primary care consultations in Malaysia occur in the general practice clinics. To date, there is no comprehensive documentation of the morbidity and practice activities in this setting. We reported the reasons for encounter, diagnoses and process of care in urban general practice and the influence of payment system on the morbidity and practice activities. 115 clinics in Kuala Lumpur, Ipoh and Penang participated in this study. General practitioners in these clinics completed a 2-page questionnaire for each of the 30 consecutive patients. The questionnaire requested for the following information: demographic data, reasons for encounter, important physical findings, diagnoses, investigations ordered, outpatient procedures performed, medical certificate given, medication prescribed and referral made. The morbidity (reasons for encounter and diagnoses) was coded using ICPC-2 and the medication data was coded using MIMS Classification Index. During 3481 encounters, 5300 RFEs (152 RFEs per 100 encounters) and 3342 diagnoses (96 diagnoses per 100 encounters) were recorded. The majority of the RFEs and diagnoses are in the following ICPC Chapters: Respiratory, General and unspecified, Digestive, Neurological, Musculoskeletal and Skin. The frequencies of selected aspects of the process of care (rate per 100 encounters) were: laboratory investigations 14.7, outpatient procedures 2.4, sick certification 26.9, referral 2.4, and medication prescription 244. Consultation for chronic diseases and acute infections were influenced more by demographic variables (age, employment) rather than payment system. Cash-paying patients were more likely to receive laboratory investigations and injections. This study demonstrated the breadth of clinical care in the general practice. Relatively fewer patients consulted specifically for preventive care and treatment of chronic diseases. The frequencies of outpatient procedures and referrals appeared to be low. Payment system results in important differences in patient mix and influences some types of practice activities.

Soft governance, restratification and the 2004 general medical services contract: the case of UK primary care organisations and general practice teams.

PubMed

Grant, Suzanne; Ring, Adele; Gabbay, Mark; Guthrie, Bruce; McLean, Gary; Mair, Frances S; Watt, Graham; Heaney, David; O'Donnell, Catherine

2015-01-01

In the UK National Health Service, primary care organisation (PCO) managers have traditionally relied on the soft leadership of general practitioners based on professional self-regulation rather than direct managerial control. The 2004 general medical services contract (nGMS) represented a significant break from this arrangement by introducing new performance management mechanisms for PCO managers to measure and improve general practice work. This article examines the impact of nGMS on the governance of UK general practice by PCO managers through a qualitative analysis of data from an empirical study in four UK PCOs and eight general practices, drawing on Hood's four-part governance framework. Two hybrids emerged: (i) PCO managers emphasised a hybrid of oversight, competition (comptrol) and peer-based mutuality by granting increased support, guidance and autonomy to compliant practices; and (ii) practices emphasised a broad acceptance of increased PCO oversight of clinical work that incorporated a restratified elite of general practice clinical peers at both PCO and practice levels. Given the increased international focus on the quality, safety and efficiency in primary care, a key issue for PCOs and practices will be to achieve an effective, contextually appropriate balance between the counterposing governance mechanisms of peer-led mutuality and externally led comptrol. © 2015 The Authors. Sociology of Health & Illness © 2015 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd.

Primary Care Physicians' Experience with Disease Management Programs

PubMed Central

Fernandez, Alicia; Grumbach, Kevin; Vranizan, Karen; Osmond, Dennis H; Bindman, Andrew B

2001-01-01

OBJECTIVE To examine primary care physicians' perceptions of how disease management programs affect their practices, their relationships with their patients, and overall patient care. DESIGN Cross-sectional mailed survey. SETTING The 13 largest urban counties in California. PARTICIPANTS General internists, general pediatricians, and family physicians. MEASUREMENTS AND MAIN RESULTS Physicians' self-report of the effects of disease management programs on quality of patient care and their own practices. Respondents included 538 (76%) of 708 physicians: 183 (34%) internists, 199 (38%) family practitioners, and 156 (29%) pediatricians. Disease management programs were available 285 to (53%) physicians; 178 had direct experience with the programs. Three quarters of the 178 physicians believed that disease management programs increased the overall quality of patient care and the quality of care for the targeted disease. Eighty-seven percent continued to provide primary care for their patients in these programs, and 70% reported participating in major patient care decisions. Ninety-one percent reported that the programs had no effect on their income, decreased (38%) or had no effect (48%) on their workload, and increased (48%)) their practice satisfaction. CONCLUSIONS Practicing primary care physicians have generally favorable perceptions of the effect of voluntary, primary care-inclusive, disease management programs on their patients and on their own practice satisfaction. PMID:11318911

Transforming family practice in British Columbia: the General Practice Services Committee.

PubMed

Cavers, William J R; Tregillus, Valerie H F; Micco, Angela; Hollander, Marcus J

2010-12-01

To describe a new approach to primary care reform developed in British Columbia (BC) under the leadership of the General Practice Services Committee (GPSC). COMPOSITION OF THE COMMITTEE: The GPSC is a joint committee of the BC Ministry of Health Services, the BC Medical Association, and the Society of General Practitioners of BC. Representatives of BC's health authorities also attend as guests. This paper is based on the 2008-2009 annual report of the GPSC. It summarizes the history and main activities of the GPSC. The GPSC is currently supporting a number of key activities to transform primary care in BC. These activities include the Full Service Family Practice Incentive Program, which provides incentive payments to promote enhanced primary care; the Practice Support Program, which provides family physicians and their medical office assistants with various practical evidence-based strategies and tools for managing practice enhancement; the Family Physicians for BC Program to develop family practices in areas of identified need; the Shared Care Committee, which supports and enables the determination of appropriate scopes of practice among GPs, specialists, and other health care professionals; the Divisions of Family Practice, which are designed to facilitate interactions among family doctors and between doctors and their respective health authorities; and the Community Healthcare and Resource Directory, a Web-based resource to help health care providers find appropriate mental health resources. Early results indicate that the GPSC's initiatives are enhancing the delivery of primary care services in BC.

Perceptions of primary care staff on a regional data quality intervention in Australian general practice: a qualitative study.

PubMed

Ghosh, Abhijeet; McCarthy, Sandra; Halcomb, Elizabeth

2016-04-26

Technological advances in clinical data capturing and storage systems have led to recent attempts at disease surveillance and region specific population health planning through regularly collected primary care administrative clinical data. However the accuracy and comprehensiveness of primary care health records remain questionable. We aimed to explore the perceptions and experiences of general practice staff in maintaining accurate patient health data within clinical software used in primary care settings of regional NSW. Focus groups were conducted with general practitioners, practice nurses and practice administrative staff from 17 practices in the Illawarra-Shoalhaven region of the state of New South Wales (NSW) in Australia that had participated in the Sentinel Practices Data Sourcing (SPDS) project - a general practice based chronic disease surveillance and data quality improvement study. A total of 25 respondents that included 12 general practitioners (GPs) and 13 practice staff participated in the 6 focus groups. Focus groups were audio-recorded and transcribed verbatim. Thematic analysis of the data was undertaken. Five key themes emerged from the data. Firstly, the theme of resourcing data management raised issues of time constraints, the lack of a dedicated data management role and the importance of multidisciplinary involvement, including a data champion. The need for incentives was identified as being important to motivate ongoing commitment to maintaining data quality. However, quality of software packages, including coding issues and software limitations and information technology skills were seen as key barriers. The final theme provided insight into the lessons learnt from the project and the increased awareness of the importance of data quality amongst practice staff. The move towards electronic methods of maintaining general practice patient records offers significant potential benefits in terms of both patient care and monitoring of health status and health needs within the community. However, this study has reinforced the importance of human factors in the maintenance of such datasets. To achieve optimal benefits of electronic health and medical records for patient care and for population health planning purposes, it is extremely essential to address the barriers that clinicians and other staff face in maintaining complete and correct primary care patient electronic health and medical information.

[Assessment of patient care needs in general practice].

PubMed

Laubach, W; Schmidt, R; Fischbeck, S; Röhrig, B; Jansky, M

2012-02-01

In the German health system general practice has changed drastically in the past few years and patients' opportunities to get medical informations have increased significantly. In light of this, patients' needs in general practice should be re-assessed. 279 patients from 16 practices mainly in Hessen and Rhineland-Palatinate were interviewed. Using principal factor analysis, 51 questions about doctors were analyzed regarding possible dimensions of patient care needs. The dimensions of patient care needs could be described with four scales: (1) social situation and emotional support, (2) the practitioner's expertise, explanations and information, (3) empathy and esteem for patients and (4) availability of the practitioner and care to chronic patients. In older age groups the importance of psychosocial care was emphasized as well as the practitioner's availability and care for patients with chronic diseases. Patient care needs are concentrated in four scales, which include psychosocial and continuous care and availability for patients with chronic diseases. These tasks should be further emphasized in medical education and also represented in the remuneration of practitioners. © Georg Thieme Verlag KG Stuttgart · New York.

Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People--the ISCOPE study.

PubMed

Blom, Jeanet; den Elzen, Wendy; van Houwelingen, Anne H; Heijmans, Margot; Stijnen, Theo; Van den Hout, Wilbert; Gussekloo, Jacobijn

2016-01-01

older people often experience complex problems. Because of multiple problems, care for older people in general practice needs to shift from a 'problem-based, disease-oriented' care aiming at improvement of outcomes per disease to a 'goal-oriented care', aiming at improvement of functioning and personal quality of life, integrating all healthcare providers. Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established. cluster randomised trial. all persons aged ≥75 in 59 general practices (30 intervention, 29 control), with a combination of problems, as identified with a structured postal questionnaire with 21 questions on four health domains. for participants with problems on ≥3 domains, general practitioners (GPs) made an integrated care plan using a functional geriatric approach. Control practices: care as usual. (i) quality of life (QoL), (ii) activities of daily living, (iii) satisfaction with delivered health care and (iv) cost-effectiveness of the intervention at 1-year follow-up. Netherlands trial register, NTR1946. of the 11,476 registered eligible older persons, 7,285 (63%) participated in the screening. One thousand nine hundred and twenty-one (26%) had problems on ≥3 health domains. For 225 randomly chosen persons, a care plan was made. No beneficial effects were found on QoL, patients' functioning or healthcare use/costs. GPs experienced better overview of the care and stability, e.g. less unexpected demands, in the care. GPs prefer proactive integrated care. 'Horizontal' care using care plans for older people with complex problems can be a valuable tool in general practice. However, no direct beneficial effect was found for older persons. © The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.

The importance of social support for people with type 2 diabetes - a qualitative study with general practitioners, practice nurses and patients.

PubMed

Goetz, Katja; Szecsenyi, Joachim; Campbell, Stephen; Rosemann, Thomas; Rueter, Gernot; Raum, Elke; Brenner, Herrmann; Miksch, Antje

2012-01-01

Social support is an important element of family medicine within a primary care setting, delivered by general practitioners and practice nurses in addition to usual clinical care. The aim of the study was to explore general practitioner's, practice nurse's and people with type 2 diabetes' views, experiences and perspectives of the importance of social support in caring for people with type 2 diabetes and their role in providing social support. Interviews with general practitioners (n=10) and focus groups with practice nurses (n=10) and people with diabetes (n=9). All data were audio-recorded, fully transcribed and thematically analysed using qualitative content analysis by Mayring. All participants emphasized the importance of the concept of social support and its impacts on well-being of people with type 2 diabetes. Social support is perceived helpful for people with diabetes in order to improve diabetes control and give support for changes in lifestyle habits (physical activity and dietary changes). General practitioners identified a lack of information about facilities in the community like sports or self-help groups. Practice nurses emphasized that they need more training, such as in dietary counselling. Social support given by general practitioners and practice nurses plays a crucial role for people with type 2 diabetes and is an additional component of social care. However there is a need for an increased awareness by general practitioners and practice nurses about the influence social support could have on the individual's diabetes management.

The Melbourne East Monash General Practice Database (MAGNET): Using data from computerised medical records to create a platform for primary care and health services research.

PubMed

Mazza, Danielle; Pearce, Christopher; Turner, Lyle Robert; De Leon-Santiago, Maria; McLeod, Adam; Ferriggi, Jason; Shearer, Marianne

2016-07-04

The Melbourne East MonAsh GeNeral PracticE DaTabase (MAGNET) research platform was launched in 2013 to provide a unique data source for primary care and health services research in Australia.  MAGNET contains information from the computerised records of 50 participating general practices and includes data from the computerised medical records of more than 1,100,000 patients.  The data extracted is patient-level episodic information and includes a variety of fields related to patient demographics and historical clinical information, along with the characteristics of the participating general practices.  While there are limitations to the data that is currently available, the MAGNET research platform continues to investigate other avenues for improving the breadth and quality of data, with the aim of providing a more comprehensive picture of primary care in Australia.

Evaluation of a practice team-supported exposure training for patients with panic disorder with or without agoraphobia in primary care - study protocol of a cluster randomised controlled superiority trial.

PubMed

Gensichen, Jochen; Hiller, Thomas S; Breitbart, Jörg; Teismann, Tobias; Brettschneider, Christian; Schumacher, Ulrike; Piwtorak, Alexander; König, Hans-Helmut; Hoyer, Heike; Schneider, Nico; Schelle, Mercedes; Blank, Wolfgang; Thiel, Paul; Wensing, Michel; Margraf, Jürgen

2014-04-06

Panic disorder and agoraphobia are debilitating and frequently comorbid anxiety disorders. A large number of patients with these conditions are treated by general practitioners in primary care. Cognitive behavioural exposure exercises have been shown to be effective in reducing anxiety symptoms. Practice team-based case management can improve clinical outcomes for patients with chronic diseases in primary care. The present study compares a practice team-supported, self-managed exposure programme for patients with panic disorder with or without agoraphobia in small general practices to usual care in terms of clinical efficacy and cost-effectiveness. This is a cluster randomised controlled superiority trial with a two-arm parallel group design. General practices represent the units of randomisation. General practitioners recruit adult patients with panic disorder with or without agoraphobia according to the International Classification of Diseases, version 10 (ICD-10). In the intervention group, patients receive cognitive behaviour therapy-oriented psychoeducation and instructions to self-managed exposure exercises in four manual-based appointments with the general practitioner. A trained health care assistant from the practice team delivers case management and is continuously monitoring symptoms and treatment progress in ten protocol-based telephone contacts with patients. In the control group, patients receive usual care from general practitioners. Outcomes are measured at baseline (T0), at follow-up after six months (T1), and at follow-up after twelve months (T2). The primary outcome is clinical severity of anxiety of patients as measured by the Beck Anxiety Inventory (BAI). To detect a standardised effect size of 0.35 at T1, 222 patients from 37 general practices are included in each group. Secondary outcomes include anxiety-related clinical parameters and health-economic costs. Current Controlled Trials [http://ISCRTN64669297].

Evaluation of a practice team-supported exposure training for patients with panic disorder with or without agoraphobia in primary care - study protocol of a cluster randomised controlled superiority trial

PubMed Central

2014-01-01

Background Panic disorder and agoraphobia are debilitating and frequently comorbid anxiety disorders. A large number of patients with these conditions are treated by general practitioners in primary care. Cognitive behavioural exposure exercises have been shown to be effective in reducing anxiety symptoms. Practice team-based case management can improve clinical outcomes for patients with chronic diseases in primary care. The present study compares a practice team-supported, self-managed exposure programme for patients with panic disorder with or without agoraphobia in small general practices to usual care in terms of clinical efficacy and cost-effectiveness. Methods/Design This is a cluster randomised controlled superiority trial with a two-arm parallel group design. General practices represent the units of randomisation. General practitioners recruit adult patients with panic disorder with or without agoraphobia according to the International Classification of Diseases, version 10 (ICD-10). In the intervention group, patients receive cognitive behaviour therapy-oriented psychoeducation and instructions to self-managed exposure exercises in four manual-based appointments with the general practitioner. A trained health care assistant from the practice team delivers case management and is continuously monitoring symptoms and treatment progress in ten protocol-based telephone contacts with patients. In the control group, patients receive usual care from general practitioners. Outcomes are measured at baseline (T0), at follow-up after six months (T1), and at follow-up after twelve months (T2). The primary outcome is clinical severity of anxiety of patients as measured by the Beck Anxiety Inventory (BAI). To detect a standardised effect size of 0.35 at T1, 222 patients from 37 general practices are included in each group. Secondary outcomes include anxiety-related clinical parameters and health-economic costs. Trial registration Current Controlled Trials [http://ISCRTN64669297] PMID:24708672

Compliance with referrals to medical specialist care: patient and general practice determinants: a cross-sectional study.

PubMed

van Dijk, Christel E; de Jong, Judith D; Verheij, Robert A; Jansen, Tessa; Korevaar, Joke C; de Bakker, Dinny H

2016-02-01

In a gatekeeper system, primary care physicians and patients jointly decide whether or not medical specialist care is needed. However, it is the patient who decides to actually use the referral. Referral non-compliance could delay diagnosis and treatment. The objective of this study was to assess patient compliance with a referral to medical specialist care and identify patient and practice characteristics that are associated with it. Observational study using data on 48,784 referrals to medical specialist care derived from electronic medical records of 58 general practices for the period 2008-2010. Referral compliance was based on claims data of medical specialist care. Logistic multilevel regression analyses were conducted to determine associations between patient and general practice characteristics and referral compliance. In 86.6% of the referrals, patients complied. Patient and not practice characteristics were significantly associated with compliance. Patients from deprived urban areas and patients aged 18-44 years were less likely to comply, whereas patients aged 65 years and older were more likely to comply. About 1 in 8 patients do not use their referral. These patients may not receive adequate care. Demographic and socio-economic factors appear to affect compliance. The results of this study may be used to make general practitioners more aware that some patients are more likely to be noncompliant with referrals.

Culture care meanings, beliefs, and practices in Rural Dominican Republic.

PubMed

Schumacher, Gretchen

2010-04-01

This ethnonursing study explored the meanings, beliefs, and practices of care for rural Dominicans in the Dominican Republic. Leininger's culture care diversity and universality theory, ethnonursing, and four-phase analysis method guided the study. Interviews were conducted with 19 general and 10 key informants. Analysis of interviews revealed three main themes: (a) family presence is essential for meaningful care experiences and care practices, (b) respect and attention are central to the meaning of care and care practices, and (c) rural Dominicans value and use both generic (folk) and professional care practices. Implications and recommendations for nursing practice, education, and research are described.

Providing end-of-life care in general practice: findings of a national GP questionnaire survey.

PubMed

Mitchell, Sarah; Loew, Joelle; Millington-Sanders, Catherine; Dale, Jeremy

2016-09-01

With increasing numbers of people living with complex life-limiting multimorbidity in the community, consideration must be given to improving the organisation and delivery of high-quality palliative and end-of-life care (EOLC). To provide insight into the experience of GPs providing EOLC in the community, particularly the facilitators and barriers to good-quality care. A web-based national UK questionnaire survey circulated via the Royal College of General Practitioners, NHS, Marie Curie, and Macmillan networks to GPs. Responses were analysed using descriptive statistics and an inductive thematic analysis. Responses were received from 516 GPs, who were widely distributed in terms of practice location. Of these, 97% felt that general practice plays a key role in the delivery of care to people approaching the end of life and their families. Four interdependent themes emerged from the data: continuity of care - which can be difficult to achieve because of resource concerns including time, staff numbers, increasing primary care workload, and lack of funding; patient and family factors - with challenges including early identification of palliative care needs and recognition of the end of life, opportunity for care planning discussions, and provision of support for families; medical management - including effective symptom-control and access to specialist palliative care services; and expertise and training - the need for training and professional development was recognised to enhance knowledge, skills, and attitudes towards EOLC. The findings reveal enduring priorities for policy, commissioning, practice development, and research in future primary palliative care. © British Journal of General Practice 2016.

Relative professional roles in antenatal care: results of a survey in Scottish rural general practice.

PubMed

Farmer, Jane; Stimpson, Paul; Tucker, Janet

2003-11-01

There is evidence of variation and some ambiguity about self-perceived relative professional roles in antenatal care in the UK. There is little information about models of antenatal care provision in UK rural areas. In rural areas, in particular, women have limited choice in accessing health care professionals or alternative primary care delivery settings. In the light of a recent review of Scottish maternity services, it is important and timely to examine models of care and interprofessional working in antenatal care in rural areas. This study explores midwives' and GPs' perceptions about their relative professional roles in remote and rural general practice in Scotland. A questionnaire survey involving all 174 Scottish remote and rural general practices (using one definition of rurality) was conducted, followed by 20 interviews. At least one professional returned a completed questionnaire from 91% of rural practices. A number of areas of dissonance were noted between GPs' and midwives' perceptions of their roles in maternity care and, given the context of service provision, these may impact upon rural patients. Findings are relevant to wider debates on extending the primary care team and strengthening inter-disciplinary working, particularly in rural areas.

General practitioners in partnership with management: an organisational model for debate.

PubMed Central

Starey, N; Bosanquet, N; Griffiths, J

1993-01-01

The role of general practitioners is changing and expanding. Doctors have more control over the treatment received by their patients but remain largely unaccountable to the public and management. This article proposes an organisational model for integrating primary and secondary care which retains the advantages of fund-holding while giving management control over overall strategy. It proposes that general practitioners control funds for all primary and secondary care. Secondary care will be contracted through a joint team of managers and an elected general practice executive committee. A new health care purchasing authority will contract for primary services with individual practices or primary care provider units. General practitioners will have local contracts reflecting their desire to provide an expanded range of services and the needs of the community. PMID:8461651

RISQy business (Relationships, Incentives, Supports, and Quality): evolution of the British Columbia Model of Primary Care (patient-centered medical home).

PubMed

MacCarthy, Dan; Hollander, Marcus J

2014-01-01

In 2002, the British Columbia Ministry of Health and the British Columbia Medical Association (now Doctors of BC) came together to form the British Columbia General Practice Services Committee to bring about transformative change in primary care in British Columbia, Canada. This committee's approach to primary care was to respond to an operational problem--the decline of family practice in British Columbia--with an operational solution--assist general practitioners to provide better care by introducing new incentive fees into the fee-for-service payment schedule, and by providing additional training to general practitioners. This may be referred to as a "soft power" approach, which can be summarized in the abbreviation RISQ: focus on Relationships; provide Incentives for general practitioners to spend more time with their patients and provide guidelines-based care; Support general practitioners by developing learning modules to improve their practices; and, through the incentive payments and learning modules, provide better Quality care to patients and improved satisfaction to physicians. There are many similarities between the British Columbian approach to primary care and the US patient-centered medical home.

Spiritual and Religious Beliefs and Practices, and Social Support's Relationship to Diabetes Self-Care Activities in African Americans

PubMed Central

Watkins, Yashika J.; Quinn, Lauretta T.; Ruggiero, Laurie; Quinn, Michael T.; Choi, Young-Ku

2013-01-01

Purpose The purpose of this study is to investigate the relationship among spiritual and religious beliefs and practices, social support, and diabetes self-care activities in African Americans with type 2 diabetes, hypothesizing that there would be a positive association. Method This cohort study used a cross-sectional design that focused on baseline data from a larger randomized control trial. Diabetes self-care activities (Summary of Diabetes Self-Care Activities; SDSCA) and sociodemographic characteristics were assessed, in addition to spiritual and religious beliefs and practices and social support using the Systems of Belief Inventory (SBI) subscale I (beliefs and practices) and subscale II (social support). Results There were 132 participants: most were female, middle-aged, obese, single, high school-educated, and not employed. Using Pearson correlation matrices, there were significant relationships between spiritual and religious beliefs and practices and general diet. Additional significant relationships were found for social support with general diet, specific diet, and foot care. Using multiple linear regression, social support was a significant predictor for general diet, specific diet, and foot care. Gender was a significant predictor for specific diet, and income was a significant predictor for blood glucose testing. Conclusions The findings of this study highlight the importance of spiritual and religious beliefs and practices and social support in diabetes self-care activities. Future research should focus on determining how providers integrate patients' beliefs and practices and social support into clinical practice and include those in behavior change interventions. PMID:23411653

Spirituality and spiritual care: a descriptive survey of nursing practices in Turkey.

PubMed

Akgün Şahin, Zümrüt; Kardaş Özdemir, Funda

2016-08-01

Nurses' spiritual care practices have been shown to affect patients' well-being, therefore understanding nurses' spiritual care perceptions and their practices. The aim of this paper is to investigate the nurses' views to practising spiritual care. A descriptive survey of 193 nurses was conducted at a general hospital in Turkey. Data was collected using a demographic questionnaire and The Spirituality and Spiritual Care Rating Scale (SSCRS). The findings of this study revealed that older nurses (p<.05); married (p<.001); higher levels of education (p<.05); work experience (p<.05); worked longer hours (p<.05); received education in spiritual care (p<.001); working in medical departments (p<.05) all tended to score higher on the SSCRS. Our research findings suggest that there is a lack of knowledge and general confusion regarding Turkish nurses perceptions and practices related to spiritual care.

Features of primary health care teams associated with successful quality improvement of diabetes care: a qualitative study.

PubMed

Stevenson, K; Baker, R; Farooqi, A; Sorrie, R; Khunti, K

2001-02-01

In quality improvement activities such as audit, some general practices succeed in improving care and some do not. With audit of care likely to be one of the major tools in clinical governance, it would be helpful to establish what features of primary health care teams are associated with successful audit in general practice. The aim of the present study was to identify those features of primary health care teams that were associated with successful quality improvement during systematic audit of diabetes care. Semi-structured tape-recorded interviews were carried out with lead GPs and practice nurses in 18 general practices in Leicestershire that had the opportunity to improve their care and had completed two data collections in a multipractice audit of diabetes care. The interviewees were asked to describe their practice's approach to audit and the transcripts were coded for common features and judged for strength of feeling by blinded independent raters. Features common to practices that had, and those that had not, managed to improve diabetes care were identified. Six features were identified reliably in the transcripts by blinded independent raters. Four were significantly associated with the successful improvement of care. Success was more likely in teams in which: the GP or nurse felt personally involved in the audit; they perceived their teamwork as good; they had recognized the need for systematic plans to address obstacles to quality improvement; and their teams had a positive attitude to continued monitoring of care. A positive attitude to audit and a personal interest in the disease were not associated with improvement in care. Success in improving diabetes care is associated with certain organizational features of primary health care teams. Experimental studies are required to determine whether the development of teamwork enables practice teams to identify and overcome systematically the obstacles to improved quality of patient care that face them.

Organisational capacity and chronic disease care: an Australian general practice perspective.

PubMed

Proudfoot, Judith; Infante, Fernando; Holton, Christine; Powell-Davies, Gawaine; Bubner, Tanya; Beilby, Justin; Harris, Mark

2007-04-01

Although we are rapidly improving our understanding of how to manage patients with chronic illness in Australian general practice, many patients are still receiving suboptimal care. General practices have limited organisational capacity to provide the structured care that is required for managing chronic conditions: regular monitoring, decision support, patient recall, supporting patient self management, team work, and information management. This requires a shift away from episodic, acute models. Overseas research has shown that areas such as team work, clinical information systems, decision support, linkages and leadership are also important in managing chronic illness, but we do not know which of these are most important in Australia.

Models of clinical reasoning with a focus on general practice: A critical review

PubMed Central

YAZDANI, SHAHRAM; HOSSEINZADEH, MOHAMMAD; HOSSEINI, FAKHROLSADAT

2017-01-01

Introduction: Diagnosis lies at the heart of general practice. Every day general practitioners (GPs) visit patients with a wide variety of complaints and concerns, with often minor but sometimes serious symptoms. General practice has many features which differentiate it from specialty care setting, but during the last four decades little attention was paid to clinical reasoning in general practice. Therefore, we aimed to critically review the clinical reasoning models with a focus on the clinical reasoning in general practice or clinical reasoning of general practitioners to find out to what extent the existing models explain the clinical reasoning specially in primary care and also identity the gaps of the model for use in primary care settings. Methods: A systematic search to find models of clinical reasoning were performed. To have more precision, we excluded the studies that focused on neurobiological aspects of reasoning, reasoning in disciplines other than medicine decision making or decision analysis on treatment or management plan. All the articles and documents were first scanned to see whether they include important relevant contents or any models. The selected studies which described a model of clinical reasoning in general practitioners or with a focus on general practice were then reviewed and appraisal or critics of other authors on these models were included. The reviewed documents on the model were synthesized. Results: Six models of clinical reasoning were identified including hypothetic-deductive model, pattern recognition, a dual process diagnostic reasoning model, pathway for clinical reasoning, an integrative model of clinical reasoning, and model of diagnostic reasoning strategies in primary care. Only one model had specifically focused on general practitioners reasoning. Conclusion: A Model of clinical reasoning that included specific features of general practice to better help the general practitioners with the difficulties of clinical reasoning in this setting is needed. PMID:28979912

The utility of an online diagnostic decision support system (Isabel) in general practice: a process evaluation.

PubMed

Henderson, Emily J; Rubin, Greg P

2013-05-01

To evaluate the utility of Isabel, an online diagnostic decision support system developed by Isabel Healthcare primarily for secondary medical care, in the general practice setting. Focus groups were conducted with clinicians to understand why and how they used the system. A modified online post-use survey asked practitioners about its impact on their decision-making. Normalization process theory (NPT) was used as a theoretical framework to determine whether the system could be incorporated into routine clinical practice. The system was introduced by NHS County Durham and Darlington in the UK in selected general practices as a three-month pilot. General practitioners and nurse practitioners who had access to Isabel as part of the Primary Care Trust's pilot. General practitioners' views, experiences and usage of the system. Seven general practices agreed to pilot Isabel. Two practices did not subsequently use it. The remaining five practices conducted searches on 16 patients. Post-use surveys (n = 10) indicated that Isabel had little impact on diagnostic decision-making. Focus group participants stated that, although the diagnoses produced by Isabel in general did not have an impact on their decision-making, they would find the tool useful if it were better tailored to the primary care setting. Our analysis concluded that normalization was not likely to occur in its current form. Isabel was of limited utility in this short pilot study and may need further modification for use in general practice.

Care Model Design for E-Health: Integration of Point-of-Care Testing at Dutch General Practices.

PubMed

Verhees, Bart; van Kuijk, Kees; Simonse, Lianne

2017-12-21

Point-of-care testing (POCT)-laboratory tests performed with new mobile devices and online technologies outside of the central laboratory-is rapidly outpacing the traditional laboratory test market, growing at a rate of 12 to 15% each year. POCT impacts the diagnostic process of care providers by yielding high efficiency benefits in terms of turnaround time and related quality improvements in the reduction of errors. However, the implementation of this disruptive eHealth technology requires the integration and transformation of diagnostic services across the boundaries of healthcare organizations. Research has revealed both advantages and barriers of POCT implementations, yet to date, there is no business model for the integration of POCT within general practice. The aim of this article is to contribute with a design for a care model that enables the integration of POCT in primary healthcare. In this research, we used a design modelling toolkit for data collection at five general practices. Through an iterative design process, we modelled the actors and value transactions, and designed an optimized care model for the dynamic integration of POCTs into the GP's network of care delivery. The care model design will have a direct bearing on improving the integration of POCT through the connectivity and norm guidelines between the general practice, the POC technology, and the diagnostic centre.

Care Model Design for E-Health: Integration of Point-of-Care Testing at Dutch General Practices

PubMed Central

Verhees, Bart; van Kuijk, Kees

2017-01-01

Point-of-care testing (POCT)—laboratory tests performed with new mobile devices and online technologies outside of the central laboratory—is rapidly outpacing the traditional laboratory test market, growing at a rate of 12 to 15% each year. POCT impacts the diagnostic process of care providers by yielding high efficiency benefits in terms of turnaround time and related quality improvements in the reduction of errors. However, the implementation of this disruptive eHealth technology requires the integration and transformation of diagnostic services across the boundaries of healthcare organizations. Research has revealed both advantages and barriers of POCT implementations, yet to date, there is no business model for the integration of POCT within general practice. The aim of this article is to contribute with a design for a care model that enables the integration of POCT in primary healthcare. In this research, we used a design modelling toolkit for data collection at five general practices. Through an iterative design process, we modelled the actors and value transactions, and designed an optimized care model for the dynamic integration of POCTs into the GP’s network of care delivery. The care model design will have a direct bearing on improving the integration of POCT through the connectivity and norm guidelines between the general practice, the POC technology, and the diagnostic centre. PMID:29267224

[Rethinking the place of primary healthcare in France--role of general practice].

PubMed

Gay, B

2013-06-01

Primary healthcare is poorly structured in France while it is well defined at the international level: it is the point of first medical contact of the population with the healthcare system. General practice is the clinical specialty oriented to primary healthcare. Data in the scientific literature highlight the need of refocusing the health system on primary care known to improve both morbi-mortality and care efficiency. In France, health authorities acknowledge general practitioners as playing a key role in the health care system: its time to move from intention to action. Structural changes are needed to achieve this reinforcement of primary healthcare: to re-orientate medical studies towards primary care; to develop research in primary care; to promote cooperation between care providers; to ease the daily workload of practitioners; to diversify methods of payment; to propose a guide for patient's use of primary care. The transformation of the healthcare system in France requires a real strategy of primary healthcare implementation. Regardless of financial constraints, it is possible to redistribute the resources towards ambulatory care. Strengthening the role of general practice and favoring its societal recognition will be the major stages of this change. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study.

PubMed

McDonald, Ruth; Harrison, Stephen; Checkland, Kath; Campbell, Stephen M; Roland, Martin

2007-06-30

To explore the impact of financial incentives for quality of care on practice organisation, clinical autonomy, and internal motivation of doctors and nurses working in primary care. Ethnographic case study. Two English general practices. 12 general practitioners, nine nurses, four healthcare assistants, and four administrative staff. Observation of practices over a five month period after the introduction of financial incentives for quality of care introduced in the 2004 general practitioner contract. After the introduction of the quality and outcomes framework there was an increase in the use of templates to collect data on quality of care. New regimens of surveillance were adopted, with clinicians seen as "chasers" or the "chased," depending on their individual responsibility for delivering quality targets. Attitudes towards the contract were largely positive, although discontent was higher in the practice with a more intensive surveillance regimen. Nurses expressed more concern than doctors about changes to their clinical practice but also appreciated being given responsibility for delivering on targets in particular disease areas. Most doctors did not question the quality targets that existed at the time or the implications of the targets for their own clinical autonomy. Implementation of financial incentives for quality of care did not seem to have damaged the internal motivation of the general practitioners studied, although more concern was expressed by nurses.

Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study

PubMed Central

Harrison, Stephen; Checkland, Kath; Campbell, Stephen M; Roland, Martin

2007-01-01

Objective To explore the impact of financial incentives for quality of care on practice organisation, clinical autonomy, and internal motivation of doctors and nurses working in primary care. Design Ethnographic case study. Setting Two English general practices. Participants 12 general practitioners, nine nurses, four healthcare assistants, and four administrative staff. Main outcome measure Observation of practices over a five month period after the introduction of financial incentives for quality of care introduced in the 2004 general practitioner contract. Results After the introduction of the quality and outcomes framework there was an increase in the use of templates to collect data on quality of care. New regimens of surveillance were adopted, with clinicians seen as “chasers” or the “chased,” depending on their individual responsibility for delivering quality targets. Attitudes towards the contract were largely positive, although discontent was higher in the practice with a more intensive surveillance regimen. Nurses expressed more concern than doctors about changes to their clinical practice but also appreciated being given responsibility for delivering on targets in particular disease areas. Most doctors did not question the quality targets that existed at the time or the implications of the targets for their own clinical autonomy. Conclusions Implementation of financial incentives for quality of care did not seem to have damaged the internal motivation of the general practitioners studied, although more concern was expressed by nurses. PMID:17580318

IS/IT the prescription to enable medical group practices attain their goals.

PubMed

Wickramasinghe, Nilmini; Silvers, J B

2003-05-01

The US spends significantly more money as a percentage of GDP on health care than any other OECD country and more importantly, this amount is anticipated to increase exponentially. In this high cost environment, two important trends have occurred: (1) the movement to managed care, and (2) large investments in Information Systems/Information Technology (IS/IT). Managed care has emerged as an attempt to provide good quality yet cost effective health care treatment. Its implications are not well discussed in the literature while, its impact on different types of medical group practices is even less well understood. The repercussions of the large investments in IS/IT on the health care sector in general and on the medical group practice in particular, although clearly of importance, are also largely ignored by the literature. This study attempts to address this significant void in the literature. By analyzing three different types of group practices; an Independent Practice Association (IPA), a Faculty Practice and a Multi Specialty Group Practice in a managed care environment during their implementation of practice management/billing systems, we are able to draw some conclusions regarding the impacts of these two central trends on health care in general as well as on the medical group practice in particular.

Blended care vs. usual care in the treatment of depressive symptoms and disorders in general practice [BLENDING]: study protocol of a non-inferiority randomized trial.

PubMed

Massoudi, Btissame; Blanker, Marco H; van Valen, Evelien; Wouters, Hans; Bockting, Claudi L H; Burger, Huibert

2017-06-13

The majority of patients with depressive disorders are treated by general practitioners (GPs) and are prescribed antidepressant medication. Patients prefer psychological treatments but they are under-used, mainly due to time constraints and limited accessibility. A promising approach to deliver psychological treatment is blended care, i.e. guided online treatment. However, the cost-effectiveness of blended care formatted as an online psychological treatment supported by the patients' own GP or general practice mental health worker (MHW) in routine primary care is unknown. We aim to demonstrate non-inferiority of blended care compared with usual care in patients with depressive symptoms or a depressive disorder in general practice. Additionally, we will explore the real-time course over the day of emotions and affect, and events within individuals during treatment. This is a pragmatic non-inferiority trial including 300 patients with depressive symptoms, recruited by collaborating GPs and MHWs. After inclusion, participants are randomized to either blended care or usual care in routine general practice. Blended care consists of the 'Act and Feel' treatment: an eight-week web-based program based on behavioral activation with integrated monitoring of depressive symptomatology and automatized feedback. GPs or their MHWs coach the participants through regular face-to-face or telephonic consultations with at least three sessions. Depressive symptomatology, health status, functional impairment, treatment satisfaction, daily activities and resource use are assessed during a follow-up period of 12 months. During treatment, real-time fluctuations in emotions and affect, and daily events will be rated using ecological momentary assessment. The primary outcome is the reduction of depressive symptoms from baseline to three months follow-up. We will conduct intention-to-treat analyses and supplementary per-protocol analyses. This trial will show whether blended care might be an appropriate treatment strategy for patients with depressive symptoms and depressive disorder in general practice. Netherlands Trial Register: NTR4757; 25 August 2014. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4757 . (Archived by WebCite® at http://www.webcitation.org/6mnXNMGef ).

Irritable bowel syndrome in general practice: an overview.

PubMed

Oberndorff-Klein Woolthuis, A H; Brummer, R J M; de Wit, N J; Muris, J W M; Stockbrügger, R W

2004-01-01

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder that is frequently seen in gastroenterological practice. Population-based studies have shown that at any point in time IBS symptoms are present in about 3%-22% of the general Western population. In general practice, half of all new patients have functional disorders and IBS is responsible for about five consultations per week. General practitioners (GPs) manage the majority of IBS patients, but most knowledge (and research) is based on the smaller percentage of patients managed in secondary care. There is a paucity of literature on differences or similarities between these two groups with regard to clinical characteristics or diagnostic approach. The literature published in English about IBS in general practice was reviewed. Irritable bowel syndrome is frequently encountered in primary care. Primary care IBS patients, compared to secondary care patients, are likely to be young, female and to have less severe symptoms. But this is only true for some symptoms; for example, non-abdominal complaints are equally reported in both groups. The disorder can be diagnosed safely using internationally agreed symptom-based criteria, such as the Rome II criteria. Additional diagnostic measures will be necessary to support the diagnosis in only a minority of situations. Many primary care IBS patients can be managed given adequate reassurance and education, frequently without additional pharmacological treatment.

Patient experience and the role of postgraduate GP training: a cross-sectional analysis of national Patient Survey data in England

PubMed Central

Ashworth, Mark; Schofield, Peter; Durbaba, Stevo; Ahluwalia, Sanjiv

2014-01-01

Background Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care. Aim The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care. Design and setting Retrospective cross-sectional study in general practices in England. Method Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. Outcome measures: multilevel regression models adjusted for clustering. Results GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the ‘doctor care’ (n = 6) and ‘overall satisfaction’ (n = 2) domains but not to any of the ‘nurse care’ or ‘out-of-hours’ domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients. Conclusion Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as ‘listening’ or ‘care and concern’. PMID:24567656

Primary care, financing and gatekeeping in western Europe.

PubMed

Gérvas, J; Pérez Fernández, M; Starfield, B H

1994-09-01

Primary care in western Europe is delivered by general practitioners (GPs) but their role within the overall health system is poorly understood. The aim of this article is to present an overview of the characteristics of general practice in the context of health systems and to describe their variability and interrelationships. Data were obtained from two main sources: publications of official organizations and EC research projects. The characteristics of general practice are described and analysed with regard to three features: mode of payment, gatekeeper function and practice organization and workload. Despite their focus on general practice as the cornerstone of the health system, western European countries differ considerably in the major characteristics of primary care. There is variability in the ratio of GPs to population and in the extent to which patients relate to individual physicians. Although all countries have universal health insurance, the mode of payment of GPs differs. In some countries, the gatekeeper function of general practice is more highly developed and the use of specialist services varies accordingly. Practice characteristics such as workload, length of consultation, ordering of tests and reappointments also vary with differences in payment and gatekeeping arrangements. In particular, fee-for-service was associated with weaker physician-patient relationships, reduced attractiveness of general practice, more home visiting and longer consultations. Strong gatekeeping arrangements are not incompatible with high public satisfaction and are associated with lower visit rates. However, strong gatekeeping is not characteristic of fee-for-service arrangements. These findings suggest a need for more concerted research that could inform policy decisions concerning primary care in the USA as well as in Europe.

Comprehensive self management and routine monitoring in chronic obstructive pulmonary disease patients in general practice: randomised controlled trial.

PubMed

Bischoff, Erik W M A; Akkermans, Reinier; Bourbeau, Jean; van Weel, Chris; Vercoulen, Jan H; Schermer, Tjard R J

2012-11-28

To assess the long term effects of two different modes of disease management (comprehensive self management and routine monitoring) on quality of life (primary objective), frequency and patients' management of exacerbations, and self efficacy (secondary objectives) in patients with chronic obstructive pulmonary disease (COPD) in general practice. 24 month, multicentre, investigator blinded, three arm, pragmatic, randomised controlled trial. 15 general practices in the eastern part of the Netherlands. Patients with COPD confirmed by spirometry and treated in general practice. Patients with very severe COPD or treated by a respiratory physician were excluded. A comprehensive self management programme as an adjunct to usual care, consisting of four tailored sessions with ongoing telephone support by a practice nurse; routine monitoring as an adjunct to usual care, consisting of 2-4 structured consultations a year with a practice nurse; or usual care alone (contacts with the general practitioner at the patients' own initiative). The primary outcome was the change in COPD specific quality of life at 24 months as measured with the chronic respiratory questionnaire total score. Secondary outcomes were chronic respiratory questionnaire domain scores, frequency and patients' management of exacerbations measured with the Nijmegen telephonic exacerbation assessment system, and self efficacy measured with the COPD self-efficacy scale. 165 patients were allocated to self management (n=55), routine monitoring (n=55), or usual care alone (n=55). At 24 months, adjusted treatment differences between the three groups in mean chronic respiratory questionnaire total score were not significant. Secondary outcomes did not differ, except for exacerbation management. Compared with usual care, more exacerbations in the self management group were managed with bronchodilators (odds ratio 2.81, 95% confidence interval 1.16 to 6.82) and with prednisolone, antibiotics, or both (3.98, 1.10 to 15.58). Comprehensive self management or routine monitoring did not show long term benefits in terms of quality of life or self efficacy over usual care alone in COPD patients in general practice. Patients in the self management group seemed to be more capable of appropriately managing exacerbations than did those in the usual care group. Clinical trials NCT00128765.

Series: The research agenda for general practice/family medicine and primary health care in Europe. Part 2. Results: Primary care management and community orientation.

PubMed

Hummers-Pradier, Eva; Beyer, Martin; Chevallier, Patrick; Eilat-Tsanani, Sophia; Lionis, Christos; Peremans, Lieve; Petek, Davorina; Rurik, Imre; Soler, Jean Karl; Stoffers, Henri Ejh; Topsever, Pinar; Ungan, Mehmet; van Royen, Paul

2010-03-01

At the WONCA Europe conference 2009 the recently published 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' was presented. It is a background paper and reference manual, providing advocacy of general practice/family medicine (GP/FM) in Europe. The Research Agenda summarizes the evidence relating to the core competencies and characteristics of the WONCA Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In this second article, the results for the core competencies 'primary care management' and 'community orientation' are presented. Though there is a large body of research on various aspects of 'primary care management', it represents a very scattered rather than a meta view. Many studies focus on care for specific diseases, the primary/secondary care interface, or the implications of electronic patient records. Cost efficiency or process indicators of quality are current outcomes. Current literature on community orientation is mainly descriptive, and focuses on either care for specific diseases, or specific patient populations, or on the uptake of preventive services. Most papers correspond poorly to the WONCA concept. For both core competencies, there is a lack of research with a longitudinal perspective and/or relevant health or quality of life outcomes as well as research on patients' preferences and education for organizational aspects of GP/FM.

Developing a framework of, and quality indicators for, general practice management in Europe.

PubMed

Engels, Yvonne; Campbell, Stephen; Dautzenberg, Maaike; van den Hombergh, Pieter; Brinkmann, Henrik; Szécsényi, Joachim; Falcoff, Hector; Seuntjens, Luc; Kuenzi, Beat; Grol, Richard

2005-04-01

To develop a framework for general practice management made up of quality indicators shared by six European countries. Two-round postal Delphi questionnaire in the setting of general practice in Belgium, France, Germany, The Netherlands, Switzerland and the United Kingdom. Six national expert panels, each consisting of 10 members, primarily primary care practitioners and experts in the field of quality in primary care participated in the study. The main outcome measures were: (a) a European framework with indicators for the organization of primary care; and (b) ratings of the face validity of the usefulness of the indicators by expert panels in six countries. Agreement was reached about a definition of practice management across five domains (infrastructure, staff, information, finance, and quality and safety), and a common set of indicators for the organization of general practice. The panellist response rate was 95%. Sixty-two indicators (37%) were rated face valid by all six panels. Examples include out of hours service, accessibility, the content of doctors' bags and staff involvement in quality improvement. No indicators were rated invalid by all six panels. It proved to be possible to develop a European set of indicators for assessing the quality of practice management, despite the differences in health care systems and cultures in the six different countries. These indicators will now be used in a quality assessment procedure of practice management in nine European countries. While organizational indicators are part of the new GMS contract in the UK, this research shows that many practice management issues within primary care are also of relevance in other European countries.

Patients' and carers' perspectives of palliative care in general practice: A systematic review with narrative synthesis.

PubMed

Green, Emilie; Knight, Selena; Gott, Merryn; Barclay, Stephen; White, Patrick

2018-04-01

General practitioners have overall responsibility for community care, including towards end of life. Current policy places generalists at the centre of palliative care provision. However, little is known about how patients and carers understand the general practitioner's role. To explore patient and carer perspectives of (1) the role of the general practitioner in providing palliative care to adult patients and (2) the facilitators and barriers to the general practitioner's capacity to fulfil this perceived role. Systematic literature review and narrative synthesis. Seven electronic databases (MEDLINE, Embase, PsycINFO, BNI, CINAHL, Cochrane and HMIC) were searched from inception to May 2017. Two reviewers independently screened papers at title, abstract and full-text stages. Grey literature, guideline, hand searches of five journals and reference list/citation searches of included papers were undertaken. Data were extracted, tabulated and synthesised using narrative, thematic analysis. A total of 25 studies were included: 14 employed qualitative methods, 8 quantitative survey methods and 3 mixed-methods. Five key themes were identified: continuity of care, communication between primary and secondary care, contact and accessibility, communication between general practitioner and patient, and knowledge and competence. Although the terminology and context of general practice vary internationally, themes relating to the perceived role of general practitioners were consistent. General practitioners are considered well placed to provide palliative care due to their breadth of clinical responsibility, ongoing relationships with patients and families, and duty to visit patients at home and coordinate healthcare resources. These factors, valued by service users, should influence future practice and policy development.

General practice after-hours incentive funding: a rationale for change.

PubMed

Neil, Amanda L; Nelson, Mark R; Richardson, Tracy; Mann-Leonard, Meghan; Palmer, Andrew J

2015-07-20

After-hours incentive funding for general practice was introduced in 1998 through the introduction of the Practice Incentives Program (PIP). In 2010, a national audit of the PIP identified after-hours incentive funding as having the greatest levels of non-compliance across 12 PIP components. The audit specified the need for secondary data sources to ensure practice compliance. In this article, we examine the drivers of the 1998-2013 PIP mechanism to inform development of a fair, transparent and auditable after-hours incentive funding scheme for Tasmania. The PIP after-hours incentive funding mechanism paid, at diminishing levels, for anticipated burden of care (practice size), claimed method of providing care (stream) and remoteness of practice. Increasing remoteness rather than practice size or stream is the primary determinant of urgent after-hours attendances per practice in Tasmania; after-hours attendances to residential aged care facilities are unrelated to individual practice location or stream but concentrated in urban areas. The PIP after-hours incentive funding mechanism does not preferentially support practices that provide after-hours care and arguably led to perverse incentives. A new after-hours incentive funding mechanism embodying pre-specified objectives - such as support for (unavoidable) burden and/or provision of care to residential aged care facilities - is required. Claimed provision is considered an inappropriate funding determinant.

The costs of care in general practice: patients compared by the council tax valuation band of their home address.

PubMed

Beale, Norman; Hollinghurst, Sandra; Taylor, Gordon; Gwynne, Mark; Peart, Carole; Straker-Cook, Dawn

2005-06-01

It is difficult to measure and compare workload in UK general practice. A GP/health economist team recently proposed a means of calculating the unit cost of a GP consulting. It is therefore now possible to extrapolate to the costs of other clinical tasks in a practice and then to compare the workloads of caring for different patients and compare between practices. The study aims were: (i) to estimate the relative costs of daily clinical activities within a practice (implying workload); and (ii) to compare the costs of caring for different types of patients categorized by gender, by age, and by socio-economic status as marked by the Council Tax Valuation Band (CTVB) of home address. The study design was a cross-sectional cost comparison of all clinical activity aggregated, by patient, over one year in an English semi-rural general practice. The subjects were 3339 practice patients, randomly selected. The main outcome measures were costs per clinical domain and overall costs per patient per year; both then compared by gender, age group and by CTVB. CTVB is as significant a predictor of patient care cost (workload) as is patient gender and age (both already known). It is now possible to estimate the cost of care of different patients in such a way that NHS planning and especially resource allocation to practices could be improved.

A tool to measure whether business management capacity in general practice impacts on the quality of chronic illness care.

PubMed

Holton, Christine H; Proudfoot, Judith G; Jayasinghe, Upali W; Grimm, Jane; Bubner, Tanya K; Winstanley, Julie; Harris, Mark F; Beilby, Justin J

2010-11-01

Our aim was to develop a tool to identify specific features of the business and financial management of practices that facilitate better quality care for chronic illness in primary care. Domains of management were identified, resulting in the development of a structured interview tool that was administered in 97 primary care practices in Australia. Interview items were screened and subjected to factor analysis, subscales identified and the overall model fit determined. The instrument's validity was assessed against another measure of quality of care. Analysis provided a four-factor solution containing 21 items, which explained 42.5% of the variance in the total scores. The factors related to administrative processes, human resources, marketing analysis and business development. All scores increased significantly with practice size. The business development subscale and total score were higher for rural practices. There was a significant correlation between the business development subscale and quality of care. The indicators of business and financial management in the final tool appear to be useful predictors of the quality of care. The instrument may help inform policy regarding the structure of general practice and implementation of a systems approach to chronic illness care. It can provide information to practices about areas for further development.

Meningococcal vaccination in primary care amongst adolescents in North West England: an ecological study investigating associations with general practice characteristics.

PubMed

Blagden, Sarah; Hungerford, Daniel; Limmer, Mark

2018-01-27

In 2015 the meningococcal ACWY (MenACWY) vaccination was introduced amongst adolescents in England following increased incidence and mortality associated with meningococcal group W. MenACWY vaccination uptake data for 17-18 years old and students delivered in primary care were obtained for 20 National Health Service clinical commissioning groups (CCGs) via the ImmForm vaccination system. Data on general practice characteristics, encompassing demographics and patient satisfaction variables, were extracted from the National General Practice Profiles resource. Univariable analysis of the associations between practice characteristics and vaccination was performed, followed by multivariable negative binomial regression. Data were utilized from 587 general practices, accounting for ~8% of all general practices in England. MenACWY vaccination uptake varied from 20.8% to 46.8% across the CCGs evaluated. Upon multivariable regression, vaccination uptake increased with increasing percentage of patients from ethnic minorities, increasing percentage of patients aged 15-24 years, increasing percentage of patients that would recommend their practice and total Quality and Outcomes Framework achievement for the practice. Conversely, vaccination uptake decreased with increasing deprivation. This study has identified several factors independently associated with MenACWY vaccination in primary care. These findings will enable a targeted approach to improve general practice-level vaccination uptake. © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Training doctors for primary care in China: Transformation of general practice education.

PubMed

Li, Donald

2016-01-01

China is known for developing a cadre of "Barefoot Doctors" to address her rural healthcare needs in past. The tradition of barefoot doctors has inspired similar developments in several other countries across world. Recently China has embarked upon an ambitious new mission to create a primary care workforce consisting of trained general practitioners having international standard skillsets. This editorial provides an insight into the current status of policy deliberations with regards to training of primary care doctors and a new surge in general practice education in China.

A shared-care model of obesity treatment for 3-10 year old children: protocol for the HopSCOTCH randomised controlled trial.

PubMed

Wake, Melissa; Lycett, Kate; Sabin, Matthew A; Gunn, Jane; Gibbons, Kay; Hutton, Cathy; McCallum, Zoe; York, Elissa; Stringer, Michael; Wittert, Gary

2012-03-28

Despite record rates of childhood obesity, effective evidence-based treatments remain elusive. While prolonged tertiary specialist clinical input has some individual impact, these services are only available to very few children. Effective treatments that are easily accessible for all overweight and obese children in the community are urgently required. General practitioners are logical care providers for obese children but high-quality trials indicate that, even with substantial training and support, general practitioner care alone will not suffice to improve body mass index (BMI) trajectories. HopSCOTCH (the Shared Care Obesity Trial in Children) will determine whether a shared-care model, in which paediatric obesity specialists co-manage obesity with general practitioners, can improve adiposity in obese children. Randomised controlled trial nested within a cross-sectional BMI survey conducted across 22 general practices in Melbourne, Australia. Children aged 3-10 years identified as obese by Centers for Disease Control criteria at their family practice, and randomised to either a shared-care intervention or usual care. A single multidisciplinary obesity clinic appointment at Melbourne's Royal Children's Hospital, followed by regular appointments with the child's general practitioner over a 12 month period. To support both specialist and general practice consultations, web-based shared-care software was developed to record assessment, set goals and actions, provide information to caregivers, facilitate communication between the two professional groups, and jointly track progress. Primary - change in BMI z-score. Secondary - change in percentage fat and waist circumference; health status, body satisfaction and global self-worth. This will be the first efficacy trial of a general-practitioner based, shared-care model of childhood obesity management. If effective, it could greatly improve access to care for obese children. Australian New Zealand Clinical Trials Registry ACTRN12608000055303.

Primary care quality and safety systems in the English National Health Service: a case study of a new type of primary care provider.

PubMed

Baker, Richard; Willars, Janet; McNicol, Sarah; Dixon-Woods, Mary; McKee, Lorna

2014-01-01

Although the predominant model of general practice in the UK National Health Service (NHS) remains the small partnership owned and run by general practitioners (GPs), new types of provider are emerging. We sought to characterize the quality and safety systems and processes used in one large, privately owned company providing primary care through a chain of over 50 general practices in England. Senior staff with responsibility for policy on quality and safety were interviewed. We also undertook ethnographic observation in non-clinical areas and interviews with staff in three practices. A small senior executive team set policy and strategy on quality and safety, including a systematic incident reporting and investigation system and processes for disseminating learning with a strong emphasis on customer focus. Standardization of systems was possible because of the large number of practices. Policies appeared generally well implemented at practice level. However, there was some evidence of high staff turnover, particularly of GPs. This caused problems for continuity of care and challenges in inducting new GPs in the company's systems and procedures. A model of primary care delivery based on a corporate chain may be useful in standardizing policies and procedures, facilitating implementation of systems, and relieving clinical staff of administrative duties. However, the model also poses some risks, including those relating to stability. Provider forms that retain the long term, personal commitment of staff to their practices, such as federations or networks, should also be investigated; they may offer the benefits of a corporate chain combined with the greater continuity and stability of the more traditional general practice.

Patient empowerment, an additional characteristic of the European definitions of general practice/family medicine.

PubMed

Mola, Ernesto

2013-06-01

Growing evidence supports the inclusion of patient empowerment as a key ingredient of care for patients with chronic conditions. In recent years, several studies based on patient empowerment, have been carried out in different European countries in the context of general practice and primary care to improve management of chronic diseases. These studies have shown good results of the care model, increasing patient and health professionals' satisfaction, adherence to guidelines and to treatment, and improving clinical outcomes. In 2011, the Wonca European Council included as the twelfth characteristic of the European definitions of general practice/family medicine: 'promote patient empowerment'. The aim of this paper is to clarify the meaning of 'patient empowerment' and to explain why family medicine should be considered the most suitable setting to promote it. The inclusion of patient empowerment as one of the essential characteristics of general practice fills a conceptual gap and clearly suggests to the European health care systems a tested model to face chronic diseases: involving and empowering patients in managing their own conditions to improve health and well-being.

Chronic heart failure management in Australia -- time for general practice centred models of care?

PubMed

Scott, Ian; Jackson, Claire

2013-05-01

Chronic heart failure (CHF) is an increasingly prevalent problem within ageing populations and accounts for thousands of hospitalisations and deaths annually in Australia. Disease management programs for CHF (CHF-DMPs) aim to optimise care, with the predominant model being cardiologist led, hospital based multidisciplinary clinics with cardiac nurse outreach. However, findings from contemporary observational studies and clinical trials raise uncertainty around the effectiveness and sustainability of traditional CHF-DMPs in real-world clinical practice. To suggest an alternative model of care that involves general practitioners with a special interest in CHF liaising with, and being up-skilled by, specialists within community based, multidisciplinary general practice settings. Preliminary data from trials evaluating primary care based CHF-DMPs are encouraging, and further studies are underway comparing this model of care with traditional hospital based, specialist led CHF-DMPs. Results of studies of similar primary care models targeting diabetes and other chronic diseases suggest potential for its application to CHF.

Knowledge, practices and expectations of preventive care: a qualitative study of patients attending government general outpatient clinics in Hong Kong.

PubMed

Tam, Denise Y S; Lo, Yvonne Y C; Tsui, Wendy

2018-05-09

Evidence-based preventive care recommendations have been well established, but studies have persistently reported gaps between these recommendations and general practitioners' practices in providing preventive care. Many studies have explored factors that affect the delivery of preventive care from the perspectives of the practitioners, but relatively few have evaluated the patients' point of view. The purpose of this study was to explore patients' understanding of preventive care, the actions they were taking in terms of preventive health and their expectations from family doctors in providing preventive care. A qualitative study was conducted based on one-on-one in-depth interviews. Twenty-eight patients without chronic illnesses were purposively recruited from government general outpatient clinics in Hong Kong. The interviews took place between November 2013 and February 2014. The participants' knowledge of preventive care was limited, and their preventive practices were mostly restricted to healthy lifestyle practices. They rarely obtained individualised preventive care advice from doctors. Screening investigations were initiated after symptoms had already occurred, and the decision of what to check was arbitrary. Few of the participants knew what they wanted from their doctors in terms of preventive care. These findings show significant gaps between evidence-based preventive recommendations and patients' current knowledge and practice, and show the need for a wider spectrum of preventive care education and reliable sources to provide individualised and affordable preventive assessment and screening services. Most importantly, primary care providers must take a more proactive role to provide preventive services.

Building compassion literacy: Enabling care in primary health care nursing.

PubMed

Burridge, Letitia Helen; Winch, Sarah; Kay, Margaret; Henderson, Amanda

This paper introduces the concept of compassion literacy and discusses its place in nursing within the general practice setting. Compassion literacy is a valuable competency for sustaining the delivery of high quality care. Being compassion literate enables practice nurses to provide compassionate care to their patients and to recognise factors that may constrain this. A compassion literate practice nurse may be more protected from compassion fatigue and its negative consequences. Understanding how to enable self-compassion and how to support the delivery of compassionate care within the primary care team can enhance the care experienced by the patient while improving the positive engagement and satisfaction of the health professionals. The capacity to deliver compassionate care can be depleted by the day-to-day demands of the clinical setting. Compassion literacy enables the replenishing of compassion, but the development of compassion literacy can be curtailed by personal and workplace barriers. This paper articulates why compassion literacy should be an integral aspect of practice nursing and considers strategies for enabling compassion literacy to develop and thrive within the workplace environment. Compassion literacy is also a valuable opportunity for practice nurses to demonstrate their key role within the multidisciplinary team of general practice, directly enhancing the quality of the care delivered.

A qualitative evaluation of New Zealand consumers perceptions of general practice nurses

PubMed Central

2013-01-01

Background An important consideration in health service delivery is ensuring that services meet consumer needs and that consumers are satisfied with service delivery. Patient satisfaction can impact on compliance with suggested treatments and therefore impact on health outcomes. Comparatively few studies have explored consumer satisfaction with nurses in general practice. Methods A sub-group of 18 consumers from a larger quantitative evaluation of consumer satisfaction with New Zealand general practice nurses participated in semi-structured telephone interviews. Interview data was analysed using thematic analysis. Results Four major themes emerged from the data. These themes highlighted that, despite confusion experienced by some consumers regarding the practice nurse role, consumers were happy with the level of care provided by them. Consumers felt valued by Practice Nurses and considered them competent and highly knowledgeable. Findings also convey that consumers appreciate the accessibility and financial benefits of utilising the services of practice nurses. Conclusions Consumers are highly satisfied with practice nurse service delivery and value their relationships with these health professionals. Consumers revealed that greater clarity around the practice nurse role and their scope of practice may enhance their utilisation. Spreading the message of practice nurses being the right person to deliver care, within their scope of practice, at the right time may have the potential to provide more timely care within the primary care setting. PMID:23433311

Primary Palliative Care for the General Internist: Integrating Goals of Care Discussions into the Outpatient Setting

PubMed Central

Ahia, Chad L.; Blais, Christopher M.

2014-01-01

Background Primary palliative care consists of the palliative care competencies required of all primary care clinicians. Included in these competencies is the ability to assist patients and their families in establishing appropriate goals of care. Goals of care help patients and their families understand the patient's illness and its trajectory and facilitate medical care decisions consistent with the patient's values and goals. General internists and family medicine physicians in primary care are central to getting patients to articulate their goals of care and to have these documented in the medical record. Case Report Here we present the case of a 71-year-old male patient with chronic obstructive pulmonary disorder, congestive heart failure, and newly diagnosed Alzheimer dementia to model pertinent end-of-life care communication and discuss practical tips on how to incorporate it into practice. Conclusion General internists and family medicine practitioners in primary care are central to eliciting patients' goals of care and achieving optimal end-of-life outcomes for their patients. PMID:25598737

The influence of experiential learning on medical equipment adoption in general practices.

PubMed

Bourke, Jane; Roper, Stephen

2014-10-01

The benefits of the availability and use of medical equipment for medical outcomes are understood by physicians and policymakers alike. However, there is limited understanding of the decision-making processes involved in adopting and using new technologies in health care organisations. Our study focuses on the adoption of medical equipment in Irish general practices which are marked by considerable autonomy in terms of commercial practice and the range of medical services they provide. We examine the adoption of six items of medical equipment taking into account commercial, informational and experiential stimuli. Our analysis is based on primary survey data collected from a sample of 601 general practices in Ireland on practice characteristics and medical equipment use. We use a multivariate Probit to identify commonalities in the determinants of the adoption. Many factors, such as GP and practice characteristics, influence medical equipment adoption. In addition, we find significant and consistent evidence of the influence of learning-by-using effects on the adoption of medical equipment in a general practice setting. Knowledge generated by experiential or applied learning can have commercial, organisational and health care provision benefits in small health care organisations. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Pre- and postdoctoral dental education compared to practice patterns in special care dentistry.

PubMed

Subar, Paul; Chávez, Elisa M; Miles, Jeffrey; Wong, Allen; Glassman, Paul; Labarre, Eugene

2012-12-01

There has been limited research into the impact of predoctoral experiences and postdoctoral general dentistry residencies on the practice patterns of dentists in the care of patients with special or complex needs. This study was undertaken to determine if educational experiences with special populations had a relationship to practice patterns after graduation or residency. University of the Pacific alumni who graduated between 1997 and 2007 were surveyed regarding their pre- and postdoctoral dental education and their practice patterns for the care of patients categorized as medically compromised, frail elders, and developmentally disabled. Definitions for each patient category were provided. Alumni were asked about their practice setting and postdoctoral education. Thirty-one percent (n=526) of those surveyed responded. Regression analyses showed respondents not in private practice were more likely to have completed a postdoctoral general dentistry program (Advanced Education in General Dentistry or General Practice Residency) after dental school compared to respondents in private practice (p<0.001). Across all age groups, respondents not in private practice treated significantly more patients with developmental disabilities than those in private practice (p<0.001). Respondents not in private practice treated more medically compromised patients younger than age sixty-five compared to respondents in private practice (p<0.01). Interestingly, those in private practice treated significantly more patients over sixty-five who were also classified as medically compromised (p<0.05). Pacific alumni who completed postdoctoral training in general dentistry were found to practice more often in non-private practice settings. Alumni in non-private practice settings reported treating a higher percentage of medically compromised patients below age sixty-five than their counterparts in a typical private practice. The pre- and postdoctoral experiences of treating special needs populations appear to have a relationship to graduates' practice setting and patient population.

The advent of mental health nurses in Australian general practice.

PubMed

Olasoji, Michael; Maude, Phil

2010-01-01

The remarkable progress that has been witnessed in the physical and material wellbeing for most Australians over the 20th century has not been paralleled by gains in the mental and subjective wellbeing of the population. General practice plays a strategic role in Australia's primary health care, which has been recognised as an essential health system that is able to deliver health to the population in a timely and equitable manner (World Health Organisation [WHO], 2008). General Practitioners are unable to provide adequate care to people experiencing a severe mental illness without support from specialist mental health professional such as a mental health nurse in the practice. The mental health nurse incentive program (MHNIP) offers opportunity for mental health nurses to work collaboratively with GPs in primary health care in the delivery of care to people with a severe mental illness.

Learning from a Special Care Dentistry Needs Assessment.

PubMed

Johnson, Ilona

2015-05-01

The General Dental Council recognised special care dentistry (SCD) as a speciality in 2008 and local service reviews have been carried out in order to develop SCD services. A needs assessment was completed to inform the implementation of recommendations from a 2010 review of SCD in Wales. The aim of this paper is to outline the process, findings and learning from the needs assessment and the implications for SCD. A focused needs assessment approach was used. Stakeholder consultations were used to develop a working definition for the needs assessment. Data were collected from existing health and social care sources and analysed using descriptives and geographic information system (GIS) mapping. Data sources for needs assessment were limited. Analysis showed that health conditions were common in the population and increased with age. The majority of people who reported seeing a dentist were seen in general dental practice. Older people with health conditions were less likely to report seeing a dentist. Patients often needed to travel for specialist care services. General dental practice teams have a significant role in caring for SCD patients. Careful planning of specialist care, joint working and enhancing skills across the general practice team will reduce the burden of care and enhance patient safety. Improvements in data for assessment of SCD needs are required to help this process.

Epidemiology of Patient Harms in New Zealand: Protocol of a General Practice Records Review Study

PubMed Central

Leitch, Sharon; Wallis, Katharine A; Eggleton, Kyle S; Cunningham, Wayne K; Williamson, Martyn I; Lillis, Steven; McMenamin, Andrew W; Tilyard, Murray W; Reith, David M; Samaranayaka, Ari; Hall, Jason E

2017-01-01

Background Knowing where and why harm occurs in general practice will assist patients, doctors, and others in making informed decisions about the risks and benefits of treatment options. Research to date has been unable to verify the safety of primary health care and epidemiological research about patient harms in general practice is now a top priority for advancing health systems safety. Objective We aim to study the incidence, distribution, severity, and preventability of the harms patients experience due to their health care, from the whole-of-health-system lens afforded by electronic general practice patient records. Methods “Harm” is defined as disease, injury, disability, suffering, and death, arising from the health system. The study design is a stratified, 2-level cluster, retrospective records review study. Both general practices and patients will be randomly selected so that the study’s results will apply nationally, after weighting. Stratification by practice size and rurality will allow comparisons between 6 study groups (large, medium-sized, small; urban and rural practices). Records of equal numbers of patients from each study group will be included in the study because there may be systematic differences in patient harms in different types of practices. Eight general practitioner investigators will review 3 years of electronic general practice health records (consultation notes, prescriptions, investigations, referrals, and summaries of hospital care) from 9000 patients registered in 60 general practices. Double-blinded reviews will check the concordance of reviewers’ assessments. Study data will comprise demographic data of all 9000 patients and reviewers’ assessments of whether patients experienced harm arising from health care. Where patient harm is identified, their types, preventability, severity, and outcomes will be coded using the Medical Dictionary for Regulatory Activities (MedDRA) 18.0. Results We have recruited practices and collected electronic records from 9078 patients. Reviews of these records are under way. The study is expected to be completed in August 2017. Conclusions The design of this complex study is presented with discussion on data collection methods, sampling weights, power analysis, and statistical approach. This study will show the epidemiology of patient harms recorded in general practice records for all of New Zealand and will show whether this epidemiology differs by rural location and clinic size. PMID:28119276

How is Primary Health Care conceptualised in nursing in Australia? A review of the literature.

PubMed

Henderson, Julie; Koehne, Kristy; Verrall, Claire; Gebbie, Kristine; Fuller, Jeffrey

2014-07-01

Australia, in common with many other countries, is expanding the role of Primary Health Care (PHC) to manage the growing burden of chronic disease and prevent hospitalisation. Australia's First National Primary Health Care Strategy released in 2010 places general practice at the centre of care delivery, reflecting a constitutional division of labour in which the Commonwealth government's primary means of affecting care delivery in this sector is through rebates for services delivered from the universal healthcare system Medicare. A review of Australian nursing literature was undertaken for 2006-2011. This review explores three issues in relation to these changes: How PHC is conceptualised within Australian nursing literature; who is viewed as providing PHC; and barriers and enablers to the provision of comprehensive PHC. A review of the literature suggests that the terms 'PHC' and 'primary care' are used interchangeably and that PHC is now commonly associated with services provided by practice nurses. Four structural factors are identified for a shift away from comprehensive PHC, namely fiscal barriers, educational preparation for primary care practice, poor role definition and interprofessional relationships. The paper concludes that while moves towards increasing capacity in general practice have enhanced nursing roles, current policy and the nature of private business funding alongside some medical opposition limit opportunities for Australian nurses working in general practice. © 2013 John Wiley & Sons Ltd.

Practice assistants in primary care in Germany - associations with organizational attributes on job satisfaction.

PubMed

Gavartina, Amina; Zaroti, Stavria; Szecsenyi, Joachim; Miksch, Antje; Ose, Dominik; Campbell, Stephen M; Goetz, Katja

2013-08-05

Job satisfaction and organizational attributes in primary care teams are important issues as they affect clinical outcomes and the quality of health care provided. As practice assistants are an integral part of these teams it is important to gain insight into their views on job satisfaction and organizational attributes. The aim of this study was to evaluate the job satisfaction of practice assistants and the organizational attributes within their general practices in Germany and to explore the existence of possible associations. This observational study was based on a job satisfaction survey and measurement of organizational attributes in general practices in the German federal state of Baden-Wuerttemberg. Job satisfaction was measured with the 10-item 'Warr-Cook-Wall job satisfaction scale'. Organizational attributes were evaluated with the 21-items 'survey of organizational attributes for primary care' (SOAPC). Linear regression analyses were performed in which each of SOAPC scales and the overall score of SOAPC was treated as outcome variables. 586 practice assistants out of 794 respondents (73.8%) from 234 general practices completed the questionnaire. Practice assistants were mostly satisfied with their colleagues and least of all satisfied with their income and recognition for their work. The regression analysis showed that 'freedom of working method' and 'recognition of work', the employment status of practice assistants and the mode of practice were almost always significantly associated with each subscale and overall score of SOAPC. Job satisfaction is highly associated with different aspects of organizational attributes for primary care ('communication', 'decision-making' and 'stress'). Consequently, improved job satisfaction could lead to a better-organized primary care team. This implication should be investigated directly in further intervention studies with a special focus on improving the recognition for work and income.

A nurse-led model of chronic disease management in general practice: Patients' perspectives.

PubMed

Young, Jacqueline; Eley, Diann; Patterson, Elizabeth; Turner, Catherine

2016-12-01

Evidence suggests that current models of chronic disease management within general practice are not effective in meeting the needs of the community. The objective of this article is to examine patients' perceptions of a nurse-led collaborative model of care trialled in three general practices in Australia. This article reports on the second phase of a mixed-methods study in which semi-structured interviews with purposively selected patients were conducted to elicit information about their perceptions of nurse-led care. Three themes emerged from the data - time, ambiance and dimensions of the nurse role. The results suggest that general practice nurses had a positive impact on patients' ability to manage their chronic disease. This infers that there is scope for general practice nurses to expand their role in chronic disease management to assist patients to better self-manage their chronic diseases.

Access to general practice for Pacific peoples: a place for cultural competency.

PubMed

Ludeke, Melissa; Puni, Ronald; Cook, Lynley; Pasene, Maria; Abel, Gillian; Sopoaga, Faafetai

2012-06-01

Access to primary health care services has been identified as a problem for Pacific peoples. Although cost is the most frequently cited barrier to Pacific service utilisation, some research has indicated that access may also be influenced by features of mainstream primary care services. This study aimed to identify features of mainstream general practice services that act as barriers to accessing these services for Pacific peoples in order to explore strategies that providers could adopt to enable their practices to be more welcoming, accessible and appropriate for Pacific peoples. Pacific participants were recruited through Pacific networks known to Pegasus Health and via 'snowball' sampling. In total, 20 participants participated in one of three focus groups. A semi-structured interview explored the participants' views and experiences of mainstream general practice care. Thematic analysis was utilised to interpret the data. The analysis revealed five themes highlighting non-financial features of mainstream general practice services that may influence the availability and acceptability of these services to Pacific peoples: language and communication; rushed consultations; appointment availability; reception; and Pacific presence. The findings indicate that all personnel within the primary care setting have the ability to directly engage in the improvement of the health status of Pacific peoples in New Zealand by developing cultural competency and incorporating flexibility and diversity into the care and service they provide.

Evaluation of a tailored implementation strategy to improve the management of patients with chronic obstructive pulmonary disease in primary care: a study protocol of a cluster randomized trial.

PubMed

Godycki-Cwirko, Maciek; Zakowska, Izabela; Kosiek, Katarzyna; Wensing, Michel; Krawczyk, Jaroslaw; Kowalczyk, Anna

2014-04-04

Chronic obstructive pulmonary disease (COPD) remains a major health problem, strongly related to smoking. Despite the publication of practice guidelines on prevention and treatment, not all patients with the disease receive the recommended healthcare, particularly with regard to smoking cessation advice where applicable. We have developed a tailored implementation strategy for enhancing general practitioners' adherence to the disease management guidelines. The primary aim of the study is to evaluate the effects of this tailored implementation intervention on general practitioners' adherence to guidelines. A pragmatic two-arm cluster randomized trial has been planned to compare care following the implementation of tailored interventions of four recommendations in COPD patients against usual care. The study will involve 18 general practices (9 in the intervention group and 9 in the control group) in Poland, each with at least 80 identified (at the baseline) patients with diagnosed COPD. The nine control practices will provide usual care without any interventions. Tailored interventions to implement four recommendations will be delivered in the remaining nine practices. At follow-up after nine months, data will be collected for all 18 general practices. The primary outcome measure is physicians' adherence to all four recommendations: brief anti-smoking advice, dyspnea assessment, care checklist utilization and demonstration to patients of correct inhaler use. This measurement will be based on data extracted from identified patients' records. Additionally, we will survey and interview patients with chronic obstructive pulmonary disease about the process of care. The results of this trial will be directly applicable to primary care in Poland and add to the growing body of evidence on interventions to improve chronic illness care. This trial has been registered with Clinical Trials Protocol Registration System. NCT01893476.

Improving communication between health-care professionals and patients with limited English proficiency in the general practice setting.

PubMed

Attard, Melanie; McArthur, Alexa; Riitano, Dagmara; Aromataris, Edoardo; Bollen, Chris; Pearson, Alan

2015-01-01

Quality service provision and patient safety and satisfaction in encounters with health-care professionals relies on effective communication between the practitioner and patient. This study aimed to identify effective practices for improving communication between clinical staff in general practice and patients with limited English proficiency, and to promote their implementation in general practice. Effective interventions and strategies were identified from a review of international research. Experiences with their use in practice were explored via focus group discussions with general practitioners and practice nurses. The results suggest that, wherever possible, communication in the patient's primary language is preferable; use of a qualified medical interpreter should be promoted, and practices should have a standardised and documented procedure for accessing interpreter services. General practice staff must increase their awareness about services that are available to facilitate communication with patients with limited English proficiency, and also develop attitudes, both individual and organisational, that will maximise the effectiveness of these strategies. These findings were used to develop brief, evidence-based practice guidelines that were disseminated to focus group participants for evaluation of utility and general feedback. This evidence-based guidance is now available to assist clinical and administrative general practice staff across regional and metropolitan South Australia.

Occupational therapy practice in acute physical hospital settings: Evidence from a scoping review.

PubMed

Britton, Lauren; Rosenwax, Lorna; McNamara, Beverley

2015-12-01

Increased accountability and growing fiscal limitations in global health care continue to challenge how occupational therapy practices are undertaken. Little is known about how these changes affect current practice in acute hospital settings. This article reviews the relevant literature to further understanding of occupational therapy practice in acute physical hospital settings. A scoping review of five electronic databases was completed using the keywords Occupational therapy, acute hospital settings/acute physical hospital settings, acute care setting/acute care hospital setting, general medicine/general medical wards, occupational therapy service provision/teaching hospitals/tertiary care hospitals. Criteria were applied to determine suitability for inclusion and the articles were analysed to uncover key themes. In total 34 publications were included in the review. Analysis of the publications revealed four themes: (1) Comparisons between the practice of novice and experienced occupational therapists in acute care (2) Occupational therapists and the discharge planning process (3) Role of occupation in the acute care setting and (4) Personal skills needed and organisation factors affecting acute care practice. The current literature has highlighted the challenges occupational therapists face in practicing within an acute setting. Findings from this review enhance understanding of how occupational therapy department managers and educators can best support staff that practise in acute hospital settings. © 2015 Occupational Therapy Australia.

Medical students' attitudes towards general practice and factors affecting career choice: a questionnaire study

PubMed Central

Garnham, Laura

2014-01-01

Background The current issue of general practice recruitment is a significant challenge and concern. In order to address this, it is vital to understand medical students' attitudes towards general practice and what influences their choice of intended career. Method We used a questionnaire study to examine these attitudes across all years at Imperial College Medical School and to understand what a group of London medical students' current intended career choices were. Results We found that only 13% of students ranked general practice as their first choice career despite having a generally realistic and positive attitude towards the speciality. They highlighted that the main influence on future career choice was interest in the specific speciality and that lifestyle factors did not seem to be so important. Conclusion Exposure to general practice, primary care research and student GP societies might play some part in increasing interest, but more work is needed to understand why students are rejecting general practice and what we can do collectively to attract students into choosing a career in primary care. PMID:25949732

Academic retainer medicine: an innovative business model for cross-subsidizing primary care.

PubMed

Lucier, David J; Frisch, Nicholas B; Cohen, Brian J; Wagner, Michael; Salem, Deeb; Fairchild, David G

2010-06-01

Retainer-medicine primary care practices, commonly referred to as "luxury" or "concierge" practices, provide enhanced services to patients beyond those available in traditional practices for a yearly retainer fee. Adoption of retainer practices has been largely absent in academic health centers (AHCs). Reasons for this trend stem primarily from ethical concerns, such as the potential for patient abandonment when physicians downsize from larger, traditional practices to smaller, retainer-medicine practices.In 2004, the Department of Medicine at Tufts Medical Center developed an academic retainer-medicine primary care practice within the Division of General Medicine that not only generates financial support for the division but also incorporates a clinical and business model that is aligned with the mission and ethics of an academic institution.In contrast to private retainer-medicine practices, this unique business model addresses several of the ethical issues associated with traditional retainer practices-it does not restrict net access to care and it neutralizes concerns about patient abandonment. Addressing the growing primary care shortage, the model also presents the opportunity for a retainer practice to cross-subsidize the expansion of general medicine in an academic medical setting. The authors elucidate the benefits, as well as the inherent challenges, of embedding an academic retainer-medicine practice within an AHC.

GPs' views of health policy changes: a qualitative 'netnography' study of UK general practice online magazine commentary.

PubMed

Elvey, Rebecca; Voorhees, Jennifer; Bailey, Simon; Burns, Taylor; Hodgson, Damian

2018-06-01

Shifts in health policy since 2010 have brought major structural changes to the English NHS, with government stating intentions to increase GPs' autonomy and improve access to care. Meanwhile, GPs' levels of job satisfaction are low, while stress levels are high. PulseToday is a popular UK general practice online magazine that provides a key discussion forum on news relevant to general practice. To analyse readers' reactions to news stories about health policy changes published in an online general practice magazine. A qualitative 'netnography' was undertaken of readers' comments to PulseToday. METHOD: A sample of readers' comments on articles published in PulseToday was collated and subjected to thematic analysis. Around 300 comments on articles published between January 2012 and March 2016 were included in the analysis, using 'access to care' as a tracer theme. Concern about the demand and strain on general practice was perhaps to be expected. However, analysis revealed various dimensions to this concern: GPs' underlying feelings about their work and place in the NHS; constraints to GPs' control of their own working practices; a perceived loss of respect for the role of GP; and disappointment with representative bodies and GP leadership. This study shows a complex mix of resistance and resignation in general practice about the changing character of GPs' roles. This ambivalence deserves further attention because it could potentially shape responses to further change in primary care in ways that are as yet unknown. © British Journal of General Practice 2018.

Historical evolution and present status of family medicine in sri lanka.

PubMed

Ramanayake, R P J C

2013-04-01

Sri Lankan health system consists of Allopathic, Ayurvedic, Unani, and several other systems of medicine and allopathic medicine is catering to the majority of the health needs of the people. As in many other countries, Sri Lankan health system consists of both the state and the private sector General practitioners, MOs in OPDs of hospitals and MOs of central dispensaries, provide primary medical care in Sri Lanka. Most of the general practices are solo practices. One does not need postgraduate qualification or training in general practice to start a general practice. There is no registered population for any particular health care institution in the state sector or in the private sector and there is no strict referral procedure from primary care to secondary or tertiary care. Family doctors have been practicing in Sri Lanka for well over 150 years. The first national organization of general practitioners was Independent Medical Practitioner (IMPA)'s organization which was founded in 1929 and the College of General Practitioners of Sri Lanka was founded in 1974. College conducts its own Membership Course and Examination (MCGP) since 1999. Family Medicine was introduced to undergraduate curriculum in Sri Lanka in early 1980s and now almost all the medical faculties in the country have included Family Medicine in their curricula. In 1979, General Practice/Family Medicine was recognized as a specialty in Sri Lanka by the postgraduate institute of Medicine. Diploma in Family Medicine (DFM) and MD Family Medicine are the pathways for postgraduate training in Sri Lanka. At present 50 to 60 doctors enroll for DFM every year and the country has about 20 specialists (with MD) in Family Medicine. The author's vision for the future is that all the primary care doctors to have a postgraduate qualification in Family Medicine either DFM, MD, or MCGP which is a far cry from the present status.

Audit on cardiovascular disease preventive care in general practice.

PubMed

Chan, S C; Lee, T W; Teoh, L C; Abdullah, Z C; Xavier, G; Sim, C K; Ng, A C; Ong, I C H; Begum, R; Leong, C C

2008-04-01

Cardiovascular disease is a major cause of morbidity and mortality. Primary care doctors as general practitioners (GPs) play a central role in prevention, as they are in contact with a large number of patients in the community through provision of first contact, comprehensive and continuing care. This study aims to assess the adequacy of cardiovascular disease preventive care in general practice through a medical audit. Nine GPs in Malaysia did a retrospective audit on the records of patients, aged 45 years and above, who attended the clinics in June 2005. The adequacy of cardiovascular disease preventive care was assessed using agreed criteria and standards. Standards achieved included blood pressure recording (92.4 percent), blood sugar screening (72.7 percent) and attaining the latest blood pressure of equal or less than 140/90 mmHg in hypertensive patients (71.3 percent). Achieved standards ranged from 11.1 percent to 66.7 percent in the maintenance of hypertension and diabetic registries, recording of smoking status, height and weight, screening of lipid profile and attaining target blood sugar levels in diabetics. In the nine general practice clinics audited, targets were achieved in three out of ten indicators of cardiovascular preventive care. There were vast differences among individual clinics.

The research agenda for general practice/family medicine and primary health care in Europe. Part 3. Results: person centred care, comprehensive and holistic approach.

PubMed

Van Royen, Paul; Beyer, Martin; Chevallier, Patrick; Eilat-Tsanani, Sophia; Lionis, Christos; Peremans, Lieve; Petek, Davorina; Rurik, Imre; Soler, Jean Karl; Stoffers, Henri E J H; Topsever, Pinar; Ungan, Mehmet; Hummers-Pradier, Eva

2010-06-01

The recently published 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. In a first article, background, objectives, and methodology were discussed. In a second article, the results for the two core competencies 'primary care management' and 'community orientation' were presented. This article reflects on the three core competencies, which deal with person related aspects of GP/FM, i.e. 'person centred care', 'comprehensive approach' and 'holistic approach'. Though there is an important body of opinion papers and (non-systematic) reviews, all person related aspects remain poorly defined and researched. Validated instruments to measure these competencies are lacking. Concerning patient-centredness, most research examined patient and doctor preferences and experiences. Studies on comprehensiveness mostly focus on prevention/care of specific diseases. For all domains, there has been limited research conducted on its implications or outcomes.

Patient Engagement and Coaching for Health: The PEACH study--a cluster randomised controlled trial using the telephone to coach people with type 2 diabetes to engage with their GPs to improve diabetes care: a study protocol.

PubMed

Young, Doris; Furler, John; Vale, Margarite; Walker, Christine; Segal, Leonie; Dunning, Patricia; Best, James; Blackberry, Irene; Audehm, Ralph; Sulaiman, Nabil; Dunbar, James; Chondros, Patty

2007-04-11

The PEACH study is based on an innovative 'telephone coaching' program that has been used effectively in a post cardiac event trial. This intervention will be tested in a General Practice setting in a pragmatic trial using existing Practice Nurses (PN) as coaches for people with type 2 diabetes (T2D). Actual clinical care often fails to achieve standards, that are based on evidence that self-management interventions (educational and psychological) and intensive pharmacotherapy improve diabetes control. Telephone coaching in our study focuses on both. This paper describes our study protocol, which aims to test whether goal focused telephone coaching in T2D can improve diabetes control and reduce the treatment gap between guideline based standards and actual clinical practice. In a cluster randomised controlled trial, general practices employing Practice Nurses (PNs) are randomly allocated to an intervention or control group. We aim to recruit 546 patients with poorly controlled T2D (HbA1c >7.5%) from 42 General Practices that employ PNs in Melbourne, Australia. PNs from General Practices allocated to the intervention group will be trained in diabetes telephone coaching focusing on biochemical targets addressing both patient self-management and engaging patients to work with their General Practitioners (GPs) to intensify pharmacological treatment according to the study clinical protocol. Patients of intervention group practices will receive 8 telephone coaching sessions and one face-to-face coaching session from existing PNs over 18 months plus usual care and outcomes will be compared to the control group, who will only receive only usual care from their GPs. The primary outcome is HbA1c levels and secondary outcomes include cardiovascular disease risk factors, behavioral risk factors and process of care measures. Understanding how to achieve comprehensive treatment of T2D in a General Practice setting is the focus of the PEACH study. This study explores the potential role for PNs to help reduce the treatment and outcomes gap in people with T2D by using telephone coaching. The intervention, if found to be effective, has potential to be sustained and embedded within real world General Practice.

The development of professional practice standards for Australian general practice nurses.

PubMed

Halcomb, Elizabeth; Stephens, Moira; Bryce, Julianne; Foley, Elizabeth; Ashley, Christine

2017-08-01

The aim of this study was to explore the current role of general practice nurses and the scope of nursing practice to inform the development of national professional practice standards for Australian general practice nurses. Increasing numbers of nurses have been employed in Australian general practice to meet the growing demand for primary care services. This has brought significant changes to the nursing role. Competency standards for nurses working in general practice were first developed in Australia in 2005, but limited attention has been placed on articulating the contemporary scope of practice for nurses in this setting. Concurrent mixed methods design. Data collection was conducted during 2013-2014 and involved two online surveys of Registered and Enrolled Nurses currently working in general practice, a series of 14 focus groups across Australia and a series of consultations with key experts. Data collection enabled the development of 22 Practice Standards separated into four domains: (i) Professional Practice; (ii) Nursing Care; (iii) General Practice Environment and (iv) Collaborative Practice. To differentiate the variations in enacting these Standards, performance indicators for the Enrolled Nurse, Registered Nurse and Registered Nurse Advanced Practice are provided under each Standard. The development of national professional practice standards for nurses working in Australian general practice will support ongoing workforce development. These Standards are also an important means of articulating the role and scope of the nurses' practice for both consumers and other health professionals, as well as being a guide for curriculum development and measurement of performance. © 2017 John Wiley & Sons Ltd.

Plural provision of primary medical care in England, 2002-2012.

PubMed

Sheaff, Rod

2013-10-01

Health care reforms often include provider diversification, including privatization, to increase competition and thereby health care quality and efficiency. Donabedian's organizational theory implies that the consequences will vary according to the providers' ownership. The aim was to examine how far that theory applies to changes in English NHS primary medical care (general practice) since 1998, and the consequences for patterns of service provision. Framework analysis whose categories and structure reflected Donabedian's theory and its implications, populated with data from a systematic review, administrative sources and press rapportage. Two patterns of provider diversification occurred: 'native' diversification among existing providers and plural provision as providers with different types of ownership were introduced. Native diversification occurred through: extensive recruitment of salaried GPs; extending the range of services provided by general practices; introducing limited liability partnerships; establishing GPs with special clinical interests; and introducing a wider range of services for GPs to refer to. All of these had little apparent effect on competition between general practices. Plural provision involved: increased primary care provision by corporations; introducing GP-owned firms; establishing social enterprises (initially mostly out-of-hours cooperatives); and Primary Care Trusts taking over general practices. Plural provision was on a smaller scale than native diversification and appeared to go into reverse in 2011. Although the available data confirm the implications of Donabedian's theory, there are exceptions. Native diversification and plural provision policies differ in their implications for service development.

A valuable approach to the use of electronic medical data in primary care research: Panning for gold.

PubMed

Barnett, Stephen; Henderson, Joan; Hodgkins, Adam; Harrison, Christopher; Ghosh, Abhijeet; Dijkmans-Hadley, Bridget; Britt, Helena; Bonney, Andrew

2017-05-01

Electronic medical data (EMD) from electronic health records of general practice computer systems have enormous research potential, yet many variables are unreliable. The aim of this study was to compare selected data variables from general practice EMD with a reliable, representative national dataset (Bettering the Evaluation and Care of Health (BEACH)) in order to validate their use for primary care research. EMD variables were compared with encounter data from the nationally representative BEACH program using χ 2 tests and robust 95% confidence intervals to test their validity (measure what they reportedly measure). The variables focused on for this study were patient age, sex, smoking status and medications prescribed at the visit. The EMD sample from six general practices in the Illawarra region of New South Wales, Australia, yielded data on 196,515 patient encounters. Details of 90,553 encounters were recorded in the 2013 BEACH dataset from 924 general practitioners. No significant differences in patient age ( p = 0.36) or sex ( p = 0.39) were found. EMD had a lower rate of current smokers and higher average scripts per visit, but similar prescribing distribution patterns. Validating EMD variables offers avenues for improving primary care delivery and measuring outcomes of care to inform clinical practice and health policy.

New Zealand rural primary health care workforce in 2005: more than just a doctor shortage.

PubMed

Goodyear-Smith, Felicity; Janes, Ron

2008-02-01

To obtain a 2005 snapshot of New Zealand (NZ) rural primary health care workforce, specifically GPs, general practice nurses and community pharmacists. Postal questionnaires, November 2005. NZ-wide rural general practices and community pharmacies. Rural general practice managers, GPs, nurses, community pharmacy managers and pharmacists. Self-reported data: demographics, country of training, years in practice, business ownership, hours worked including on-call, intention to leave rural practice. General practices: response rate 95% (206/217); 70% GP-owned, practice size ranged from one GP/one nurse to 12 GPs/nine nurses. PHARMACIES: Response rate 90% (147/163). Majority had one (33%) or two (32%) pharmacists; <10% had more than three pharmacists. GPs: response rate 64% (358/559), 71% male, 73% aged >40, 61% full-time, 79% provide on-call, 57% overseas-trained, 78% male and 57% female GPs aged >40; more full-time male GPs (76%) than female (37%) . Nurses: response rate 65% (445/685), 97% female, 72% aged >40, 31% full-time, 28% provide on-call, 84% NZ-trained, 45% consulted independently in 'nurse-clinics' within practice setting. Pharmacists: response rate 96% (248/258), 52% male, 66% aged >40, 71% full-time, 33% provide on-call, 92% NZ-trained, 55% sole/partner pharmacy owners. Many intend to leave NZ rural practice within 5 years: GPs (34%), nurses (25%) and pharmacists (47%). This is the first NZ-wide rural workforce survey to include a range of rural primary health care providers (GPs, nurses and pharmacists). Ageing rural primary health care workforce and intentions to leave herald worsening workforce shortages.

Preparing palliative home care nurses to act as facilitators for physicians' learning: Evaluation of a training programme.

PubMed

Pype, Peter; Mertens, Fien; Wens, Johan; Stes, Ann; Van den Eynden, Bart; Deveugele, Myriam

2015-05-01

Palliative care requires a multidisciplinary care team. General practitioners often ask specialised palliative home care teams for support. Working with specialised nurses offers learning opportunities, also called workplace learning. This can be enhanced by the presence of a learning facilitator. To describe the development and evaluation of a training programme for nurses in primary care. The programme aimed to prepare palliative home care team nurses to act as facilitators for general practitioners' workplace learning. A one-group post-test only design (quantitative) and semi-structured interviews (qualitative) were used. A multifaceted train-the-trainer programme was designed. Evaluation was done through assignments with individual feedback, summative assessment through videotaped encounters with simulation-physicians and individual interviews after a period of practice implementation. A total of 35 nurses followed the programme. The overall satisfaction was high. Homework assignments interfered with the practice workload but showed to be fundamental in translating theory into practice. Median score on the summative assessment was 7 out of 14 with range 1-13. Interviews revealed some aspects of the training (e.g. incident analysis) to be too difficult for implementation or to be in conflict with personal preferences (focus on patient care instead of facilitating general practitioners' learning). Training palliative home care team nurses as facilitator of general practitioners' workplace learning is a feasible but complex intervention. Personal characteristics, interpersonal relationships and contextual variables have to be taken into account. Training expert palliative care nurses to facilitate general practitioners' workplace learning requires careful and individualised mentoring. © The Author(s) 2014.

A survey of audit activity in general practice.

PubMed Central

Hearnshaw, H; Baker, R; Cooper, A

1998-01-01

BACKGROUND: Since 1991, all general practices have been encouraged to undertake clinical audit. Audit groups report that participation is high, and some local surveys have been undertaken, but no detailed national survey has been reported. AIM: To determine audit activities in general practices and the perceptions of general practitioners (GPs) regarding the future of clinical audit in primary care. METHOD: A questionnaire on audit activities was sent to 707 practices from 18 medical audit advisory group areas. The audit groups had been ranked by annual funding from 1992 to 1995. Six groups were selected at random from the top, middle, and lowest thirds of this rank order. RESULTS: A total of 428 (60.5%) usable responses were received. Overall, 346 (85%) responders reported 125.7 audits from the previous year with a median of three audits per practice. There was no correlation between the number of audits reported and the funding per GP for the medical audit advisory group. Of 997 audits described in detail, changes were reported as 'not needed' in 220 (22%), 'not made' in 142 (14%), 'made' in 439 (44%), and 'made and remeasured' in 196 (20%). Thus, 635 (64%) audits were reported to have led to changes. Some 853 (81%) of the topics identified were on clinical care. Responders made 242 (42%) positive comments on the future of clinical audit in primary care, and 152 (26%) negative views were recorded. CONCLUSION: The level of audit activity in general practice is reasonably high, and most of the audits result in change. The number of audits per practice seems to be independent of the level of funding that the medical audit advisory group has received. Although there is room for improvement in the levels of effective audit activity in general practice, continued support by the professionally led audit groups could enable all practices to undertake effective audit that leads to improvement in patient care. PMID:9624769

Patient satisfaction surveys as a market research tool for general practices.

PubMed

Khayat, K; Salter, B

1994-05-01

Recent policy developments, embracing the notions of consumer choice, quality of care, and increased general practitioner control over practice budgets have resulted in a new competitive environment in primary care. General practitioners must now be more aware of how their patients feel about the services they receive, and patient satisfaction surveys can be an effective tool for general practices. A survey was undertaken to investigate the use of a patient satisfaction survey and whether aspects of patient satisfaction varied according to sociodemographic characteristics such as age, sex, social class, housing tenure and length of time in education. A sample of 2173 adults living in Medway District Health Authority were surveyed by postal questionnaire in September 1991 in order to elicit their views on general practice services. Levels of satisfaction varied with age, with younger people being consistently less satisfied with general practice services than older people. Women, those in social classes 1-3N, home owners and those who left school aged 17 years or older were more critical of primary care services than men, those in social classes 3M-5, tenants and those who left school before the age of 17 years. Surveys and analyses of this kind, if conducted for a single practice, can form the basis of a marketing strategy aimed at optimizing list size, list composition, and service quality. Satisfaction surveys can be readily incorporated into medical audit and financial management.

Identifying factors associated with experiences of coronary heart disease patients receiving structured chronic care and counselling in European primary care

PubMed Central

2012-01-01

Background Primary care for chronic illness varies across European healthcare systems. In patients suffering from coronary heart disease (CHD), factors associated with patients’ experiences of receiving structured chronic care and counselling at the patient and practice level were investigated. Methods In an observational study comprising 140 general practices from five European countries (Austria, Germany, the Netherlands, Switzerland and the United Kingdom), 30 patients with Coronary Heart Disease (CHD) per practice were chosen at random to partake in this research. Patients were provided with a questionnaire and the Patient Assessment of Chronic Illness Care (PACIC-5A) - instrument. Practice characteristics were assessed through a practice questionnaire and face to face interviews. Data were aggregated to obtain two practice scores representing quality management and CHD care, respectively. A hierarchical multilevel analysis was performed to examine the impact of patient and practice characteristics on PACIC scores. Results The final sample included 1745 CHD-patients from 131 general practices with a mean age of 67.8 (SD 9.9) years. The overall PACIC score was 2.84 (95%CI: 2.79; 2.89) and the 5A score reflecting structured lifestyle counselling was 2.75 (95% CI: 2.69; 2.79). At the patient level, male gender, more frequent practice contact and fewer related or unrelated conditions were associated with higher PACIC scores. At the practice level, performance scores reflecting quality management (p = 0.013) and CHD care (p = 0.009) were associated with improved assessment of the structured chronic care and counselling received. Conclusions Patients’ perceived quality of care varies. However, good practice management and organisation of care were positively reflected in patients’ assessments of receiving structured chronic illness care. This highlights the importance of integrating patient experiences into quality measurements to provide feedback to health care professionals. PMID:22838403

[The practice guideline 'Pregnancy and puerperium' (first revision) from the Dutch College of General Practitioners; a response from the perspective of gynaecology].

PubMed

Heringa, M P

2004-01-10

The major benefit of the revised version of the Dutch College of General Practitioners' practice guideline about pregnancy and puerperium is the formal starting point of professional equality of midwives and general practitioners as care providers in antenatal and postpartum care. This thorough evidence-based practice guideline is behind the most recent developments in this field. Scientific evidence on vertical HIV transmission favours screening all pregnant women and not just the selective procedure proposed in this guideline. The restrictive attitude towards routine ultrasound screening during pregnancy hardly seems in line with scientific evidence and the public demand. On the other hand the guideline is very progressive as far as the care of women with thyroid disorders is concerned even though evidence on this subject is meagre. Most importantly the transition of antenatal care from the current almost conveyor belt-like procedure to an efficient but individually-adapted care process was not addressed.

Implementing new care models: learning from the Greater Manchester demonstrator pilot experience.

PubMed

Elvey, Rebecca; Bailey, Simon; Checkland, Kath; McBride, Anne; Parkin, Stephen; Rothwell, Katy; Hodgson, Damian

2018-06-19

Current health policy focuses on improving accessibility, increasing integration and shifting resources from hospitals to community and primary care. Initiatives aimed at achieving these policy aims have supported the implementation of various 'new models of care', including general practice offering 'additional availability' appointments during evenings and at weekends. In Greater Manchester, six 'demonstrator sites' were funded: four sites delivered additional availability appointments, other services included case management and rapid response. The aim of this paper is to explore the factors influencing the implementation of services within a programme designed to improve access to primary care. The paper consists of a qualitative process evaluation undertaken within provider organisations, including general practices, hospitals and care homes. Semi-structured interviews, with the data subjected to thematic analysis. Ninety-one people participated in interviews. Six key factors were identified as important for the establishment and running of the demonstrators: information technology; information governance; workforce and organisational development; communications and engagement; supporting infrastructure; federations and alliances. These factors brought to light challenges in the attempt to provide new or modify existing services. Underpinning all factors was the issue of trust; there was consensus amongst our participants that trusting relationships, particularly between general practices, were vital for collaboration. It was also crucial that general practices trusted in the integrity of anyone external who was to work with the practice, particularly if they were to access data on the practice computer system. A dialogical approach was required, which enabled staff to see themselves as active rather than passive participants. The research highlights various challenges presented by the context within which extended access is implemented. Trust was the fundamental underlying issue; there was consensus amongst participants that trusting relationships were vital for effective collaboration in primary care.

A Research Agenda to Advance the Coordination of Care for General Medical and Substance Use Disorders.

PubMed

Quinn, Amity E; Rubinsky, Anna D; Fernandez, Anne C; Hahm, Hyeouk Chris; Samet, Jeffrey H

2017-04-01

The separation of addiction care from the general medical care system has a negative impact on patients' receipt of high-quality medical care. Clinical and policy-level strategies to improve the coordination of addiction care and general medical care include identifying and engaging patients with unhealthy substance use in general medical settings, providing effective chronic disease management of substance use disorders in primary care, including patient and family perspectives in care coordination, and implementing pragmatic models to pay for the coordination of addiction and general medical care. This Open Forum discusses practice and research recommendations to advance the coordination of general medical and addiction care. The discussion is based on the proceedings of a national meeting of experts in 2014.

Australian general practitioner attitudes to clinical practice guidelines and some implications for translating osteoarthritis care into practice.

PubMed

Basedow, Martin; Runciman, William B; Lipworth, Wendy; Esterman, Adrian

2016-11-01

Clinical practice guidelines (CPGs) have been shown to improve processes of care and health outcomes, but there is often a discrepancy between recommendations for care and clinical practice. This study sought to explore general practitioner (GP) attitudes towards CPGs, in general and specifically for osteoarthritis (OA), with the implications for translating OA care into practice. A self-administered questionnaire was conducted in January 2013 with a sample of 228 GPs in New South Wales and South Australia. Seventy-nine GPs returned questionnaires (response rate 35%). Nearly all GPs considered that CPGs support decision-making in practice (94%) and medical education (92%). Very few respondents regarded CPGs as a threat to clinical autonomy, and most recognised that individual patient circumstances must be taken into account. Shorter CPG formats were preferred over longer and more comprehensive formats, with preferences being evenly divided among respondents for short, 2-3-page summaries, flowcharts or algorithms and single page checklists. GPs considered accessibility to CPGs to be important, and electronic formats were popular. Familiarity and use of The Royal Australian College of General Practitioners OA Guideline was poor, with most respondents either not aware of it (30%; 95% confidence interval (CI) 27 - 41%), had never used it (19%; 95% CI 12 - 29%) or rarely used it (34%; 95% CI 25-45%). If CPGs are to assist with the translation of evidence into practice, they must be easily accessible and in a format that encourages use.

Immunising Children in Primary Care in the UK--What Are the Concerns of Principal Immunisers?

ERIC Educational Resources Information Center

Maconachie, Moira; Lewendon, Gill

2004-01-01

Objective: To determine the levels of concern about risks associated with childhood immunisations among principal immunisers in general practice. Design: Self-administered postal questionnaire survey. Setting: South & West Devon Health Authority. Participants: Eighty-eight/102 general practices: 78 practice nurses, 7 general practitioners, 3…

A preliminary study of the relationship between general practice care and hospitalisation using a diabetes register, CARDIAB.

PubMed

Comino, Elizabeth J; Tran, Duong Thuy; Taggart, Jane R; Liaw, Siaw-Teng; Ruscoe, Warwick; Snow, Jill M; Harris, Mark F

2013-05-01

Diabetes can be effectively managed in general practice (GP). This study used record linkage to explore associations between diabetes care in GP and hospitalisation. Data on patients with type 2 diabetes were extracted from a Division of GP diabetes register (CARDIAB) for 2002-05 and were linked to the New South Wales Admitted Patient and Emergency Department (ED) Data Collection to create a unit record data collection containing demographic, clinical and health service records. Rates of admission and ED presentation per patient-year of follow up were calculated for the year following CARDIAB record. The study included 1178 diabetic patients with 2959 patient-years of follow up. Their mean age was 65.7 years and duration of diabetes was 5.9 years. All-cause admission and ED presentation rates were 0.7 and 0.2 per patient-year of follow up respectively and length of admission 3.2 days (s.d. 11.7 days). Admission was associated with age, duration of diabetes and prior admission. The number of processes of care recorded for each patient-year was associated with admission. Admission and length of stay were not associated with achievement of clinical targets. These data suggest that receipt of processes of care, rather than clinical targets, will prevent admission. One explanation may be that continuity of care in GP provides opportunity for early intervention and treatment. WHAT IS KNOWN ABOUT THE TOPIC? Diabetes is a serious public health problem that is largely managed in primary care. Health care planners use health service use (hospital admissions) for diabetes as an indicator of primary care. Guidelines for diabetes care are known to be effective in reducing diabetes-related complications. WHAT DOES THIS PAPER ADD? This paper created a linked data collection comprising demographic and clinical data from general practice and administrative health records of hospital admissions and emergency department presentations. The paper explores the associations between processes of primary care and control of diabetes and cardiovascular risk factors, and use of health services for a general practice population with diabetes. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? The study suggests that processes of care and not technical control of diabetes and cardiovascular risk factors are important in preventing hospital admission. Continuity of care in general practice that ensures implementation of processes of care provides opportunity for early intervention and treatment.

Transforming family practice in British Columbia

PubMed Central

Cavers, William J.R.; Tregillus, Valerie H.F.; Micco, Angela; Hollander, Marcus J.

2010-01-01

ABSTRACT OBJECTIVE To describe a new approach to primary care reform developed in British Columbia (BC) under the leadership of the General Practice Services Committee (GPSC). COMPOSITION OF THE COMMITTEE The GPSC is a joint committee of the BC Ministry of Health Services, the BC Medical Association, and the Society of General Practitioners of BC. Representatives of BC’s health authorities also attend as guests. METHOD This paper is based on the 2008–2009 annual report of the GPSC. It summarizes the history and main activities of the GPSC. REPORT The GPSC is currently supporting a number of key activities to transform primary care in BC. These activities include the Full Service Family Practice Incentive Program, which provides incentive payments to promote enhanced primary care; the Practice Support Program, which provides family physicians and their medical office assistants with various practical evidence-based strategies and tools for managing practice enhancement; the Family Physicians for BC Program to develop family practices in areas of identified need; the Shared Care Committee, which supports and enables the determination of appropriate scopes of practice among GPs, specialists, and other health care professionals; the Divisions of Family Practice, which are designed to facilitate interactions among family doctors and between doctors and their respective health authorities; and the Community Healthcare and Resource Directory, a Web-based resource to help health care providers find appropriate mental health resources. CONCLUSION Early results indicate that the GPSC’s initiatives are enhancing the delivery of primary care services in BC. PMID:21156899

Can self-care health books affect amount of contact with the primary health care team? A randomized controlled trial in general practice.

PubMed

Platts, Amanda; Mitton, Rosly; Boniface, David; Friedli, Karin

2005-09-01

To investigate the effects of two differently styled self-care health books in general practice on the frequency and duration of patients' consultations and their views of the books. Random allocation of patients to either a descriptive or a decision-tree based self-care health book, or a no-book control condition. Three- and 12-months follow-up by postal questionnaire and monitoring of consultations. A large general practice in the South East of England. A total of 1967 volunteer, adult patients who attended the practice in 2001 participated. Demographics; health problems; use of health services; use and perceptions of the trial book; frequency and duration of consultations. Response rates to postal questionnaires at 3 and 12 months were 80% and 74%. In all, 48% consulted their allocated book, compared with 25% who consulted any healthcare book in the Control group. Those reporting health problems were more likely to have consulted their allocated book; 60% reported that the allocated book made them more likely to deal with a problem themselves and 40% reported themselves less likely to consult the practice. However, there were no differences in consultation rates or durations of consultations between the three groups. Handing out of self-care health books may provide qualitative benefits for patients but is unlikely to reduce attendance at the GP practice.

Stressors, social support, religious practice, and general well-being among Korean adult immigrants.

PubMed

Lee, Kyoung Hag; Woo, Hyeyoung

2013-10-01

Through this cross-sectional study the authors explore how stressors, social support, and religious practice are associated with the general well-being of 147 Korean adult immigrants through interviews. Hierarchical regression analysis reveals that low English proficiency and financial hardship are significantly related to low general well-being. However, high social support and religious practice are significantly associated with high general well-being. Social service and health care providers need to carefully assess stressors, social support systems, and spiritual issues for providing appropriate services/programs for English, culture, or social activities as well as spiritual intervention to maximize the strengths of Korean immigrants coping with health issues.

Primary healthcare solo practices: homogeneous or heterogeneous?

PubMed

Pineault, Raynald; Borgès Da Silva, Roxane; Provost, Sylvie; Beaulieu, Marie-Dominique; Boivin, Antoine; Couture, Audrey; Prud'homme, Alexandre

2014-01-01

Introduction. Solo practices have generally been viewed as forming a homogeneous group. However, they may differ on many characteristics. The objective of this paper is to identify different forms of solo practice and to determine the extent to which they are associated with patient experience of care. Methods. Two surveys were carried out in two regions of Quebec in 2010: a telephone survey of 9180 respondents from the general population and a postal survey of 606 primary healthcare (PHC) practices. Data from the two surveys were linked through the respondent's usual source of care. A taxonomy of solo practices was constructed (n = 213), using cluster analysis techniques. Bivariate and multilevel analyses were used to determine the relationship of the taxonomy with patient experience of care. Results. Four models were derived from the taxonomy. Practices in the "resourceful networked" model contrast with those of the "resourceless isolated" model to the extent that the experience of care reported by their patients is more favorable. Conclusion. Solo practice is not a homogeneous group. The four models identified have different organizational features and their patients' experience of care also differs. Some models seem to offer a better organizational potential in the context of current reforms.

Primary Healthcare Solo Practices: Homogeneous or Heterogeneous?

PubMed Central

Beaulieu, Marie-Dominique; Boivin, Antoine; Prud'homme, Alexandre

2014-01-01

Introduction. Solo practices have generally been viewed as forming a homogeneous group. However, they may differ on many characteristics. The objective of this paper is to identify different forms of solo practice and to determine the extent to which they are associated with patient experience of care. Methods. Two surveys were carried out in two regions of Quebec in 2010: a telephone survey of 9180 respondents from the general population and a postal survey of 606 primary healthcare (PHC) practices. Data from the two surveys were linked through the respondent's usual source of care. A taxonomy of solo practices was constructed (n = 213), using cluster analysis techniques. Bivariate and multilevel analyses were used to determine the relationship of the taxonomy with patient experience of care. Results. Four models were derived from the taxonomy. Practices in the “resourceful networked” model contrast with those of the “resourceless isolated” model to the extent that the experience of care reported by their patients is more favorable. Conclusion. Solo practice is not a homogeneous group. The four models identified have different organizational features and their patients' experience of care also differs. Some models seem to offer a better organizational potential in the context of current reforms. PMID:24523964

A strategy for the implementation of a quality indicator system in German primary care.

PubMed

van den Heuvel, Henricus

2011-01-01

The Quality and Outcomes Framework (QOF) has had a major impact on the quality of care in British general practice. It is seen as a major innovation amongst quality indicator systems and as a result various countries are looking at whether such initiatives could be used in their primary care. In Germany also the development of similar schemes has started. To propose a strategy indicating key issues for the implementation of a quality indicator scheme in German primary care. Literature review with a focus on the QOF and German quality indicator literature. There are major differences between the German and British healthcare and primary care systems. The development of quality indicator systems for German general practice is in progress and there is a net force for the implementation of such systems. The following ten key factors are suggested for the successful implementation of such a system in German primary care: involvement of general practitioners (GPs) at all levels of the development, a clear implementation process, investment in practice information technology (IT) systems, an accepted quality indicator set, a quality indicator setting institution and data collection organisation, clear financial and non-financial incentives, a 'practice registration' structure, an exception reporting mechanism, delegation of routine clinical data collection tasks to practice assistants, a stepped implementation approach and adequate evaluation processes. For the successful implementation of a quality indicator system in German primary care a number of key issues, as presented in this article, need to be taken into account.

Measuring safety culture in Dutch primary care: psychometric characteristics of the SCOPE-PC questionnaire.

PubMed

Verbakel, Natasha J; Zwart, Dorien L M; Langelaan, Maaike; Verheij, Theo J M; Wagner, Cordula

2013-09-17

Patient safety has been a priority in primary healthcare in the last years. The prevailing culture is seen as an important condition for patient safety in practice and several tools to measure patient safety culture have therefore been developed. Although Dutch primary care consists of different professions, such as general practice, dental care, dietetics, physiotherapy and midwifery, a safety culture questionnaire was only available for general practices. The purpose of this study was to modify and validate this existing questionnaire to a generic questionnaire for all professions in Dutch primary care. A validated Dutch questionnaire for general practices was modified to make it usable for all Dutch primary care professions. Subsequently, this questionnaire was administered to a random sample of 2400 practices from eleven primary care professions. The instrument's factor structure, reliability and validity were examined using confirmatory and explorative factor analyses. 921 questionnaires were returned. Of these, 615 were eligible for factor analysis. The resulting SCOPE-PC questionnaire consisted of seven dimensions: 'open communication and learning from errors', 'handover and teamwork', 'adequate procedures and working conditions', 'patient safety management', 'support and fellowship', 'intention to report events' and 'organisational learning' with a total of 41 items. All dimensions had good reliability with Cronbach's alphas ranging from 0.70-0.90, and the questionnaire had a good construct validity. The SCOPE-PC questionnaire has sound psychometric characteristics for use by the different professions in Dutch primary care to gain insight in their safety culture.

Family physicians who have focused practices in oncology: results of a national survey.

PubMed

Sisler, Jeffrey J; DeCarolis, Mary; Robinson, Deborah; Sivananthan, Gokulan

2013-06-01

To characterize the demographic characteristics, practice profile, and current work life of general practitioners in oncology (GPOs) for the first time. National Web survey performed in March 2011. Canada. Members of the national GPO organization. Respondents were asked to forward the survey to non-member colleagues. Profile of work as GPOs and in other medical roles, training received, demographic characteristics, and professional satisfaction. The response rate was 73.3% for members of the Canadian Association of General Practitioners in Oncology; overall, 120 surveys were completed. Respondents worked in similar proportions in small and larger communities. About 60% of them had participated in formal training programs. Most respondents worked part-time as GPOs and also worked in other medical roles, particularly palliative care, primary care practice, teaching, and hospital work. More GPOs from cities with populations of greater than 100 000 worked solely as GPOs than those from smaller communities (P = .0057). General practitioners in oncology played a variety of roles in the cancer care system, particularly in systemic therapy, palliative care, inpatient care, and teaching. As a group, more than half of respondents were involved in the care of each of the 11 common cancer types. Overall, 87.8% of respondents worked in outpatient care, 59.1% provided inpatient care, and 33.0% provided on-call services; 92.8% were satisfied with their work as GPOs. General practitioners in oncology are involved in all cancer care settings and usually combine this work with other roles, particularly with palliative care in rural Canada. Training is inconsistent but initiatives are under way to address this. Job satisfaction is better than that of Canadian FPs in general. As generalists, FPs bring a valuable skill set to their work as GPOs in the cancer care system.

Native American health: traditional healing and culturally competent health care internet resources.

PubMed

Carlock, Danielle

2006-01-01

Health disparities between Native Americans and the general population of the United States are a major health concern. Traditional healing and culturally competent health care offer much promise in raising the health status of Native Americans. Traditional healing, although uniquely practiced by each indigenous culture, is generally a system of medicine based on the inseparability of mind, body, and spirit. Culturally competent health care, care that is congruent with the culture and language of the patient, is a growing initiative in western medicine. This article outlines Internet sites and online resources relevant to the study and practice of traditional healing and culturally competent health care.

Interpretive medicine: Supporting generalism in a changing primary care world.

PubMed

Reeve, Joanne

2010-01-01

Patient-centredness is a core value of general practice; it is defined as the interpersonal processes that support the holistic care of individuals. To date, efforts to demonstrate their relationship to patient outcomes have been disappointing, whilst some studies suggest values may be more rhetoric than reality. Contextual issues influence the quality of patient-centred consultations, impacting on outcomes. The legitimate use of knowledge, or evidence, is a defining aspect of modern practice, and has implications for patient-centredness. Based on a critical review of the literature, on my own empirical research, and on reflections from my clinical practice, I critique current models of the use of knowledge in supporting individualised care. Evidence-Based Medicine (EBM), and its implementation within health policy as Scientific Bureaucratic Medicine (SBM), define best evidence in terms of an epistemological emphasis on scientific knowledge over clinical experience. It provides objective knowledge of disease, including quantitative estimates of the certainty of that knowledge. Whilst arguably appropriate for secondary care, involving episodic care of selected populations referred in for specialist diagnosis and treatment of disease, application to general practice can be questioned given the complex, dynamic and uncertain nature of much of the illness that is treated. I propose that general practice is better described by a model of Interpretive Medicine (IM): the critical, thoughtful, professional use of an appropriate range of knowledges in the dynamic, shared exploration and interpretation of individual illness experience, in order to support the creative capacity of individuals in maintaining their daily lives. Whilst the generation of interpreted knowledge is an essential part of daily general practice, the profession does not have an adequate framework by which this activity can be externally judged to have been done well. Drawing on theory related to the recognition of quality in interpretation and knowledge generation within the qualitative research field, I propose a framework by which to evaluate the quality of knowledge generated within generalist, interpretive clinical practice. I describe three priorities for research in developing this model further, which will strengthen and preserve core elements of the discipline of general practice, and thus promote and support the health needs of the public.

Standing order use in general practice: the views of medicine, nursing and pharmacy stakeholder organisations.

PubMed

Taylor, Robyn; McKinlay, Eileen; Morris, Caroline

2017-03-01

INTRODUCTION Standing orders are used by many general practices in New Zealand. They allow a practice nurse to assess patients and administer and/or supply medicines without needing intervention from a general practitioner. AIM To explore organisational strategic stakeholders' views of standing order use in general practice nationally. METHODS Eight semi-structured, qualitative, face-to-face interviews were conducted with participants representing key primary care stakeholder organisations from nursing, medicine and pharmacy. Data were analysed using a qualitative inductive thematic approach. RESULTS Three key themes emerged: a lack of understanding around standing order use in general practice, legal and professional concerns, and the impact on workforce and clinical practice. Standing orders were perceived to extend nursing practice and seen as a useful tool in enabling patients to access medicines in a safe and timely manner. DISCUSSION The variability in understanding of the definition and use of standing orders appears to relate to a lack of leadership in this area. Leadership should facilitate the required development of standardised resources and quality assurance measures to aid implementation. If these aspects are addressed, then standing orders will continue to be a useful tool in general practice and enable patients to have access to health care and, if necessary, to medicines without seeing a general practitioner.

Advance care planning for nursing home residents with dementia: policy vs. practice.

PubMed

Ampe, Sophie; Sevenants, Aline; Smets, Tinne; Declercq, Anja; Van Audenhove, Chantal

2016-03-01

The aims of this study were: to evaluate the advance care planning policy for people with dementia in nursing homes; to gain insight in the involvement of residents with dementia and their families in advance care planning, and in the relationship between the policy and the actual practice of advance care planning. Through advance care planning, nursing home residents with dementia are involved in care decisions, anticipating their reduced decision-making capacity. However, advance care planning is rarely realized for this group. Prevalence and outcomes have been researched, but hardly any research has focused on the involvement of residents/families in advance care planning. Observational cross-sectional study in 20 nursing homes. The ACP audit assessed the views of the nursing homes' staff on the advance care planning policy. In addition, individual conversations were analysed with 'ACP criteria' (realization of advance care planning) and the 'OPTION' instrument (involvement of residents/families). June 2013-September 2013. Nursing homes generally met three quarters of the pre-defined criteria for advance care planning policy. In almost half of the conversations, advance care planning was explained and discussed substantively. Generally, healthcare professionals only managed to involve residents/families on a baseline skill level. There were no statistically significant correlations between policy and practice. The evaluations of the policy were promising, but the actual practice needs improvement. Future assessment of both policy and practice is recommended. Further research should focus on communication interventions for implementing advance care planning in the daily practice. © 2015 John Wiley & Sons Ltd.

Family-centered Care in the Outpatient General Psychiatry Clinic.

PubMed

Heru, Alison M

2015-09-01

Although family research supports family-centered care for all medical specialties, the benefit of family-centered care has not been fully realized in outpatient practice. Physicians, including psychiatrists, are not routinely taught how to work with families and may not be aware of the evidence-base for family interventions. However, some medical specialties, such as family medicine and palliative care, have a clinical practice that routinely includes the family. Clinicians working in medical clinics, such as diabetes clinics, know that successful management of chronic illness requires family involvement. Psychiatric clinics, such as The Family Center for Bipolar Disorder at Beth Israel Medical Center in New York City, also have a family-centered practice and show improved patient outcomes. This article provides guidelines, including clinical interview questions, to help psychiatrists practice family-centered care, either in a private office or in a general psychiatric outpatient clinic. The guidelines include questions that identify when to seek an in-depth family assessment or consultation. Family-centered care will become more useful when health care reimbursement focuses on patient outcome.

Knowledge of newborn health care among pregnant women: basis for promotional and educational programs on breastfeeding.

PubMed

Issler, H; de Sá, M B; Senna, D M

2001-01-04

Promotional and educational programs relating to breast feeding are important for reversing the decline in this practice. Most programs are centered exclusively on breast feeding, although general knowledge about newborn health care may be important, especially among pregnant women. To study pregnant women's knowledge about general health care of newborns, including breast feeding aspects. Cross-sectional. Prof. Samuel Barnsley Pessoa Health School Center, Faculty of Medicine, University of São Paulo, Brazil. All pregnant women who were registered in the prenatal care program during six consecutive months. Aspects of the current gestation, previous gestations and childbirth, knowledge of the general aspects of newborn health care and of breast feeding practices. The results show that only a little over half of the pregnant women had received any information on newborn health care. Misinformation was clearly present regarding proper care of the umbilical stump and the nature of jaundice, and worst regarding how to treat oral thrush and jaundice, and about vaccination. In relation to breast feeding, even though almost all the pregnant women declared their intention to breast feeding, less than half had a concrete response regarding how long to do it for. The low rates obtained in the topics dealing with the duration, nursing intervals and the attitude to be taken towards hypogalactia show unfamiliarity with the breast feeding technique. The "weak milk" belief, the misinformation about contraceptive methods during breast feeding and the cost of artificial formulas also have a negative impact on this practice. Pregnant women's knowledge of newborn health care is low, as much in the aspects of general care as in relation to the practice of breast feeding. These findings must be taken into consideration in educative programs promoting breast feeding.

Advanced dental education programs: status and implications for access to care in California.

PubMed

Glassman, Paul

2012-01-01

Primary care residencies in dentistry include general practice residency and advanced education in general dentistry--collectively known as postdoctoral general--dentistry and pediatric dentistry. These primary care programs are the most likely to serve underserved populations during the training experience. An expansion of primary care dental residency positions in California has the potential to positively impact access to care in California. However, there are significant political and financial barriers to realizing this potential.

Need of Department of General Practice / Family Medicine at AIIMS (All India Institute of Medical Sciences): Why the apex medical institute in India should also contribute towards training and education of general practitioners and family physicians.

PubMed

Pal, Ranabir; Kumar, Raman

2017-01-01

Family medicine or general practice is the practicing discipline of the majority doctors in India, however formal academic departments of general practice (or family medicine) do not exist in India, as it is not a mandatory requirement as prescribed by the Medical Council of India; the principal regulator of medical education. Currently India has capacity to produce more than 60,000 medical graduates per year, majority of whom are expected to become general practitoners or primary care doctors without under going any vocational training in general practice or family medicine. The 92 nd parliamentary standing committee report (on health and family welfare) of the Indian Parliament recommended that Government of India in coordination with State Governments should establish robust postgraduate programs in Family Medicine and facilitate introducing Family Medicine discipline in all medical colleges. This will not only minimize the need for frequent referrals to specialist and decrease the load on tertiary care but also provide continuous health care for the individuals and families. The authors concur with the parliament of India and strongly feel that "Family Medicine" (community-based comprehensive clinical practice) deserves dedicated and distinct department at all medical colleges in India in order to availability of qualified medical doctors in the community-based health system. AIIMS, New Delhi, along with other newly established AIIMS, should rise to their foundation mandate of supporting excellence in all disciplines of medical science and to this historic responsibility; and not just remain an ivory tower of tertiary care based fragmented (into sub specialties) hospital culture.

Need of Department of General Practice / Family Medicine at AIIMS (All India Institute of Medical Sciences): Why the apex medical institute in India should also contribute towards training and education of general practitioners and family physicians

PubMed Central

Pal, Ranabir; Kumar, Raman

2017-01-01

Family medicine or general practice is the practicing discipline of the majority doctors in India, however formal academic departments of general practice (or family medicine) do not exist in India, as it is not a mandatory requirement as prescribed by the Medical Council of India; the principal regulator of medical education. Currently India has capacity to produce more than 60,000 medical graduates per year, majority of whom are expected to become general practitoners or primary care doctors without under going any vocational training in general practice or family medicine. The 92nd parliamentary standing committee report (on health and family welfare) of the Indian Parliament recommended that Government of India in coordination with State Governments should establish robust postgraduate programs in Family Medicine and facilitate introducing Family Medicine discipline in all medical colleges. This will not only minimize the need for frequent referrals to specialist and decrease the load on tertiary care but also provide continuous health care for the individuals and families. The authors concur with the parliament of India and strongly feel that “Family Medicine” (community-based comprehensive clinical practice) deserves dedicated and distinct department at all medical colleges in India in order to availability of qualified medical doctors in the community-based health system. AIIMS, New Delhi, along with other newly established AIIMS, should rise to their foundation mandate of supporting excellence in all disciplines of medical science and to this historic responsibility; and not just remain an ivory tower of tertiary care based fragmented (into sub specialties) hospital culture. PMID:29302511

Suicide prevention in primary care: General practitioners' views on service availability

PubMed Central

2010-01-01

Background Primary care may be a key setting for suicide prevention. However, comparatively little is known about the services available in primary care for suicide prevention. The aims of the current study were to describe services available in general practices for the management of suicidal patients and to examine GPs views on these services. We carried out a questionnaire and interview study in the North West of England. We collected data on GPs views of suicide prevention generally as well as local mental health service provision. Findings During the study period (2003-2005) we used the National Confidential Inquiry Suicide database to identify 286 general practitioners (GPs) who had registered patients who had died by suicide. Data were collected from GPs and practice managers in 167 practices. Responses suggested that there was greater availability of services and training for general mental health issues than for suicide prevention specifically. The three key themes which emerged from GP interviews were: barriers accessing primary or secondary mental health services; obstacles faced when referring a patient to mental health services; managing change within mental health care services Conclusions Health professionals have an important role to play in preventing suicide. However, GPs expressed concerns about the quality of primary care mental health service provision and difficulties with access to secondary mental health services. Addressing these issues could facilitate future suicide prevention in primary care. PMID:20920302

Individual care plans for chronically ill patients within primary care in the Netherlands: Dissemination and associations with patient characteristics and patient-perceived quality of care.

PubMed

Jansen, Daphne L; Heijmans, Monique; Rijken, Mieke

2015-06-01

To examine the use of individual care plans (ICPs) within primary chronic illness care in the Netherlands, and to explore the relationships between ICP use, patient characteristics, and patient-perceived quality of care. Cross-sectional study using survey data from a panel of chronically ill patients and medical registration data provided by their general practices. A sample of 1377 patients with somatic chronic disease(s) randomly selected in general practices throughout the Netherlands, supplemented with a sample of 225 COPD patients, also recruited from general practices. (i) Percentage of ICP use based on self-report by chronically ill patients, and (ii) patient-perceived quality of care as assessed using the Patient Assessment of Chronic Illness Care (PACIC). ICP use among the total generic sample was low (9%), but slightly higher (13%) among patients diagnosed with diabetes or COPD, diseases for which disease management programmes have been set up in the Netherlands. Patients with a low educational level and patients with poor(er) self-rated health were more likely to have an ICP. Compared with patients without an ICP, patients with an ICP more often reported that the care they received was patient-centred, proactive, planned, and included collaborative goal setting, problem-solving, and follow-up support. Findings reveal a discrepancy between practice and policy aspirations regarding ICP use in primary chronic illness care. More research is needed to gain insight into the effectiveness of ICPs to improve the quality of chronic illness care in various patient populations.

The Future of General Internal Medicine

PubMed Central

Larson, Eric B; Fihn, Stephan D; Kirk, Lynne M; Levin, Wendy; Loge, Ronald V; Reynolds, Eileen; Sandy, Lewis; Schroeder, Steven; Wenger, Neil; Williams, Mark

2004-01-01

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep—ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine. PMID:14748863

Strategic directions for developing the Australian general practice nurse role in cardiovascular disease management.

PubMed

Halcomb, Elizabeth J; Davidson, Patricia M; Yallop, Julie; Griffiths, Rhonda; Daly, John

2007-08-01

Practice nursing is an integral component of British and New Zealand primary care, but in Australia it remains an emerging specialty. Despite an increased focus on the Australian practice nurse role, there has been limited strategic role development, particularly relating to national health priority areas. This paper reports the third stage of a Project exploring the Australian practice nurse role in the management of cardiovascular disease (CVD). This stage involved a consensus development conference, undertaken to identify strategic, priority recommendations for practice nurse role development. 1. Practice nurses have an important role in developing systems and processes for CVD management; 2. A change in the culture of general practice is necessary to promote acceptance of nurse-led CVD management; 3. Future research needs to evaluate specific models of care, incorporating outcome measures sensitive to nursing interventions; 4. Considerable challenges exist in conducting research in general practice; and 5. Changes in funding models are necessary for widespread practice nurse role development. The shifting of funding models provides evidence to support interdisciplinary practice in Australian general practice. The time is ripe, therefore, to engage in prospective and strategic planning to inform development of the practice nurse role.

Dental care for pregnant women: an assessment of North Carolina general dentists.

PubMed

Da Costa, Elizabeth Prada; Lee, Jessica Y; Rozier, R Gary; Zeldin, Leslie

2010-08-01

The authors conducted a study to examine factors associated with general dentists' provision of care for pregnant women and the extent to which they provide comprehensive dental care. The authors mailed an 86-item questionnaire to 1,000 practicing general dentists in North Carolina. Survey domains included provider knowledge about pregnancy and dental health, dental treatment practices, barriers to providing care, outcome expectancy, and personal and practice demographics. The primary dependent variables the authors analyzed were whether dentists provided any treatment to pregnant women and, among those who did, the extent to which they provided comprehensive services. The authors performed multivariate regression analyses to determine factors associated with dentists' provision of care to pregnant women (P < .05). A total of 513 surveys were returned (a response rate of 51.3 percent), of which 495 surveys had complete responses. The authors included the completed surveys in their analyses. The mean age of the respondents was 46 years. The results of multivariate analysis showed that respondents who perceived a lack of demand for services among pregnant women and provided preconception counseling were less likely to provide any treatment for pregnant patients than were those who perceived a demand for services and who did not provide preconception counseling, respectively. Dentists who were male, had a low knowledge score, provided preconception counseling and treated largely white populations of patients were less likely than female dentists, those who had moderate or high knowledge scores, and those who treated a population of minority patients to provide comprehensive care for pregnant women. Most general dentists in private practice provide care for pregnant women, but the authors found notable gaps in dental provider knowledge and comprehensive dental services available for pregnant women. Although many general dentists provide some dental care to pregnant women, more should be done to ensure that this care is comprehensive.

American primary care physicians' decisions to leave their practice: evidence from the 2009 commonwealth fund survey of primary care doctors.

PubMed

Gray, Bradford H; Stockley, Karen; Zuckerman, Stephen

2012-07-01

The status of the primary care workforce is a major health policy concern. It is affected not only by the specialty choices of young physicians but also by decisions of physicians to leave their practices. This study examines factors that may contribute to such decisions. We analyzed data from a 2009 Commonwealth Fund mail survey of American physicians in internal medicine, family or general practice, or pediatrics to examine characteristics associated with their plans to retire or leave their practice for other reasons in the next 5 years. Just over half (53%) of the physicians age 50 years or older and 30% of physicians between age 35 and 49 years may leave their practices for these reasons. Having such plans was associated with many factors, but the strongest predictor concerned problems regarding time spent coordinating care for their patients, possibly reflecting dissatisfaction with tasks that do not require medical expertise and are not generally paid for in fee-for-service medicine. Factors that predict plans to retire differ from those associated with plans to leave practices for other reasons. Provisions of the Patient Protection and Affordable Care Act that reduce the number of uninsured patients as well as innovations such as medical homes and accountable care organizations may reduce pressures that lead to attrition in the primary care workforce. Reasons why primary care physicians' decide to leave their practices deserve more attention from researchers and policy makers.

Job satisfaction of practice assistants in general practice in Germany: an observational study.

PubMed

Goetz, Katja; Campbell, Stephen; Broge, Bjoern; Brodowski, Marc; Steinhaeuser, Jost; Wensing, Michel; Szecsenyi, Joachim

2013-08-01

Job satisfaction of practice staff is important for optimal health care delivery and for minimizing the turnover of non-medical professions. To document the job satisfaction of practice assistants in German general practice and to explore associations between job satisfaction, staff characteristics and culture in general practice organizations. The study was based on data from the European Practice Assessment accreditation scheme for general practices and used an observational design. The study population consisted of 1158 practice assistants from 345 general practices across Germany. Job satisfaction was measured with the 10-item Warr-Cook-Wall questionnaire. Organizational culture was evaluated with four items. A linear regression analysis was performed in which each of the job satisfaction items was handled as dependent variable. Out of 1716 staff member questionnaires handed out to practice assistants, 1158 questionnaires were completed (response rate: 67.5%). Practice assistants were most satisfied with their colleagues and least satisfied with their income. Higher job satisfaction was associated with issues of organizational culture, particularly a good working atmosphere, opportunities to suggest and influence areas for improvement and clear responsibilities within the practice team. Prioritizing initiatives to maintain high levels of, or to improve the job satisfaction of practice assistants, is important for recruitment and retention. It will also help to improve working conditions for both practice assistants and GPs and create an environment to provide better quality care.

Palliative care for cirrhosis: a UK survey of health professionals’ perceptions, current practice and future needs

PubMed Central

Low, Joseph; Vickerstaff, Victoria; Davis, Sarah; Bichard, Julia; Greenslade, Lynda; Hopkins, Katherine; Marshall, Aileen; Thorburn, Douglas; Jones, Louise

2016-01-01

Objective To determine the knowledge and practice patterns of a UK cohort of relevant healthcare professionals (HCPs) about delivering palliative care in cirrhosis, and to inform priorities for future research. Design An on-line questionnaire survey with closed and open responses. Setting HCPs identified from the mailing list of special interest groups in hepatology and gastroenterology (liver), general practice and specialist palliative care (SPC) across the UK. Results Of the 6181 potential contacts identified, 517 HCPs responded. Most believed a role exists for SPC in caring for people with cirrhosis, but many SPC HCPs felt ill prepared to provide good care to those facing death. Further training was needed in managing liver-related symptoms, symptom control and end of life issues. All HCP groups wished to increase community provision of palliative care support, but many general practitioners felt unable to manage advanced cirrhosis in the community. There were differences in the optimal trigger for SPC referral with liver HCPs less likely to refer at symptom deterioration. Prognostication, symptom management and service configuration were key areas identified for future research. Conclusions All who responded acknowledged the role of SPC in caring for those dying with cirrhosis and need for further training to improve confidence and enable joint working between SPC, general practice and liver teams. Low response rates make it difficult to generalise these findings, which require further validation. PMID:28839829

Diabetic Retinopathy Screening and Monitoring of Early Stage Disease in Australian General Practice: Tackling Preventable Blindness within a Chronic Care Model.

PubMed

Crossland, Lisa; Askew, Deborah; Ware, Robert; Cranstoun, Peter; Mitchell, Paul; Bryett, Andrew; Jackson, Claire

2016-01-01

Diabetic retinopathy (DR) is the leading cause of preventable blindness in Australia. Up to 50% of people with proliferative DR who do not receive timely treatment will become legally blind within five years. Innovative and accessible screening, involving a variety of primary care providers, will become increasingly important if patients with diabetes are to receive optimal eye care. An open controlled trial design was used. Five intervention practices in urban, regional, and rural Australia partnered with ophthalmologists via telehealth undertook DR screening and monitoring of type 2 diabetes patients and were compared with control practices undertaking usual care 2011-2014. Recorded screening rates were 100% across intervention practices, compared with 22-53% in control practices. 31/577 (5%) of patients in the control practices were diagnosed with mild-moderate DR, of whom 9 (29%) had appropriate follow-up recorded. This was compared with 39/447 (9%) of patients in the intervention group, of whom 37 (95%) had appropriate follow-up recorded. General practice-based DR screening via Annual Cycle of Care arrangements is effective across differing practice locations. It offers improved recording of screening outcomes for Australians with type 2 diabetes and better follow-up of those with screen abnormalities.

Does responsibility drive learning? Lessons from intern rotations in general practice.

PubMed

Cantillon, Peter; Macdermott, Maeve

2008-01-01

The intern (or pre-registration) year has been criticised in the past for its emphasis on service delivery at the expense of educational achievement. It is hoped that new approaches to early postgraduate training such as the foundation programmes in the UK, will make clinical education more structured and effective. Intern placements in non-traditional settings such as general practice have been shown in the past to improve the quality of learning. Little is known however about which features of the general practice learning environment contribute most to the perception of improved learning. This aim of this study was to examine the learning environment in general practice from the perspective of interns, (the learners), to determine the factors that contribute most to motivating effective learning in a general practice setting. This study used a qualitative case study approach to explore the effects of two different learning environments, (general practice and hospital) on learner motivation amongst a small group of interns. We found that the biggest difference between the hospital and general practice learning environments was the increased individual responsibility for patient care experienced by interns in general practice. Greater responsibility was associated with greater motivation for learning. Increased intern responsibility for patient care does appear to motivate learning. More work needs to be done on providing interns in hospital posts with greater patient responsibility within an effective supervisory structure.

Primary Care Practice: Uncertainty and Surprise

NASA Astrophysics Data System (ADS)

Crabtree, Benjamin F.

I will focus my comments on uncertainty and surprise in primary care practices. I am a medical anthropologist by training, and have been a full-time researcher in family medicine for close to twenty years. In this talk I want to look at primary care practices as complex systems, particularly taking the perspective of translating evidence into practice. I am going to discuss briefly the challenges we have in primary care, and in medicine in general, of translating new evidence into the everyday care of patients. To do this, I will look at two studies that we have conducted on family practices, then think about how practices can be best characterized as complex adaptive systems. Finally, I will focus on the implications of this portrayal for disseminating new knowledge into practice.

Register-Recall Systems: Tools for Chronic Disease Management in General Practice.

PubMed

Georgiou, Andrew; Burns, Joan; Penn, Danielle; Infante, Fernando; Harris, Mark

2004-09-01

The Divisions Diabetes and Cardiovascular Disease Quality Improvement Project (DDCQIP) is a national project that aims to promote quality improvement initiatives among Divisions of General Practice. DDCQIP has investigated the growth of Division-based diabetes and cardiovascular disease register-recall systems and the role they play in promoting evidence-based structured care within general practice. In the period 2000-2002, an increase in the number of GPs using register-recall systems and the rise in the number of active registered patients have made it possible to monitor quality of care and health outcome indicators, and contributed to the growth of a Division-based population health program.

Organisational determinants of production and efficiency in general practice: a population-based study.

PubMed

Olsen, Kim Rose; Gyrd-Hansen, Dorte; Sørensen, Torben Højmark; Kristensen, Troels; Vedsted, Peter; Street, Andrew

2013-04-01

Shortage of general practitioners (GPs) and an increased political focus on primary care have enforced the interest in efficiency analysis in the Danish primary care sector. This paper assesses the association between organisational factors of general practices and production and efficiency. We assume that production and efficiency can be modelled using a behavioural production function. We apply the Battese and Coelli (Empir Econ 20:325-332, 1995) estimator to accomplish a decomposition of exogenous variables to determine the production frontier and variables determining the individual GPs distance to this frontier. Two different measures of practice outputs (number of office visits and total production) were applied and the results compared. The results indicate that nurses do not substitute GPs in the production. The production function exhibited constant returns to scale. The mean level of efficiency was between 0.79 and 0.84, and list size was the most important determinant of variation in efficiency levels. Nurses are currently undertaking other tasks than GPs, and larger practices do not lead to increased production per GP. However, a relative increase in list size increased the efficiency. This indicates that organisational changes aiming to increase capacity in general practice should be carefully designed and tested.

What determines medical students' career preference for general practice residency training?: a multicenter survey in Japan.

PubMed

Ie, Kenya; Murata, Akiko; Tahara, Masao; Komiyama, Manabu; Ichikawa, Shuhei; Takemura, Yousuke C; Onishi, Hirotaka

2018-01-01

Few studies have systematically explored factors affecting medical students' general practice career choice. We conducted a nationwide multicenter survey (Japan MEdical Career of Students: JMECS) to examine factors associated with students' general practice career aspirations in Japan, where it has been decided that general practice will be officially acknowledged as a new discipline. From April to December 2015, we distributed a 21-item questionnaire to final year medical students in 17 medical schools. The survey asked students about their top three career preferences from 19 specialty fields, their demographics and their career priorities. Multivariable logistic regression was used to determine the effect of each item. A total of 1264 responses were included in the analyses. The top three specialty choice were internal medicine: 833 (65.9%), general practice: 408 (32.3%), and pediatrics: 372 (29.4%). Among demographic factors, "plan to inherit other's practice" positively associated with choosing general practice, whereas "having physician parent" had negative correlation. After controlling for potential confounders, students who ranked the following items as highly important were more likely to choose general practice: "clinical diagnostic reasoning (adjusted odds ratio (aOR): 1.65, 95% CI 1.40-1.94)", "community-oriented practice (aOR: 1.33, 95% CI 1.13-1.57)", and" involvement in preventive medicine (aOR: 1.18, 95% CI 1.01-1.38)". On the contrary, "acute care rather than chronic care", "mastering advanced procedures", and "depth rather than breadth of practice" were less likely to be associated with general practice aspiration. Our nationwide multicenter survey found several features associated with general practice career aspirations: clinical diagnostic reasoning; community-oriented practice; and preventive medicine. These results can be fundamental to future research and the development of recruitment strategies.

General practitioners' views on leadership roles and challenges in primary health care: a qualitative study.

PubMed

Spehar, Ivan; Sjøvik, Hege; Karevold, Knut Ivar; Rosvold, Elin Olaug; Frich, Jan C

2017-03-01

To explore general practitioners' (GPs) views on leadership roles and leadership challenges in general practice and primary health care. We conducted focus groups (FGs) with 17 GPs. Norwegian primary health care. 17 GPs who attended a 5 d course on leadership in primary health care. Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement. GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance. KEY POINTS Little is known about doctors' experiences and views about leadership in general practice and primary health care. Our study suggests that: There is a lack of preparation and formal training for the leadership role. GPs experience tensions between the clinical and leadership role. GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.

General practitioners’ views on leadership roles and challenges in primary health care: a qualitative study

PubMed Central

Spehar, Ivan; Sjøvik, Hege; Karevold, Knut Ivar; Rosvold, Elin Olaug; Frich, Jan C.

2017-01-01

Objective To explore general practitioners’ (GPs) views on leadership roles and leadership challenges in general practice and primary health care. Design We conducted focus groups (FGs) with 17 GPs. Setting Norwegian primary health care. Subjects 17 GPs who attended a 5 d course on leadership in primary health care. Results Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement. Conclusions GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance. Key points Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that: There is a lack of preparation and formal training for the leadership role. GPs experience tensions between the clinical and leadership role. GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care. PMID:28277051

Evaluation of a program to strengthen general practice care for patients with chronic disease in Germany.

PubMed

Wensing, Michel; Szecsenyi, Joachim; Stock, Christian; Kaufmann Kolle, Petra; Laux, Gunter

2017-01-21

A program to strengthen general practice care for patients with chronic disease was offered in Germany. Enrollment was a free individual choice for both patients and physicians. This study aimed to examine the long-term impact of this program. Two comparative evaluations were done, at 4 and 5 years (T1 and T2) after start of the program. In each year, patients in the program were compared with patients in usual care. Measures were based on routinely collected data and concerned 11 aspects of primary care and hospital care. Study groups were compared, using regression analysis adjusted for confounders and clustering. Data on 1.187.597 and 1.591.017 eligible patients were available for the analysis for T1 and T2, respectively. Compared to usual care, the program was associated with more visits to the GP per patient (adjusted difference at T2: +1.98), more drugs prescribed per patient (+0.071), lower percentage of drugs that should be avoided (-0.699), and lower yearly medication costs per patient (-85.39 euro). The number of referrals to ambulatory specialists, either with or without referral from GP, was reduced at T2. In hospital care, the program was associated with fewer hospital admissions per patient per year (-0.017) and fewer avoidable hospital admissions of all admissions (-1.165%). Total hospital costs were slightly higher in T1, but lower in T2. Days in hospital and number of readmissions were lower at T2 only. The program has increased the role of general practice in healthcare for patients who chose to be included in the program of intensified general practice care.

Organisational quality, nurse staffing and the quality of chronic disease management in primary care: observational study using routinely collected data.

PubMed

Griffiths, Peter; Maben, Jill; Murrells, Trevor

2011-10-01

An association between quality of care and staffing levels, particularly registered nurses, has been established in acute hospitals. Recently an association between nurse staffing and quality of care for several chronic conditions has also been demonstrated for primary care in English general practice. A smaller body of literature identifies organisational factors, in particular issues of human resource management, as being a dominant factor. However the literature has tended to consider staffing and organisational factors separately. We aim to determine whether relationships between the quality of clinical care and nurse staffing in general practice are attenuated or enhanced when organisational factors associated with quality of care are considered. We further aim to determine the relative contribution and interaction between these factors. We used routinely collected data from 8409 English general practices. The data, on organisational factors and the quality of clinical care for a range of long term conditions, is gathered as part of "Quality and Outcomes Framework" pay for performance system. Regression models exploring the relationship of staffing and organisational factors with care quality were fitted using MPLUS statistical modelling software. Higher levels of nurse staffing, clinical recording, education and reflection on the results of patient surveys were significantly associated with improved clinical care for COPD, CHD, Diabetes and Hypothyroidism after controlling for organisational factors. There was some evidence of attenuation of the estimated nurse staffing effect when organisational factors were considered, but this was small. The effect of staffing interacted significantly with the effect of organisational factors. Overall however, the characteristics that emerged as the strongest predictors of quality of clinical care were not staffing levels but the organisational factors of clinical recording, education and training and use of patient experience surveys. Organisational factors contribute significantly to observed variation in the quality of care in English general practices. Levels of nurse staffing have an independent association with quality but also interact with organisational factors. The observed relationships are not necessarily causal but a causal relationship is plausible. The benefits and importance of education, training and personal development of nursing and other practice staff was clearly indicated. Copyright © 2011. Published by Elsevier Ltd.

Effect of medicolegal liability on patterns of general and family practice in Canada.

PubMed Central

Woodward, C A; Rosser, W

1989-01-01

As part of the Federal/Provincial/Territorial Review on Liability and Compensation Issues in Health Care, in 1988 we surveyed Canadian general practitioners and family physicians to determine the effect of liability concerns on their practices in the previous 5 years. Questionnaires were sent to a random, stratified national sample of 1295 physicians, with a response rate of 64.6%. However, a high proportion of the returned questionnaires were ineligible because the physicians were not in general or family practice, were not involved in direct patient care, or had died or moved; thus, the corrected response rate was 50.8%. The newsletter of the Canadian Medical Protective Association was the source of information on liability most frequently cited (by 88.1% of the physicians) and most influential (to 62.4%). Only 15.5% of the physicians cited personal involvement with medicolegal issues as a source of information; the rate was higher for Ontario physicians and those in urban areas generally. A total of 74.6% of the respondents had altered their style of practice in the previous 5 years, and 56.3% reported changes in the scope of their practice. Concern about litigation was the most important reason for changing style of practice and reducing or eliminating administration of anesthesia, whereas lifestyle and other issues along with liability concerns most influenced decisions to reduce obstetric care and emergency department work. Our findings suggest that physicians' perceptions of liability issues have had a profound influence on primary care practice in Canada in the past several years. PMID:2766164

Australia's first transition to professional practice in primary care program for graduate registered nurses: a pilot study.

PubMed

Aggar, Christina; Bloomfield, Jacqueline; Thomas, Tamsin H; Gordon, Christopher J

2017-01-01

Increases in ageing, chronic illness and complex co-morbidities in the Australian population are adding pressure to the primary care nursing workforce. Initiatives to attract and retain nurses are needed to establish a sustainable and skilled future primary care nursing workforce. We implemented a transition to professional practice program in general practice settings for graduate nurses and evaluated graduate nurse competency, the graduate nurse experience and program satisfaction. This study aimed to determine whether a transition to professional practice program implemented in the general practice setting led to competent practice nurses in their first year post-graduation. A longitudinal, exploratory mixed-methods design was used to assess the pilot study. Data were collected at three times points (3, 6, 12 months) with complete data sets from graduate nurses ( n =  4) and preceptors ( n =  7). We assessed perceptions of the graduates' nursing competency and confidence, satisfaction with the preceptor/graduate relationship, and experiences and satisfaction with the program. Graduate nurse competency was assessed using the National Competency Standards for Nurses in General Practice. Semi-structured interviews with participants at Time 3 sought information about barriers, enablers, and the perceived impact of the program. Graduate nurses were found to be competent within their first year of clinical practice. Program perceptions from graduate nurses and preceptors were positive and the relationship between the graduate nurse and preceptor was key to this development. With appropriate support registered nurses can transition directly into primary care and are competent in their first year post-graduation. While wider implementation and research is needed, findings from this study demonstrate the potential value of transition to professional practice programs within primary care as a nursing workforce development strategy.

Does a higher 'quality points' score mean better care in stroke? An audit of general practice medical records.

PubMed

Williams, Peter Huw; de Lusignan, Simon

2006-01-01

The Royal College of Physicians (RCP) have produced guidelines for stroke management in primary care; this guidance is taken to be the gold standard for the care of people with stroke. UK general practitioners now have a quality-based contract which includes a Quality and Outcomes Framework (QOF). This consists of financially remunerated 'quality points' for specific disease areas, including stroke. Achievement of these quality points is measured by extracting a limited list of computer codes from practice computer systems. To investigate whether a high stroke quality score is associated with adherence to RCP guidelines. Examination of computer and written medical records of all patients with a diagnosis of stroke. Two general practices, one in southwest London, one in Surrey, with a combined practice population of over 20 000. Both practices had a similar age-sex profile and prevalence of stroke. One practice scored 93.5% (29/31) of the available stroke quality points. The other practice achieved 73.4% (22.75/31), and only did better in one stroke quality target. However, the practice scoring fewer quality points had much better adherence to RCP guidance: 96% of patients were assessed in secondary care compared with 79% (P=0.001); 64% of stroke patients were seen the same day, compared with 44%; 56% received rehabilitation compared with 37%. Higher quality points did not reflect better adherence to RCP guidance. This audit highlights a gap between relatively simplistic measures of quality in the QOF, dependent on the recording of a narrow range of computer codes, and the actual standard of care being delivered. Research is needed to see whether this finding is generalisable and how the Quality and Outcomes Framework might be better aligned with delivering best practice.

A Changing Health Care Environment: Its Impact on UCSF Graduates' Practice Patterns and Perceptions.

ERIC Educational Resources Information Center

Sauer, Barbara L.; Koda-Kimble, Mary Anne

1998-01-01

A survey of 754 University of California at San Francisco doctoral pharmacy graduates from 1980 to 1994 investigated how managed care affected practice patterns and perceptions of the profession. Graduates generally remained satisfied with their education and were optimistic about the profession. Although managed care has created a stressful…

Evaluation of a tailored implementation strategy to improve the management of patients with chronic obstructive pulmonary disease in primary care: a study protocol of a cluster randomized trial

PubMed Central

2014-01-01

Background Chronic obstructive pulmonary disease (COPD) remains a major health problem, strongly related to smoking. Despite the publication of practice guidelines on prevention and treatment, not all patients with the disease receive the recommended healthcare, particularly with regard to smoking cessation advice where applicable. We have developed a tailored implementation strategy for enhancing general practitioners’ adherence to the disease management guidelines. The primary aim of the study is to evaluate the effects of this tailored implementation intervention on general practitioners’ adherence to guidelines. Methods/Design A pragmatic two-arm cluster randomized trial has been planned to compare care following the implementation of tailored interventions of four recommendations in COPD patients against usual care. The study will involve 18 general practices (9 in the intervention group and 9 in the control group) in Poland, each with at least 80 identified (at the baseline) patients with diagnosed COPD. The nine control practices will provide usual care without any interventions. Tailored interventions to implement four recommendations will be delivered in the remaining nine practices. At follow-up after nine months, data will be collected for all 18 general practices. The primary outcome measure is physicians’ adherence to all four recommendations: brief anti-smoking advice, dyspnea assessment, care checklist utilization and demonstration to patients of correct inhaler use. This measurement will be based on data extracted from identified patients’ records. Additionally, we will survey and interview patients with chronic obstructive pulmonary disease about the process of care. Discussion The results of this trial will be directly applicable to primary care in Poland and add to the growing body of evidence on interventions to improve chronic illness care. Trial registration This trial has been registered with Clinical Trials Protocol Registration System. Trial number: NCT01893476. PMID:24708623

Management of first-episode pelvic inflammatory disease in primary care: results from a large UK primary care database.

PubMed

Nicholson, Amanda; Rait, Greta; Murray-Thomas, Tarita; Hughes, Gwenda; Mercer, Catherine H; Cassell, Jackie

2010-10-01

Prompt and effective treatment of pelvic inflammatory disease (PID) may help prevent long-term complications. Many PID cases are seen in primary care but it is not known how well management follows recommended guidelines. To estimate the incidence of first-episode PID cases seen in UK general practice, describe their management, and assess its adequacy in relation to existing guidelines. Cohort study. UK general practices contributing to the General Practice Research Database (GPRD). Women aged 15 to 40 years, consulting with a first episode of PID occurring between 30 June 2003 and 30 June 2008 were identified, based on the presence of a diagnostic code. The records within 28 days either side of the diagnosis date were analysed to describe management. A total of 3797 women with a first-ever coded diagnosis of PID were identified. Incidence fell during the study period from 19.3 to 8.9/10 000 person-years. Thirty-four per cent of cases had evidence of care elsewhere, while 2064 (56%) appeared to have been managed wholly within the practice. Of these 2064 women, 34% received recommended treatment including metronidazole, and 54% had had a Chlamydia trachomatis test, but only 16% received both. Management was more likely to follow guidelines in women in their 20s, and later in the study period. These analyses suggest that the management of PID in UK primary care, although improving, does not follow recommended guidelines for the majority of women. Further research is needed to understand the delivery of care in general practice and the coding of such complex syndromic conditions.

Clinical and administrative review in general practice

PubMed Central

Stott, N. C. H.; Davis, R. H.

1975-01-01

Clinical and administrative review in primary medical care can be an enjoyable and creative part of group-practice life. A series of such reviews are described which improve internal or external communication for the primary care team. PMID:1223278

The place of knowledge and evidence in the context of Australian general practice nursing.

PubMed

Mills, Jane; Field, John; Cant, Robyn

2009-01-01

The purpose of the study was to ascertain the place of knowledge and evidence in the context of Australian general practice nursing. General practice nursing is a rapidly developing area of specialized nursing in Australia. The provision of primary care services in Australia rests largely with medical general practitioners who employ nurses in a small business model. A statistical research design was used that included a validated instrument: the developing evidence-based practice questionnaire (Gerrish et al. 2007). A total of 1,800 Victorian practice nurses were surveyed with a return of 590 completed questionnaires, equaling a response rate of 33%. Lack of time to access knowledge for practice was a barrier for participants in this study. In-service education and training opportunities were ranked as the number one source of knowledge for general practice nurses. Experiential learning and interactions with clients, peers, medical practitioners, and specialist nurses were also considered very important sources of knowledge. Research journals were ranked much lower than experiential learning and personal interactions. Participants assessed their own skills at sourcing and translating evidence into practice knowledge as low. Younger general practice nurses were more likely than older nurses to assess themselves as competent at using the library and Internet to locate evidence. The predominantly oral culture of nursing needs to be identified and incorporated into methods for disseminating evidence from research findings in order to increase the knowledge base of Australian general practice nurses. Findings from this study will be significant for policy makers and funders of Australian nursing in general practice. The establishment of a career structure for general practice nurses that includes salaried positions for clinical nurse specialists would assist in the translation of evidence into knowledge for utilization at the point of care.

42 CFR 417.106 - Quality assurance program; Availability, accessibility, and continuity of basic and supplemental...

Code of Federal Regulations, 2012 CFR

2012-10-01

... emergency care service, if the number of providers of that basic health service who will provide the service... includes general practice, family practice, general internal medicine, general pediatrics, and general... after-hours services. (Medically necessary emergency services must be available 24 hours a day, 7 days a...

42 CFR 417.106 - Quality assurance program; Availability, accessibility, and continuity of basic and supplemental...

Code of Federal Regulations, 2014 CFR

2014-10-01

... emergency care service, if the number of providers of that basic health service who will provide the service... includes general practice, family practice, general internal medicine, general pediatrics, and general... after-hours services. (Medically necessary emergency services must be available 24 hours a day, 7 days a...

42 CFR 417.106 - Quality assurance program; Availability, accessibility, and continuity of basic and supplemental...

Code of Federal Regulations, 2013 CFR

2013-10-01

... emergency care service, if the number of providers of that basic health service who will provide the service... includes general practice, family practice, general internal medicine, general pediatrics, and general... after-hours services. (Medically necessary emergency services must be available 24 hours a day, 7 days a...

Experiences of general practices with a participatory pay-for-performance program: a qualitative study in primary care.

PubMed

Kirschner, Kirsten; Braspenning, Jozé; Jacobs, J E Annelies; Grol, Richard

2013-01-01

The involvement of target users in the design choices of a pay-for-performance program may enhance its impact, but little is known about the views of participants in these programs. To explore general practices' experiences with pay-for-performance in primary care we conducted a qualitative study in general practices in the Netherlands. Thirty out of 65 general practices participating in a pay-for-performance program, stratified for bonus, were invited for a semistructured interview on feasibility, feedback and the bonus, spending of the bonus, unintended consequences, and future developments. Content analysis was used to process the resulting transcripts. We included 29 practices. The feasibility of the pay-for-performance program was questioned due to the substantial time investment. The feedback on clinical care, practice management and patient experience was mostly discussed in the team, and used for improvement plans, but was also qualified as annoying for one GP and for another GP it brought feelings of insecurity. Most practices considered the bonus a stimulus to improve quality of care, in addition to compensation for their effort and time invested. Distinctive performance features were not displayed, for instance, on a website. The bonus was mainly spent on new equipment or team building. Practices referred to gaming and focusing on those aspects that were incentivised ('tunnel vision') as unintended consequences. Future developments should be directed to absolute thresholds, new indicators to keep the process going, and an independent audit. Linking a part of the bonus to innovation was also suggested. The participants thought the pay-for-performance program was a labour-intensive positive breakthrough to stimulate quality improvement, but warned of unintended consequences of the program and the sustainability of the indicator set.

General practice, primary care, and health service psychology: concepts, competencies, and the Combined-Integrated model.

PubMed

Schulte, Timothy J; Isley, Elayne; Link, Nancy; Shealy, Craig N; Winfrey, LaPearl Logan

2004-10-01

The profession of psychology is being impacted profoundly by broader changes within the national system of health care, as mental and behavioral health services are being recognized as essential components of a comprehensive, preventive, and cost-efficient primary care system. To fully define and embrace this role, the discipline of professional psychology must develop a shared disciplinary identity of health service psychology and a generalized competency-based model for doctoral education and training. This very framework has been adopted by Combined-Integrated (C-I) doctoral programs in professional psychology, which train across the practice areas (clinical, counseling, and school psychology) to provide a general and integrative foundation for their students. Because C-I programs produce general practitioners who are competent to function within a variety of health service settings, this innovative training approach has great potential to educate and train psychologists for a changing health care marketplace. Copyright 2004 Wiley Periodicals, Inc.

[Prevalence of chronic fatigue syndrome in 4 family practices in Leiden].

PubMed

Versluis, R G; de Waal, M W; Opmeer, C; Petri, H; Springer, M P

1997-08-02

To determine the prevalence of chronic fatigue syndrome (CFS) in general practice. Descriptive. General practice and primary health care centres in Leyden region, the Netherlands. RNUH-LEO is a computerized database which contains the anonymous patient information of one general practice (with two practitioners) and four primary health care centres. The fourteen participating general practitioners were asked what International Classification of Primary Care (ICPC) code they used to indicate a patient with chronic fatigue or with CFS. With these codes and with the code for depression patients were selected from the database. It then was determined whether these patients met the criteria of CFS by Holmes et al. The general practitioners used 10 codes. Including the code for depression a total of 601 patients were preselected from a total of 23,000 patients in the database. Based on the information from the patients' records in the database, 42 of the preselected patients were selected who might fulfill the Holmes' criteria of CFS. According to the patients' own general practitioner, 25 of the 42 patients would fulfil the Holmes' criteria. The men:women ratio was 1:5. The prevalence of CFS in the population surveyed was estimated to be at least 1.1 per 1,000 patients.

Feasibility of automatic evaluation of clinical rules in general practice.

PubMed

Opondo, Dedan; Visscher, Stefan; Eslami, Saied; Medlock, Stephanie; Verheij, Robert; Korevaar, Joke C; Abu-Hanna, Ameen

2017-04-01

To assess the extent to which clinical rules (CRs) can be implemented for automatic evaluation of quality of care in general practice. We assessed 81 clinical rules (CRs) adapted from a subset of Assessing Care of Vulnerable Elders (ACOVE) clinical rules, against Dutch College of General Practitioners (NHG) data model. Each CR was analyzed using the Logical Elements Rule METHOD: (LERM). LERM is a stepwise method of assessing and formalizing clinical rules for decision support. Clinical rules that satisfied the criteria outlined in the LERM method were judged to be implementable in automatic evaluation in general practice. Thirty-three out of 81 (40.7%) Dutch-translated ACOVE clinical rules can be automatically evaluated in electronic medical record systems. Seven out of 7 CRs (100%) in the domain of diabetes can be automatically evaluated, 9/17 (52.9%) in medication use, 5/10 (50%) in depression care, 3/6 (50%) in nutrition care, 6/13 (46.1%) in dementia care, 1/6 (16.6%) in end of life care, 2/13 (15.3%) in continuity of care, and 0/9 (0%) in the fall-related care. Lack of documentation of care activities between primary and secondary health facilities and ambiguous formulation of clinical rules were the main reasons for the inability to automate the clinical rules. Approximately two-fifths of the primary care Dutch ACOVE-based clinical rules can be automatically evaluated. Clear definition of clinical rules, improved GP database design and electronic linkage of primary and secondary healthcare facilities can improve prospects of automatic assessment of quality of care. These findings are relevant especially because the Netherlands has very high automation of primary care. Copyright © 2017 Elsevier B.V. All rights reserved.

Interactive web-based learning modules prior to general medicine advanced pharmacy practice experiences.

PubMed

Isaacs, Alex N; Walton, Alison M; Nisly, Sarah A

2015-04-25

To implement and evaluate interactive web-based learning modules prior to advanced pharmacy practice experiences (APPEs) on inpatient general medicine. Three clinical web-based learning modules were developed for use prior to APPEs in 4 health care systems. The aim of the interactive modules was to strengthen baseline clinical knowledge before the APPE to enable the application of learned material through the delivery of patient care. For the primary endpoint, postassessment scores increased overall and for each individual module compared to preassessment scores. Postassessment scores were similar among the health care systems. The survey demonstrated positive student perceptions of this learning experience. Prior to inpatient general medicine APPEs, web-based learning enabled the standardization and assessment of baseline student knowledge across 4 health care systems.

[Practice of Internal Medicine in Latin America. Role of the internist].

PubMed

Varela, Nacor

2002-01-01

This article explores the causes of the crisis in the role of internists. As in the United States, the progressive specialization of internists lead to a dehumanized, expensive and technical practice of medicine. Aiming to better incomes and prestige, more than 60% of internists practice as specialists. Primary care physicians, with a very low rate of problem solving, cover 75% of consultations. Specialists, with increasing costs, cover the rest of consultations. Patients, medical schools and health organizations are claiming the return of the general internal medicine specialist. To increase the interest for general internal medicine, several strategies are applicable. Medical students interested in general internal medicine could receive a focused training, provided by these specialists. A greater emphasis should be put on primary care. More independent, secondary care diagnostic and treatment centers, should be created. Continuous medical education should be done with periodical re certification of physicians. The public health system should increase its wages and the generalist view should be maintained by physicians when practicing at their private offices.

Chronic debilitating fatigue in Irish general practice: a survey of general practitioners' experience.

PubMed

Fitzgibbon, E J; Murphy, D; O'Shea, K; Kelleher, C

1997-10-01

Doctors are called upon to treat chronic debilitating fatigue without the help of a protocol of care. To estimate the incidence of chronic debilitating fatigue in Irish general practice, to obtain information on management strategy and outcome, to explore the attitudes of practitioners (GPs) towards the concept of a chronic fatigue syndrome (CFS), and to recruit practitioners to a prospective study of chronic fatigue in primary care. A total of 200 names were selected from the database of the Irish College of General Practitioners (ICGP); 164 of these were eligible for the study. Altogether, 118 questionnaires were returned (72%). Ninety-two (78%) responders identified cases of chronic fatigue, giving an estimated 2.1 cases per practice and an incidence of 1 per 1000 population. All social classes were represented, with a male to female ratio of 1:2. Eleven disparate approaches to treatment were advocated. Many (38%) were dissatisfied with the quality of care delivered, and 45% seldom or hardly ever referred cases for specialist opinion. The majority (58%) accepted CFS as a distinct entity, 34% were undecided, and 8% rejected it. Forty-two (35%) GPs volunteered for a prospective study. Chronic fatigue is found in Irish general practice among patients of both sexes and all social classes. Doctors differ considerably in their management of patients and are dissatisfied with the quality of care they deliver. Many cases are not referred for specialist opinion. A prospective database is required to accurately assess the scale of this public health problem and to develop a protocol of care.

Series: The research agenda for general practice/family medicine and primary health care in Europe. Part 4. Results: specific problem solving skills.

PubMed

Hummers-Pradier, Eva; Beyer, Martin; Chevallier, Patrick; Eilat-Tsanani, Sophia; Lionis, Christos; Peremans, Lieve; Petek, Davorina; Rurik, Imre; Soler, Jean Karl; Stoffers, Henri Ejh; Topsever, Pinar; Ungan, Mehmet; van Royen, Paul

2010-09-01

The 'Research Agenda for General Practice/Family Medicine and Primary Health Care in Europe' summarizes the evidence relating to the core competencies and characteristics of the Wonca Europe definition of GP/FM, and its implications for general practitioners/family doctors, researchers and policy makers. The European Journal of General Practice publishes a series of articles based on this document. The previous articles presented background, objectives, and methodology, as well results on 'primary care management' and 'community orientation' and the person-related core competencies of GP/FM. This article reflects on the general practitioner's 'specific problem solving skills'. These include decision making on diagnosis and therapy of specific diseases, accounting for the properties of primary care, but also research questions related to quality management and resource use, shared decision making, or professional education and development. Clinical research covers most specific diseases, but often lacks pragmatism and primary care relevance. Quality management is a stronghold of GP/FM research. Educational interventions can be effective when well designed for a specific setting and situation. However, their message that 'usual care' by general practitioners is insufficient may be problematic. GP and their patients need more research into diagnostic reasoning with a step-wise approach to increase predictive values in a setting characterized by uncertainty and low prevalence of specific diseases. Pragmatic comparative effectiveness studies of new and established drugs or non-pharmaceutical therapy are needed. Multi-morbidity and complexity should be addressed. Studies on therapy, communication strategies and educational interventions should consider impact on health and sustainability of effects.

Provision of mental health care in general practice in Italy.

PubMed Central

Tansella, M; Bellantuono, C

1991-01-01

The main features of the psychiatric system and of the general practice system in Italy since the psychiatric reform and the introduction of a national health service are briefly described. Research conducted in Italy confirms that a large proportion of patients seen by general practitioners have psychological disorders and that only some of those patients whose psychological problems are identified by general practitioners are referred to specialist psychiatric care. Thus, the need to identify the best model of collaboration between psychiatric services and general practice services is becoming increasingly urgent. The chances of improving links between the two services and of developing a satisfactory liaison model are probably greater in countries such as Italy where psychiatric services are highly decentralized and community-based, than in countries where the psychiatric services are hospital-based. PMID:1807308

Judgements about fellow professionals and the management of patients receiving palliative care in primary care: a qualitative study.

PubMed

Walshe, Catherine; Todd, Chris; Caress, Ann-Louise; Chew-Graham, Carolyn

2008-04-01

Policies emphasise the importance of collaborative working in community palliative care. Collaborations are generally formed through formal and informal referral processes, but little is known about what influences professionals' decisions to refer to such services. To explore the influences on referrals within general and specialist community palliative care services. Qualitative, multiple-case study. Three primary care trusts in the north-west of England. Multiple data collection methods were employed, including documentary analysis, observation of referral team meetings and interviews. This paper primarily reports data from interviews with 47 health professionals, including GPs, district nurses, and specialist palliative care professionals. Judgements -- positive and negative -- about aspects of fellow professionals' performances appeared to influence referral decisions and ongoing collaboration and care. Attributes upon which these judgements were based included professional responsiveness and communication, respect, working and workload management practices, perceived expertise, and notions of elite practice. The effects of such judgements on referral and healthcare practices were altered by professional "game playing" to achieve professionals' desired outcomes. Palliative care policies and protocols need to take account of these complex and subtle influences on referrals and collaboration. In particular, teamwork and partnership are encouraged within palliative care work, but critical judgements indicate that such partnerships may be difficult or fragile. It is likely that such judgemental attitudes and practices affect many aspects of primary care, not just palliative care.

Cheques and challenges: business performance in New Zealand general practice.

PubMed

Greatbanks, Richard; Doolan-Noble, Fiona; McKenna, Alex

2017-09-01

INTRODUCTION New Zealand general practice mainly functions as small businesses, usually owned by a single or small group of doctors. Consequently, owners often have to balance the provision of patient care with varying funding priorities, changing patient needs and the pressures of running a sustainable business. Such balancing inevitably leads to tensions developing between these factors. AIM To explore and understand these tensions and responses to them, by examining the business performance measurements used by general practice. METHODS For this study, the unit of analysis and focus were individual practices, but qualitative semi-structured interviews with general practitioners (GPs) and practice managers were used to gather the data. RESULTS All participating practices had some form of governance or board review, where high-level aggregated business performance data were presented. More sophisticated business performance measures were evident in the larger, more developed practices and in practices functioning as community trusts. Examples of such measures included doctor utilisation and efficiency, appraisal of risk, patient satisfaction with services and responses to changes in patient demand. DISCUSSION As the number of general practices based on the traditional model decrease, a corresponding increase is likely in the establishment and development of 'super practices' based on a corporatized, multi-service, single-location model. Consequently, service delivery will become increasingly complex and will drive a need for increased sophistication in how general practice measures its business performance, thus ensuring a balance between high-quality, safe patient care and the maintenance of a sustainable business.

Policy implementation in practice: the case of national service frameworks in general practice.

PubMed

Checkland, Kath; Harrison, Stephen

2004-10-01

National Service Frameworks are an integral part of the government's drive to 'modernise' the NHS, intended to standardise both clinical care and the design of the services used to deliver that clinical care. This article uses evidence from qualitative case studies in three general practices to illustrate the difficulties associated with the implementation of such top-down guidelines and models of service. In these studies it was found that, while there had been little explicit activity directed at implementation overall, the National Service Framework for coronary heart disease had in general fared better than that for older people. Gunn's notion of 'perfect implementation' is used to make sense of the findings.

The uses and implications of standards in general practice consultations.

PubMed

Lippert, Maria Laura; Reventlow, Susanne; Kousgaard, Marius Brostrøm

2017-01-01

Quality standards play an increasingly important role in primary care through their inscription in various technologies for improving professional practice. While 'hard' biomedical standards have been the most common and debated, current quality development initiatives increasingly seek to include standards for the 'softer' aspects of care. This article explores the consequences of both kinds of quality standards for chronic care consultations. The article presents findings from an explorative qualitative field study in Danish general practice where a standardized technology for quality development has been introduced. Data from semi-structured interviews and observations among 17 general practitioners were analysed using an iterative analytical approach, which served to identify important variations in the uses and impacts of the technology. The most pronounced impact of the technology was observed among general practitioners who strictly adhered to the procedural standards on the interactional aspects of care. Thus, when allowed to function as an overall frame for consultations, those standards supported adherence to general recommendations regarding which elements to be included in chronic disease consultations. However, at the same time, adherence to those standards was observed to narrow the focus of doctor-patient dialogues and to divert general practitioners' attention from patients' personal concerns. Similar consequences of quality standards have previously been framed as manifestations of an inherent conflict between principles of patient-centredness and formal biomedical quality standards. However, this study suggests that standards on the 'softer' aspects of care may just as well interfere with a clinical approach relying on situated and attentive interactions with patients.

Audit and feedback by medical students to improve the preventive care practices of general practice supervisors.

PubMed

Gilkes, Lucy A; Liira, Helena; Emery, Jon

Medical students benefit from their contact with clinicians and patients in the clinical setting. However, little is known about whether patients and clinicians also benefit from medical students. We developed an audit and feedback intervention activity to be delivered by medical students to their general practice supervisors. We tested whether the repeated cycle of audit had an effect on the preventive care practices of general practitioners (GPs). The students performed an audit on topics of preventive medicine and gave feedback to their supervisors. Each supervisor in the study had more than one student performing the audit over the academic year. After repetitive cycles of audit and feedback, the recording of social history items by GPs improved. For example, recording alcohol history increased from 24% to 36%. This study shows that medical students can be effective auditors, and their repeated audits may improve their general practice supervisors' recording of some aspects of social history.

The payment for performance model and its influence on British general practitioners' principles and practice.

PubMed

Norman, Armando Henrique; Russell, Andrew J; Macnaughton, Jane

2014-01-01

This article explores some effects of the British payment for performance model on general practitioners' principles and practice, which may contribute to issues related to financial incentive modalities and quality of primary healthcare services in low and middle-income countries. Aiming to investigate what general practitioners have to say about the effect of the British payment for performance on their professional ethos we carried out semi-structured interviews with 13 general practitioner educators and leaders working in academic medicine across the UK. The results show a shift towards a more biomedical practice model and fragmented care with nurse practitioners and other health care staff focused more on specific disease conditions. There has also been an increased medicalisation of the patient experience both through labelling and the tendency to prescribe medications rather than non-pharmacological interventions. Thus, the British payment for performance has gradually strengthened a scientific-bureaucratic model of medical practice which has had profound effects on the way family medicine is practiced in the UK.

Illness perception, diabetes knowledge and self-care practices among type-2 diabetes patients: a cross-sectional study.

PubMed

Kugbey, Nuworza; Oppong Asante, Kwaku; Adulai, Korkor

2017-08-10

Self-care practices among persons living with type-2 diabetes are very crucial in diabetes manages as poor self-care results in complications. However, little research exists within the Ghanaian context. This study examined whether type-2 diabetes patients' illness perception and diabetes knowledge significantly predict diabetes self-care practices. A cross-sectional survey design was employed and a total of 160 participants (45 males and 115 females) were sampled from a general hospital in Accra. A self-administered questionnaire measuring illness perception, diabetes knowledge and diabetes self-care practices as well as demographic checklist were used collect data. Results showed that illness perception and diabetes knowledge significantly predicted overall diabetes self-care practices. Analysis of domain specific self-care practices showed that patients' diet was significantly predicted by illness perception and diabetes knowledge. Exercise was significantly predicted by only illness perception while blood sugar testing and diabetes foot-care were significantly predicted by diabetes knowledge. Cognitive and emotional representation of diabetes and diabetes knowledge are key determinants of patients' diabetes self-care practices. It is therefore important that appropriate psychosocial interventions are developed to help patients' adherence to recommended self-care practices.

Attitudes of Malaysian general hospital staff towards patients with mental illness and diabetes

PubMed Central

2011-01-01

Background The context of the study is the increased assessment and treatment of persons with mental illness in general hospital settings by general health staff, as the move away from mental hospitals gathers pace in low and middle income countries. The purpose of the study was to examine whether general attitudes of hospital staff towards persons with mental illness, and extent of mental health training and clinical experience, are associated with different attitudes and behaviours towards a patient with mental illness than towards a patients with a general health problem - diabetes. Methods General hospital health professionals in Malaysia were randomly allocated one of two vignettes, one describing a patient with mental illness and the other a patient with diabetes, and invited to complete a questionnaire examining attitudes and health care practices in relation to the case. The questionnaires completed by respondents included questions on demographics, training in mental health, exposure in clinical practice to people with mental illness, attitudes and expected health care behaviour towards the patient in the vignette, and a general questionnaire exploring negative attitudes towards people with mental illness. Questionnaires with complete responses were received from 654 study participants. Results Stigmatising attitudes towards persons with mental illness were common. Those responding to the mental illness vignette (N = 356) gave significantly lower ratings on care and support and higher ratings on avoidance and negative stereotype expectations compared with those responding the diabetes vignette (N = 298). Conclusions Results support the view that, in the Malaysian setting, patients with mental illness may receive differential care from general hospital staff and that general stigmatising attitudes among professionals may influence their care practices. More direct measurement of clinician behaviours than able to be implemented through survey method is required to support these conclusions. PMID:21569613

Management and prevalence of long-term conditions in primary health care for adults with intellectual disabilities compared with the general population: A population-based cohort study.

PubMed

Cooper, Sally-Ann; Hughes-McCormack, Laura; Greenlaw, Nicola; McConnachie, Alex; Allan, Linda; Baltzer, Marion; McArthur, Laura; Henderson, Angela; Melville, Craig; McSkimming, Paula; Morrison, Jill

2018-01-01

In the UK, general practitioners/family physicians receive pay for performance on management of long-term conditions, according to best-practice indicators. Management of long-term conditions was compared between 721 adults with intellectual disabilities and the general population (n = 764,672). Prevalence of long-term conditions was determined, and associated factors were investigated via logistic regression analyses. Adults with intellectual disabilities received significantly poorer management of all long-term conditions on 38/57 (66.7%) indicators. Achievement was high (75.1%-100%) for only 19.6% of adults with intellectual disabilities, compared with 76.8% of the general population. Adults with intellectual disabilities had higher rates of epilepsy, psychosis, hypothyroidism, asthma, diabetes and heart failure. There were no clear associations with neighbourhood deprivation. Adults with intellectual disabilities receive poorer care, despite conditions being more prevalent. The imperative now is to find practical, implementable means of supporting the challenges that general practices face in delivering equitable care. © 2017 John Wiley & Sons Ltd.

Healthcare improvement as planned system change or complex responsive processes? a longitudinal case study in general practice

PubMed Central

2013-01-01

Background Interest in how to implement evidence-based practices into routine health care has never been greater. Primary care faces challenges in managing the increasing burden of chronic disease in an ageing population. Reliable prescriptions for translating knowledge into practice, however, remain elusive, despite intense research and publication activity. This study seeks to explore this dilemma in general practice by challenging the current way of thinking about healthcare improvement and asking what can be learned by looking at change through a complexity lens. Methods This paper reports the local level of an embedded case study of organisational change for better chronic illness care over more than a decade. We used interviews, document review and direct observation to explore how improved chronic illness care developed in one practice. This formed a critical case to compare, using pattern matching logic, to the common prescription for local implementation of best evidence and a rival explanation drawn from complexity sciences interpreted through modern sociology and psychology. Results The practice changed continuously over more than a decade to deliver better chronic illness care in line with research findings and policy initiatives – re-designing care processes, developing community linkages, supporting patient self-management, using guidelines and clinical information systems, and integrating nurses into the practice team. None of these improvements was designed and implemented according to an explicit plan in response to a documented gap in chronic disease care. The process that led to high quality chronic illness care exhibited clear complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics in a network of agents and relationships where a stable yet evolving way of organizing emerged from local level communicative interaction, power relating and values based choices. Conclusions The current discourse of implementation science as planned system change did not match organisational reality in this critical case of improvement in general practice. Complexity concepts translated in human terms as complex responsive processes of relating fit the pattern of change more accurately. They do not provide just another fashionable blueprint for change but inform how researchers, policymakers and providers participate in improving healthcare. PMID:23617833

Proactive and integrated primary care for frail older people: design and methodological challenges of the Utrecht primary care PROactive frailty intervention trial (U-PROFIT).

PubMed

Bleijenberg, Nienke; Drubbel, Irene; Ten Dam, Valerie H; Numans, Mattijs E; Schuurmans, Marieke J; de Wit, Niek J

2012-04-25

Currently, primary care for frail older people is reactive, time consuming and does not meet patients' needs. A transition is needed towards proactive and integrated care, so that daily functioning and a good quality of life can be preserved. To work towards these goals, two interventions were developed to enhance the care of frail older patients in general practice: a screening and monitoring intervention using routine healthcare data (U-PRIM) and a nurse-led multidisciplinary intervention program (U-CARE). The U-PROFIT trial was designed to evaluate the effectiveness of these interventions. The aim of this paper is to describe the U-PROFIT trial design and to discuss methodological issues and challenges. The effectiveness of U-PRIM and U-CARE is being tested in a three-armed, cluster randomized trial in 58 general practices in the Netherlands, with approximately 5000 elderly individuals expected to participate. The primary outcome is the effect on activities of daily living as measured with the Katz ADL index. Secondary outcomes are quality of life, mortality, nursing home admission, emergency department and out-of-hours General Practice (GP), surgery visits, and caregiver burden. In a large, pragmatic trial conducted in daily clinical practice with frail older patients, several challenges and methodological issues will occur. Recruitment and retention of patients and feasibility of the interventions are important issues. To enable broad generalizability of results, careful choices of the design and outcome measures are required. Taking this into account, the U-PROFIT trial aims to provide robust evidence for a structured and integrated approach to provide care for frail older people in primary care. NTR2288.

General practice and residential aged care: A qualitative study of barriers to access to care and the role of remuneration.

PubMed

Burgess, Stephen; Davis, Jenny; Morgans, Amee

2015-01-01

More than 169,000 people live in residential aged care facilities (RACFs). As people age they use health services, particularly general practitioner (GP) services, more frequently but many GPs do not attend patients in RACFs. To examine GPs' perceptions of barriers to providing care to patients in RACFs. This study was conducted in June 2014 in the Bayside Medicare Local (BML) region in Victoria, Australia; all participants were drawn from this region. Two focus groups (FGs) were conducted. One was for GPs (n=5) that have a specific interest in practicing in RACFs, the other with RACF staff (n=8) representing public, private, and not-for-profit aged care providers. Results were presented to the Royal Australian College of General Practitioners (RACGP) National Standing Committee for General Practice Advocacy and Support for feedback and validation of the findings against national perspectives of the effect of remuneration on the provision of GP services in RACFs. Remuneration problems are a barrier to the provision of GP services to patients in RACFs. These problems can be grouped into: direct remuneration, opportunity cost, additional administrative burden, and unremunerated work. GPs' perceptions of the effects of these problems on willingness to practice in RACFs are described. Innovative models of remuneration for GPs attending RACFs are needed to ameliorate the problems identified. Such models need to capture and pay for activities that are time consuming but often unremunerated.

Level of Satisfaction of Older Persons with Their General Practitioner and Practice: Role of Complexity of Health Problems

PubMed Central

Poot, Antonius J.; den Elzen, Wendy P. J.; Blom, Jeanet W.; Gussekloo, Jacobijn

2014-01-01

Background Satisfaction is widely used to evaluate and direct delivery of medical care; a complicated relationship exists between patient satisfaction, morbidity and age. This study investigates the relationships between complexity of health problems and level of patient satisfaction of older persons with their general practitioner (GP) and practice. Methods and Findings This study is embedded in the ISCOPE (Integrated Systematic Care for Older Persons) study. Enlisted patients aged ≥75 years from 59 practices received a written questionnaire to screen for complex health problems (somatic, functional, psychological and social). For 2664 randomly chosen respondents (median age 82 years; 68% female) information was collected on level of satisfaction (satisfied, neutral, dissatisfied) with their GP and general practice, and demographic and clinical characteristics including complexity of health problems. Of all participants, 4% was dissatisfied with their GP care, 59% neutral and 37% satisfied. Between these three categories no differences were observed in age, gender, country of birth or education level. The percentage of participants dissatisfied with their GP care increased from 0.4% in those with 0 problem domains to 8% in those with 4 domains, i.e. having complex health problems (p<0.001). Per additional health domain with problems, the risk of being dissatisfied increased 1.7 times (95% CI 1.4–2.14; p<0.001). This was independent of age, gender, and demographic and clinical parameters (adjusted OR 1.4, 95% CI 1.1–1.8; p = 0.021). Conclusion In older persons, dissatisfaction with general practice is strongly correlated with rising complexity of health problems, independent of age, demographic and clinical parameters. It remains unclear whether complexity of health problems is a patient characteristic influencing the perception of care, or whether the care is unable to handle the demands of these patients. Prospective studies are needed to investigate the causal associations between care organization, patient characteristics, indicators of quality, and patient perceptions. PMID:24710557

Level of satisfaction of older persons with their general practitioner and practice: role of complexity of health problems.

PubMed

Poot, Antonius J; den Elzen, Wendy P J; Blom, Jeanet W; Gussekloo, Jacobijn

2014-01-01

Satisfaction is widely used to evaluate and direct delivery of medical care; a complicated relationship exists between patient satisfaction, morbidity and age. This study investigates the relationships between complexity of health problems and level of patient satisfaction of older persons with their general practitioner (GP) and practice. This study is embedded in the ISCOPE (Integrated Systematic Care for Older Persons) study. Enlisted patients aged ≥75 years from 59 practices received a written questionnaire to screen for complex health problems (somatic, functional, psychological and social). For 2664 randomly chosen respondents (median age 82 years; 68% female) information was collected on level of satisfaction (satisfied, neutral, dissatisfied) with their GP and general practice, and demographic and clinical characteristics including complexity of health problems. Of all participants, 4% was dissatisfied with their GP care, 59% neutral and 37% satisfied. Between these three categories no differences were observed in age, gender, country of birth or education level. The percentage of participants dissatisfied with their GP care increased from 0.4% in those with 0 problem domains to 8% in those with 4 domains, i.e. having complex health problems (p<0.001). Per additional health domain with problems, the risk of being dissatisfied increased 1.7 times (95% CI 1.4-2.14; p<0.001). This was independent of age, gender, and demographic and clinical parameters (adjusted OR 1.4, 95% CI 1.1-1.8; p = 0.021). In older persons, dissatisfaction with general practice is strongly correlated with rising complexity of health problems, independent of age, demographic and clinical parameters. It remains unclear whether complexity of health problems is a patient characteristic influencing the perception of care, or whether the care is unable to handle the demands of these patients. Prospective studies are needed to investigate the causal associations between care organization, patient characteristics, indicators of quality, and patient perceptions.

[Frequent attendance in a Primary Health Care District].

PubMed

Menéndez Granados, Nicolás; Vaquero Abellán, Manuel; Toledano Estepa, Manuel; Pérez Díaz, Manuel Modesto; Redondo Pedraza, Rosa

2017-10-09

To describe the distribution of frequent attenders (FA) through the different primary care practices in Cordoba-Guadalquivir Health District (Córdoba, Spain). An ecological study was performed, including data from 2011 to 2015. Defining FA as those subjects who made12 or more appointments per year; independently analysed for nursing, general practice and paediatrics. Prevalence of frequent attendance and FA/professional ratio were used as dependent variables. Demographic characteristics from district population, number of health professionals and use of general facilities were also examinated. Aiming to understand FA distribution, primary health settings were classified according to facility size and environmental location (urban, suburban and rural). The mean prevalence for FA was 10.86% (0.5 SE) for nursing; general practice 21.70% (0.7 SE) and for paediatrics 16.96% (0.7 SE). FA/professional ratios for the different professional categories were: 101.07 (5.0 SE) for nursing, 239.74 (9.0 SE) for general practice and 159.54 (9.8 SE) for paediatrics. A major part of primary health care users make a high number of consultations. From this group, women overuse nursing and general practitioner services more compared to men. A higher prevalence of FAs was observed in smaller settings, in rural areas. Although taking the FAs:professional ratio as the bar, medium-size practices are more highly overused. Copyright © 2017 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

Design of the POINT study: Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in a primary care Team (POINT).

PubMed

Hazen, Ankie C M; Sloeserwij, Vivianne M; Zwart, Dorien L M; de Bont, Antoinette A; Bouvy, Marcel L; de Gier, Johan J; de Wit, Niek J; Leendertse, Anne J

2015-07-02

In the Netherlands, 5.6 % of acute hospital admissions are medication-related. Almost half of these admissions are potentially preventable. Reviewing medication in patients at risk in primary care might prevent these hospital admissions. At present, implementation of medication reviews in primary care is suboptimal: pharmacists lack access to patient information, pharmacists are short of clinical knowledge and skills, and working processes of pharmacists (focus on dispensing) and general practitioners (focus on clinical practice) match poorly. Integration of the pharmacist in the primary health care team might improve pharmaceutical care outcomes. The aim of this study is to evaluate the effect of integration of a non-dispensing pharmacist in general practice on the safety of pharmacotherapy in the Netherlands. The POINT study is a non-randomised controlled intervention study with pre-post comparison in an integrated primary care setting. We compare three different models of pharmaceutical care provision in primary care: 1) a non-dispensing pharmacist as an integral member of a primary care team, 2) a pharmacist in a community pharmacy with a predefined training in performing medication reviews and 3) a pharmacist in a community pharmacy (care as usual). In all models, GPs remain accountable for individual medication prescription. In the first model, ten non-dispensing clinical pharmacists are posted in ten primary care practices (including 5 - 10 000 patients each) for a period of 15 months. These non-dispensing pharmacists perform patient consultations, including medication reviews, and share responsibility for the pharmaceutical care provided in the practice. The two other groups consist of ten primary care practices with collaborating pharmacists. The main outcome measurement is the number of medication-related hospital admissions during follow-up. Secondary outcome measurements are potential medication errors, drug burden index and costs. Parallel to this study, a qualitative study is conducted to evaluate the feasibility of introducing a NDP in general practice. As the POINT study is a large-scale intervention study, it should provide evidence as to whether integration of a non-dispensing clinical pharmacist in primary care will result in safer pharmacotherapy. The qualitative study also generates knowledge on the optimal implementation of this model in primary care. Results are expected in 2016. NTR4389 , The Netherlands National Trial Register, 07-01-2014.

A spatial analysis of the expanding roles of nurses in general practice.

PubMed

Pearce, Christopher; Hall, Sally; Phillips, Christine; Dwan, Kathryn; Yates, Rachael; Sibbald, Bonnie

2012-08-07

Changes to the workforce and organisation of general practice are occurring rapidly in response to the Australian health care reform agenda, and the changing nature of the medical profession. In particular, the last five years has seen the rapid introduction and expansion of a nursing workforce in Australian general practices. This potentially creates pressures on current infrastructure in general practice. This study used a mixed methods, 'rapid appraisal' approach involving observation, photographs, and interviews. Nurses utilise space differently to GPs, and this is part of the diversity they bring to the general practice environment. At the same time their roles are partly shaped by the ways space is constructed in general practices. The fluidity of nursing roles in general practice suggests that nurses require a versatile space in which to maximize their role and contribution to the general practice team.

Family Medicine, the specialty of the future: the Portuguese situation within the European context

PubMed Central

2009-01-01

General Practice/Family Medicine is a specialty focused on the provision of comprehensive, continuing, and community oriented, person-centred care. The lack of prestige and the difficulty in attracting trainees to the specialty have been longstanding problems in most countries around the world. In Europe, General Practice/Family Medicine is also hampered for not being recognized as a specialty throughout Europe. As for Portugal, General Practice/Family Medicine is undergoing a massive organizational reform, as well as unprecedented levels of popularity among trainees. General Practice/Family holds tremendous latent potential, and is thus a specialty with a bright future ahead. It could well establish itself as the specialty of the future if it is able to overcome the barriers that currently make of General Practice/Family Medicine an unpopular career choice. It is important to train confident, competent and polyvalent family physicians, but it is also necessary to overhaul payment schemes, to invest in primary care infra-structure and organization, and to continue to attract more and more bright and motivated trainees. PMID:19906299

Digital communication between clinician and patient and the impact on marginalised groups: a realist review in general practice.

PubMed

Huxley, Caroline J; Atherton, Helen; Watkins, Jocelyn Anstey; Griffiths, Frances

2015-12-01

Increasingly, the NHS is embracing the use of digital communication technology for communication between clinicians and patients. Policymakers deem digital clinical communication as presenting a solution to the capacity issues currently faced by general practice. There is some concern that these technologies may exacerbate existing inequalities in accessing health care. It is not known what impact they may have on groups who are already marginalised in their ability to access general practice. To assess the potential impact of the availability of digital clinician-patient communication on marginalised groups' access to general practice in the UK. Realist review in general practice. A four-step realist review process was used: to define the scope of the review; to search for and scrutinise evidence; to extract and synthesise evidence; and to develop a narrative, including hypotheses. Digital communication has the potential to overcome the following barriers for marginalised groups: practical access issues, previous negative experiences with healthcare service/staff, and stigmatising reactions from staff and other patients. It may reduce patient-related barriers by offering anonymity and offers advantages to patients who require an interpreter. It does not impact on inability to communicate with healthcare professionals or on a lack of candidacy. It is likely to work best in the context of a pre-existing clinician-patient relationship. Digital communication technology offers increased opportunities for marginalised groups to access health care. However, it cannot remove all barriers to care for these groups. It is likely that they will remain disadvantaged relative to other population groups after their introduction. © British Journal of General Practice 2015.

Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions

PubMed Central

Reeve, Joanne; Dowrick, Christopher F; Freeman, George K; Gunn, Jane; Mair, Frances; May, Carl; Mercer, Stewart; Palmer, Victoria; Howe, Amanda; Irving, Greg; Shiner, Alice; Watson, Jessica

2013-01-01

Objectives Provision of person-centred generalist care is a core component of quality primary care systems. The World Health Organisation believes that a lack of generalist primary care is contributing to inefficiency, ineffectiveness and inequity in healthcare. In UK primary care, General Practitioners (GPs) are the largest group of practising generalists. Yet GPs fulfil multiple roles and the pressures of delivering these roles along with wider contextual changes create real challenges to generalist practice. Our study aimed to explore GP perceptions of enablers and constraints for expert generalist care, in order to identify what is needed to ensure health systems are designed to support the generalist role. Design Qualitative study in General Practice. Setting UK primary care. Main outcome measures A qualitative study – interviews, surveys and focus groups with GPs and GP trainees. Data collection and analysis was informed by Normalisation Process Theory. Design and setting Qualitative study in General Practice. We conducted interviews, surveys and focus groups with GPs and GP trainees based mainly, but not exclusively, in the UK. Data collection and analysis were informed by Normalization Process Theory. Participants UK based GPs (interview and surveys); European GP trainees (focus groups). Results Our findings highlight key gaps in current training and service design which may limit development and implementation of expert generalist practice (EGP). These include the lack of a consistent and universal understanding of the distinct expertise of EGP, competing priorities inhibiting the delivery of EGP, lack of the consistent development of skills in interpretive practice and a lack of resources for monitoring EGP. Conclusions We describe four areas for change: Translating EGP, Priority setting for EGP, Trusting EGP and Identifying the impact of EGP. We outline proposals for work needed in each area to help enhance the expert generalist role. PMID:24475347

[MODERN EDUCATIONAL TECHNOLOGY MASTERING PRACTICAL SKILLS OF GENERAL PRACTITIONERS].

PubMed

Kovalchuk, L I; Prokopchuk, Y V; Naydyonova, O V

2015-01-01

The article presents the experience of postgraduate training of general practitioners--family medicine. Identified current trends, forms and methods of pedagogical innovations that enhance the quality of learning and mastering the practical skills of primary professionals providing care.

National standard setting for quality of care in general practice: attitudes of general practitioners and response to a set of standards.

PubMed Central

Grol, R

1990-01-01

The Nederlands Huisartsen Genootschap (NHG), the college of general practitioners in the Netherlands, has begun a national programme of standard setting for the quality of care in general practice. When the standards have been drawn up and assessed they are disseminated via the journal Huisarts en Wetenschap. In a survey, carried out among a randomized sample of 10% of all general practitioners, attitudes towards national standard setting in general and to the first set of standards (diabetes care) were studied. The response was 70% (453 doctors). A majority of the respondents said they were well informed about the national standard setting initiatives instigated by the NHG (71%) and about the content of the first standards (77%). The general practitioners had a positive attitude towards the setting of national standards for quality of care, and this was particularly true for doctors who were members of the NHG. Although a large majority of doctors said they agreed with most of the guidelines in the diabetes standards fewer respondents were actually working to the guidelines and some of the standards are certain to meet with a lot of resistance. A better knowledge of the standards and a more positive attitude to the process of national standard setting correlated with a more positive attitude to the guidelines formulated in the diabetes standards. The results could serve as a starting point for an exchange of views about standard setting in general practice in other countries. PMID:2265001

Gambling problems among patients in primary care: a cross-sectional study of general practices.

PubMed

Cowlishaw, Sean; Gale, Lone; Gregory, Alison; McCambridge, Jim; Kessler, David

2017-04-01

Primary care is an important context for addressing health-related behaviours, and may provide a setting for identification of gambling problems. To indicate the extent of gambling problems among patients attending general practices, and explore settings or patient groups that experience heightened vulnerability. Cross-sectional study of patients attending 11 general practices in Bristol, South West England. Adult patients ( n = 1058) were recruited from waiting rooms of practices that were sampled on the basis of population characteristics. Patients completed anonymous questionnaires comprising measures of mental health problems (for example, depression) and addictive behaviours (for example, risky alcohol use). The Problem Gambling Severity Index (PGSI) measured gambling problems, along with a single-item measure of gambling problems among family members. Estimates of extent and variability according to practice and patient characteristics were produced. There were 0.9% of all patients exhibiting problem gambling (PGSI ≥5), and 4.3% reporting problems that were low to moderate in severity (PGSI 1-4). Around 7% of patients reported gambling problems among family members. Further analyses indicated that rates of any gambling problems (PGSI ≥1) were higher among males and young adults, and more tentatively, within a student healthcare setting. They were also elevated among patients exhibiting drug use, risky alcohol use, and depression. There is need for improved understanding of the burden of, and responses to, patients with gambling problems in general practices, and new strategies to increase identification to facilitate improved care and early intervention. © British Journal of General Practice 2017.

Clinical accuracy of point-of-care urine culture in general practice.

PubMed

Holm, Anne; Cordoba, Gloria; Sørensen, Tina Møller; Jessen, Lisbeth Rem; Frimodt-Møller, Niels; Siersma, Volkert; Bjerrum, Lars

2017-06-01

To assess the clinical accuracy (sensitivity (SEN), specificity (SPE), positive predictive value and negative predictive value) of two point-of-care (POC) urine culture tests for the identification of urinary tract infection (UTI) in general practice. Prospective diagnostic accuracy study comparing two index tests (Flexicult™ SSI-Urinary Kit or ID Flexicult™) with a reference standard (urine culture performed in the microbiological department). General practice in the Copenhagen area patients. Adult female patients consulting their general practitioner with suspected uncomplicated, symptomatic UTI. (1) Overall accuracy of POC urine culture in general practice. (2) Individual accuracy of each of the two POC tests in this study. (3) Accuracy of POC urine culture in general practice with enterococci excluded, since enterococci are known to multiply in boric acid used for transportation for the reference standard. (4) Accuracy based on expert reading of photographs of POC urine cultures performed in general practice. Standard culture performed in the microbiological department was used as reference standard for all four measures. Twenty general practices recruited 341 patients with suspected uncomplicated UTI. The overall agreement between index test and reference was 0.76 (CI: 0.71-0.80), SEN 0.88 (CI: 0.83-0.92) and SPE 0.55 (CI: 0.46-0.64). The two POC tests produced similar results individually. Overall agreement with enterococci excluded was 0.82 (0.77-0.86) and agreement between expert readings of photographs and reference results was 0.81 (CI: 0.76-0.85). POC culture used in general practice has high SEN but low SPE. Low SPE could be due to both misinterpretation in general practice and an imperfect reference standard. Registration number: ClinicalTrials.gov NCT02323087.

Should measures of patient experience in primary care be adjusted for case mix? Evidence from the English General Practice Patient Survey

PubMed Central

Paddison, Charlotte; Elliott, Marc; Parker, Richard; Staetsky, Laura; Lyratzopoulos, Georgios; Campbell, John L

2012-01-01

Objectives Uncertainties exist about when and how best to adjust performance measures for case mix. Our aims are to quantify the impact of case-mix adjustment on practice-level scores in a national survey of patient experience, to identify why and when it may be useful to adjust for case mix, and to discuss unresolved policy issues regarding the use of case-mix adjustment in performance measurement in health care. Design/setting Secondary analysis of the 2009 English General Practice Patient Survey. Responses from 2 163 456 patients registered with 8267 primary care practices. Linear mixed effects models were used with practice included as a random effect and five case-mix variables (gender, age, race/ethnicity, deprivation, and self-reported health) as fixed effects. Main outcome measures Primary outcome was the impact of case-mix adjustment on practice-level means (adjusted minus unadjusted) and changes in practice percentile ranks for questions measuring patient experience in three domains of primary care: access; interpersonal care; anticipatory care planning, and overall satisfaction with primary care services. Results Depending on the survey measure selected, case-mix adjustment changed the rank of between 0.4% and 29.8% of practices by more than 10 percentile points. Adjusting for case-mix resulted in large increases in score for a small number of practices and small decreases in score for a larger number of practices. Practices with younger patients, more ethnic minority patients and patients living in more socio-economically deprived areas were more likely to gain from case-mix adjustment. Age and race/ethnicity were the most influential adjustors. Conclusions While its effect is modest for most practices, case-mix adjustment corrects significant underestimation of scores for a small proportion of practices serving vulnerable patients and may reduce the risk that providers would ‘cream-skim’ by not enrolling patients from vulnerable socio-demographic groups. PMID:22626735

Should measures of patient experience in primary care be adjusted for case mix? Evidence from the English General Practice Patient Survey.

PubMed

Paddison, Charlotte; Elliott, Marc; Parker, Richard; Staetsky, Laura; Lyratzopoulos, Georgios; Campbell, John L; Roland, Martin

2012-08-01

Uncertainties exist about when and how best to adjust performance measures for case mix. Our aims are to quantify the impact of case-mix adjustment on practice-level scores in a national survey of patient experience, to identify why and when it may be useful to adjust for case mix, and to discuss unresolved policy issues regarding the use of case-mix adjustment in performance measurement in health care. Secondary analysis of the 2009 English General Practice Patient Survey. Responses from 2 163 456 patients registered with 8267 primary care practices. Linear mixed effects models were used with practice included as a random effect and five case-mix variables (gender, age, race/ethnicity, deprivation, and self-reported health) as fixed effects. Primary outcome was the impact of case-mix adjustment on practice-level means (adjusted minus unadjusted) and changes in practice percentile ranks for questions measuring patient experience in three domains of primary care: access; interpersonal care; anticipatory care planning, and overall satisfaction with primary care services. Depending on the survey measure selected, case-mix adjustment changed the rank of between 0.4% and 29.8% of practices by more than 10 percentile points. Adjusting for case-mix resulted in large increases in score for a small number of practices and small decreases in score for a larger number of practices. Practices with younger patients, more ethnic minority patients and patients living in more socio-economically deprived areas were more likely to gain from case-mix adjustment. Age and race/ethnicity were the most influential adjustors. While its effect is modest for most practices, case-mix adjustment corrects significant underestimation of scores for a small proportion of practices serving vulnerable patients and may reduce the risk that providers would 'cream-skim' by not enrolling patients from vulnerable socio-demographic groups.

The prevention access and risk taking in young people (PARTY) project protocol: a cluster randomised controlled trial of health risk screening and motivational interviewing for young people presenting to general practice.

PubMed

Sanci, Lena; Grabsch, Brenda; Chondros, Patty; Shiell, Alan; Pirkis, Jane; Sawyer, Susan; Hegarty, Kelsey; Patterson, Elizabeth; Cahill, Helen; Ozer, Elizabeth; Seymour, Janelle; Patton, George

2012-06-06

There are growing worldwide concerns about the ability of primary health care systems to manage the major burden of illness in young people. Over two thirds of premature adult deaths result from risks that manifest in adolescence, including injury, neuropsychiatric problems and consequences of risky behaviours. One policy response is to better reorientate primary health services towards prevention and early intervention. Currently, however, there is insufficient evidence to support this recommendation for young people. This paper describes the design and implementation of a trial testing an intervention to promote psychosocial risk screening of all young people attending general practice and to respond to identified risks using motivational interviewing. clinicians' detection of risk-taking and emotional distress, young people's intention to change and reduction of risk taking. pathways to care, trust in the clinician and likelihood of returning for future visits. The design of the economic and process evaluation are not detailed in this protocol. PARTY is a cluster randomised trial recruiting 42 general practices in Victoria, Australia. Baseline measures include: youth friendly practice characteristics; practice staff's self-perceived competency in young people's care and clinicians' detection and response to risk taking behaviours and emotional distress in 14-24 year olds, attending the practice. Practices are then stratified by a social disadvantage index and billing methods and randomised. Intervention practices receive: nine hours of training and tools; feedback of their baseline data and two practice visits over six weeks. Comparison practices receive a three hour seminar in youth friendly practice only. Six weeks post-intervention, 30 consecutive young people are interviewed post-consultation from each practice and followed-up for self-reported risk taking behaviour and emotional distress three and 12 months post consultation. The PARTY trial is the first to examine the effectiveness and efficiency of a psychosocial risk screening and counselling intervention for young people attending primary care. It will provide important data on health risk profiles of young people attending general practice and on the effects of the intervention on engagement with primary care and health outcomes over 12 months. ISRCTN16059206.

The prevention access and risk taking in young people (PARTY) project protocol: A cluster randomised controlled trial of health risk screening and motivational interviewing for young people presenting to general practice

PubMed Central

2012-01-01

Background There are growing worldwide concerns about the ability of primary health care systems to manage the major burden of illness in young people. Over two thirds of premature adult deaths result from risks that manifest in adolescence, including injury, neuropsychiatric problems and consequences of risky behaviours. One policy response is to better reorientate primary health services towards prevention and early intervention. Currently, however, there is insufficient evidence to support this recommendation for young people. This paper describes the design and implementation of a trial testing an intervention to promote psychosocial risk screening of all young people attending general practice and to respond to identified risks using motivational interviewing. Main outcomes: clinicians’ detection of risk-taking and emotional distress, young people’s intention to change and reduction of risk taking. Secondary outcomes: pathways to care, trust in the clinician and likelihood of returning for future visits. The design of the economic and process evaluation are not detailed in this protocol. Methods PARTY is a cluster randomised trial recruiting 42 general practices in Victoria, Australia. Baseline measures include: youth friendly practice characteristics; practice staff’s self-perceived competency in young people’s care and clinicians’ detection and response to risk taking behaviours and emotional distress in 14–24 year olds, attending the practice. Practices are then stratified by a social disadvantage index and billing methods and randomised. Intervention practices receive: nine hours of training and tools; feedback of their baseline data and two practice visits over six weeks. Comparison practices receive a three hour seminar in youth friendly practice only. Six weeks post-intervention, 30 consecutive young people are interviewed post-consultation from each practice and followed-up for self-reported risk taking behaviour and emotional distress three and 12 months post consultation. Discussion The PARTY trial is the first to examine the effectiveness and efficiency of a psychosocial risk screening and counselling intervention for young people attending primary care. It will provide important data on health risk profiles of young people attending general practice and on the effects of the intervention on engagement with primary care and health outcomes over 12 months. Trial registration ISRCTN16059206 PMID:22672481

Organizational culture, team climate and diabetes care in small office-based practices.

PubMed

Bosch, Marije; Dijkstra, Rob; Wensing, Michel; van der Weijden, Trudy; Grol, Richard

2008-08-21

Redesigning care has been proposed as a lever for improving chronic illness care. Within primary care, diabetes care is the most widespread example of restructured integrated care. Our goal was to assess to what extent important aspects of restructured care such as multidisciplinary teamwork and different types of organizational culture are associated with high quality diabetes care in small office-based general practices. We conducted cross-sectional analyses of data from 83 health care professionals involved in diabetes care from 30 primary care practices in the Netherlands, with a total of 752 diabetes mellitus type II patients participating in an improvement study. We used self-reported measures of team climate (Team Climate Inventory) and organizational culture (Competing Values Framework), and measures of quality of diabetes care and clinical patient characteristics from medical records and self-report. We conducted multivariate analyses of the relationship between culture, climate and HbA1c, total cholesterol, systolic blood pressure and a sum score on process indicators for the quality of diabetes care, adjusting for potential patient- and practice level confounders and practice-level clustering. A strong group culture was negatively associated to the quality of diabetes care provided to patients (beta = -0.04; p = 0.04), whereas a more 'balanced culture' was positively associated to diabetes care quality (beta = 5.97; p = 0.03). No associations were found between organizational culture, team climate and clinical patient outcomes. Although some significant associations were found between high quality diabetes care in general practice and different organizational cultures, relations were rather marginal. Variation in clinical patient outcomes could not be attributed to organizational culture or teamwork. This study therefore contributes to the discussion about the legitimacy of the widespread idea that aspects of redesigning care such as teamwork and culture can contribute to higher quality of care. Future research should preferably combine quantitative and qualitative methods, focus on possible mediating or moderating factors and explore the use of instruments more sensitive to measure such complex constructs in small office-based practices.

High workload and job stress are associated with lower practice performance in general practice: an observational study in 239 general practices in the Netherlands

PubMed Central

van den Hombergh, Pieter; Künzi, Beat; Elwyn, Glyn; van Doremalen, Jan; Akkermans, Reinier; Grol, Richard; Wensing, Michel

2009-01-01

Background The impact of high physician workload and job stress on quality and outcomes of healthcare delivery is not clear. Our study explored whether high workload and job stress were associated with lower performance in general practices in the Netherlands. Methods Secondary analysis of data from 239 general practices, collected in practice visits between 2003 to 2006 in the Netherlands using a comprehensive set of measures of practice management. Data were collected by a practice visitor, a trained non-physician observer using patients questionnaires, doctors and staff. For this study we selected five measures of practice performance as outcomes and six measures of GP workload and job stress as predictors. A total of 79 indicators were used out of the 303 available indicators. Random coefficient regression models were applied to examine associations. Results and discussion Workload and job stress are associated with practice performance. Workload: Working more hours as a GP was associated with more positive patient experiences of accessibility and availability (b = 0.16). After list size adjustment, practices with more GP-time per patient scored higher on GP care (b = 0.45). When GPs provided more than 20 hours per week per 1000 patients, patients scored over 80% on the Europep questionnaire for quality of GP care. Job stress: High GP job stress was associated with lower accessibility and availability (b = 0.21) and insufficient practice management (b = 0.25). Higher GP commitment and more satisfaction with the job was associated with more prevention and disease management (b = 0.35). Conclusion Providing more time in the practice, and more time per patient and experiencing less job stress are all associated with perceptions by patients of better care and better practice performance. Workload and job stress should be assessed by using list size adjusted data in order to realise better quality of care. Organisational development using this kind of data feedback could benefit both patients and GP. PMID:19604386

Interacting institutional logics in general dental practice.

PubMed

Harris, Rebecca; Holt, Robin

2013-10-01

We investigate the organisational field of general dental practice and how agents change or maintain the institution of values associated with the everyday work of health care provision. Our dataset comprise archival literature and policy documents, interview data from field level actors, as well as service delivery level interview data and secondary data gathered (2011-12) from 16 English dental practices. Our analysis provides a typology of institutional logics (prevailing systems of value) experienced in the field of dental practice. Confirming current literature, we find two logics dominate how care is assessed: business-like health care and medical professionalism. We advance the literature by finding the business-like health care logic further distinguished by values of commercialism on the one hand and those of accountability and procedural diligence on the other. The logic of professionalism we also find is further distinguished into a commitment to clinical expertise and independence in delivering patient care on the one hand, and concerns for the autonomy and sustainability of a business enterprise on the other. Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.

Patients' experiences of continuity in the care of type 2 diabetes: a focus group study in primary care

PubMed Central

Alazri, Mohammed H; Neal, Richard D; Heywood, Phil; Leese, Brenda

2006-01-01

Background Continuity of care is fundamental to general practice and type 2 diabetes is a common chronic disease with major health and social impacts. Nevertheless continuity, as experienced by patients with type 2 diabetes, remains a neglected area. Aim To explore perceptions and experiences of continuity of care in general practice from the perspectives of patients with type 2 diabetes, focusing on the advantages and disadvantages of different types of continuity. Design of study Focus groups with patients. Setting Seven practices with different organisational structures in Leeds, UK. Method Seventy-nine patients with type 2 diabetes were recruited. Focus group interviews were conducted with 79 patients with type 2 diabetes from seven practices in Leeds, UK. Results Patients experienced three different types of continuity: relational (or longitudinal) continuity, cross-boundary (or team) continuity, and continuity of information. Patients' perceptions of continuity were influenced by several factors including a personal relationship between themselves and their healthcare professional, their own beliefs and behaviours, presence of diabetes, and the systems and structures of general practices. Patients identified the advantages and disadvantages of two types of continuity. Relational or longitudinal continuity was important in providing psychosocial care, but with a risk of misdiagnosis. The advantages of cross-boundary or team continuity were to provide physical care, whereas the main disadvantages were the absence of personal care and patient confusion. Conclusion Perceptions of continuity by patients with type 2 diabetes were influenced by several factors; they perceived several advantages and disadvantages associated with different types of continuity. Patients might expect certain healthcare benefits by following certain types of continuity. PMID:16834874

"Saying no is no easy matter" A qualitative study of competing concerns in rationing decisions in general practice

PubMed Central

Carlsen, Benedicte; Norheim, Ole Frithjof

2005-01-01

Background The general practitioner in Norway is expected to ensure equity and effectiveness through fair rationing. At the same time, due to recent reforms of the Norwegian health care sector, both the role of economic incentives and patient autonomy have been strengthened. Studies indicate that modern general practitioners, both in Norway and in other countries are uncomfortable with the gatekeeper role, but there is little knowledge about how general practitioners experience rationing in practice. Methods Through focus group interviews with Norwegian general practitioners, we explore physicians' attitudes toward factors of influence on medical decision making and how rationing dilemmas are experienced in everyday practice. Results Four major concerns appeared in the group discussions: The obligation to ration health care, professional autonomy, patient autonomy, and competition. A central finding was that the physicians find rationing difficult because saying no in face to face relations often is felt uncomfortable and in conflict with other important objectives for the general practitioner. Conclusion It is important to understand the association between using economic incentives in the management of health care, increasing patient autonomy, and the willingness among physicians to contribute to efficient, fair and legitimate resource allocation. PMID:16281967

Public and private funding of general practice services for children and adolescents in New Zealand.

PubMed

Dovey, Susan; Tilyard, Murray; Cunningham, Wayne; Williamson, Martyn

2011-11-01

To measure public and private funding of general practice services for New Zealand children. Computerized records from 111 general practices provided private payments for 118,905 general practice services to children aged 6-17 years. Government subsidies and public insurance payments provided public funding amounts for seven services. Overall and for each service we estimated the ratio of public:private payments (RPPP). 64.0% of annual expenditure was public, 36.0% private, (RPPP=1:0.56). General medical consultations were 67.2% of services (RPPP=1:0.57); 15.3% were injury-related (RPPP=1:0.36); 5.2% were prescribing services (all private); 4.9% were immunizations (RPPP=1:0.12); 2.9% were nursing (RPPP=1:1.33); 4.4% were administration (all private); and 0.1% were for maternity care (RPPP=1:0.007). Before capitation funding, public and private funding levels for general medical consultations were similar (RPPP=1:0.93) but after capitation public payments more than doubled (RPPP=1:0.40). There is a complex of pattern of public and private payments for general practice services for children and adolescents in New Zealand. Both funding sources are critical. Capitation funding changed the balance substantially but did not remove ongoing reliance on private funding to support general practice care for children. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Evaluation of computerized decision support for oral anticoagulation management based in primary care.

PubMed

Fitzmaurice, D A; Hobbs, F D; Murray, E T; Bradley, C P; Holder, R

1996-09-01

Increasing indications for oral anticoagulation has led to pressure on general practices to undertake therapeutic monitoring. Computerized decision support (DSS) has been shown to be effective in hospitals for improving clinical management. Its usefulness in primary care has previously not been investigated. To test the effectiveness of using DSS for oral anticoagulation monitoring in primary care by measuring the proportions of patients adequately controlled, defined as within the appropriate therapeutic range of International Normalised Ratio (INR). All patients receiving warfarin from two Birmingham inner city general practices were invited to attend a practice-based anticoagulation clinic. In practice A all patients were managed using DSS. In practice B patients were randomized to receive dosing advice either through DSS or through the local hospital laboratory. Clinical outcomes, adverse events and patient acceptability were recorded. Forty-nine patients were seen in total. There were significant improvements in INR control from 23% to 86% (P > 0.001) in the practice where all patients received dosing through DSS. In the practice where patients were randomized to either DSS or hospital dosing, logistic regression showed a significant trend for improvement in intervention patients which was not apparent in the hospital-dosed patients (P < 0.001). Mean recall times were significantly extended in patients who were dosed by the practice DSS through the full 12 months (24 days to 36 days) (P = 0.033). Adverse events were comparable between hospital and practice-dosed patients, although a number of esoteric events occurred. Patient satisfaction with the practice clinics was high. Computerized DSS enables the safe and effective transfer of anticoagulation management from hospital to primary care and may result in improved patient outcome in terms of the level of control, frequency of review and general acceptability.

Practice assistants in primary care in Germany – associations with organizational attributes on job satisfaction

PubMed Central

2013-01-01

Background Job satisfaction and organizational attributes in primary care teams are important issues as they affect clinical outcomes and the quality of health care provided. As practice assistants are an integral part of these teams it is important to gain insight into their views on job satisfaction and organizational attributes. The aim of this study was to evaluate the job satisfaction of practice assistants and the organizational attributes within their general practices in Germany and to explore the existence of possible associations. Methods This observational study was based on a job satisfaction survey and measurement of organizational attributes in general practices in the German federal state of Baden-Wuerttemberg. Job satisfaction was measured with the 10-item ‘Warr-Cook-Wall job satisfaction scale’. Organizational attributes were evaluated with the 21-items ‘survey of organizational attributes for primary care’ (SOAPC). Linear regression analyses were performed in which each of SOAPC scales and the overall score of SOAPC was treated as outcome variables. Results 586 practice assistants out of 794 respondents (73.8%) from 234 general practices completed the questionnaire. Practice assistants were mostly satisfied with their colleagues and least of all satisfied with their income and recognition for their work. The regression analysis showed that ‘freedom of working method’ and ‘recognition of work’, the employment status of practice assistants and the mode of practice were almost always significantly associated with each subscale and overall score of SOAPC. Conclusions Job satisfaction is highly associated with different aspects of organizational attributes for primary care (‘communication’, ‘decision-making’ and ‘stress’). Consequently, improved job satisfaction could lead to a better-organized primary care team. This implication should be investigated directly in further intervention studies with a special focus on improving the recognition for work and income. PMID:23915225

Quality improvement activities associated with organisational capacity in general practice.

PubMed

Amoroso, Cheryl; Proudfoot, Judy; Bubner, Tanya; Swan, Edward; Espinel, Paola; Barton, Christopher; Beilby, Justin; Harris, Mark

2007-01-01

Clinical audit is recognised worldwide as a useful tool for quality improvement. A feedback report profiling capacity for chronic disease care was sent to 97 general practices. These practices were invited to complete a clinical audit activity based on that feedback. Data were analysed quantitatively and case studies were developed based on the free text responses. Eighty-two (33%) of 247 general practitioners participated in the clinical audit process, representing 57 (59%) of 97 general practices. From the data in their feedback report, 37 (65%) of the 57 practices recognised the area most in need of improvement. This was most likely where the need related to clinical practice or teamwork, and least likely where the need related to linkages with other services, and business and finance. Only 25 practices (46%) developed an action plan related to their recognised area for improvement, and 22 (39%) practices implemented their chosen activity. Participating GPs judged that change activity focused on teamwork was most successful. The clinical audit process offered participating GPs and practices an opportunity to reflect on their performance across a number of key areas and to implement change to enhance the practice's capacity for quality chronic disease care. The relationship between need and action was weak, suggesting a need for greater support to overcome barriers.

General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland.

PubMed

McLean, Gary; Guthrie, Bruce; Mercer, Stewart W; Watt, Graham C M

2015-12-01

Universal access to health care, as provided in the NHS, does not ensure that patients' needs are met. To explore the relationships between multimorbidity, general practice funding, and workload by deprivation in a national healthcare system. Cross-sectional study using routine data from 956 general practices in Scotland. Estimated numbers of patients with multimorbidity, estimated numbers of consultations per 1000 patients, and payments to practices per patient are presented and analysed by deprivation decile at practice level. Levels of multimorbidity rose with practice deprivation. Practices in the most deprived decile had 38% more patients with multimorbidity compared with the least deprived (222.8 per 1000 patients versus 161.1; P<0.001) and over 120% more patients with combined mental-physical multimorbidity (113.0 per 1000 patients versus 51.5; P<0.001). Practices in the most deprived decile had 20% more consultations per annum compared with the least deprived (4616 versus 3846, P<0.001). There was no association between total practice funding and deprivation (Spearman ρ -0.09; P = 0.03). Although consultation rates increased with deprivation, the social gradients in multimorbidity were much steeper. There was no association between consultation rates and levels of funding. No evidence was found that general practice funding matches clinical need, as estimated by different definitions of multimorbidity. Consultation rates provide only a partial estimate of the work involved in addressing clinical needs and are poorly related to the prevalence of multimorbidity. In these circumstances, general practice is unlikely to mitigate health inequalities and may increase them. © British Journal of General Practice 2015.

Human resource management in general practice: survey of current practice.

PubMed Central

Newton, J; Hunt, J; Stirling, J

1996-01-01

BACKGROUND: The organization and management of general practice is changing as a result of government policies designed to expand primary health care services. One aspect of practice management which has been underresearched concerns staffing: the recruitment, retention, management and motivation of practice managers. AIM: A study set out to find out who is routinely involved in making decisions about staffing matters in general practice, to establish the extent to which the human resource management function is formalized and specialized, and to describe the characteristics of the practice managers. METHOD: A postal questionnaire was sent to a stratified random sample of 750 general practices in England and Wales in February 1994 enquiring about the practice (for example, the fundholding status and number of general practitioner partners), how the practice dealt with a range of staffing matters and about the practice manager (for example, employment background and training in human resource management). Practices were classed as small (single-handed and two or three general practitioner partners), medium (four or five partners) or large (six or more partners). RESULTS: Replies were received from 477 practices (64%). Practice managers had limited authority to make decisions alone in the majority of practices although there was a greater likelihood of them taking independent action as the size of practice increased. Formality in handling staffing matters (as measured by the existence and use of written policies and procedures) also increased with practice size. Larger practices were more likely than smaller practices to have additional tiers in their management structure through the creation of posts with the titles assistant practice manager, fund manager and senior receptionist. Most practice managers had been recruited from within general practice but larger practices were more likely than smaller practices to recruit from outwith general practice. Three quarters of practice managers reported having received some type of formal training in staff management. CONCLUSION: This study shows that practice size is a major factor associated with differences in the organization and management of staffing. Any initiatives which increase the scale of primary care functions and services would have to address the issues of communication and coordination that might be associated with such a change. PMID:8855013

Implementation of cardiovascular disease prevention in primary health care: enhancing understanding using normalisation process theory.

PubMed

Volker, Nerida; Williams, Lauren T; Davey, Rachel C; Cochrane, Thomas; Clancy, Tanya

2017-02-24

The reorientation of primary health care towards prevention is fundamental to addressing the rising burden of chronic disease. However, in Australia, cardiovascular disease prevention practice in primary health care is not generally consistent with existing guidelines. The Model for Prevention study was a whole-of-system cardiovascular disease prevention intervention, with one component being enhanced lifestyle modification support and addition of a health coaching service in the general practice setting. To determine the feasibility of translating intervention outcomes into real world practice, implementation work done by stakeholders was examined using Normalisation Process Theory as a framework. Data was collected through interviews with 40 intervention participants and included general practitioners, practice nurses, practice managers, lifestyle advisors and participants. Data analysis was informed by normalisation process theory constructs. Stakeholders were in agreement that, while prevention is a key function of general practice, it was not their usual work. There were varying levels of engagement with the intervention by practice staff due to staff interest, capacity and turnover, but most staff reconfigured their work for required activities. The Lifestyle Advisors believed staff had varied levels of interest in and understanding of, their service, but most staff felt their role was useful. Patients expanded their existing relationships with their general practice, and most achieved their lifestyle modification goals. While the study highlighted the complex nature of the change required, many of the new or enhanced processes implemented as part of the intervention could be scaled up to improve the systems approach to prevention. Overcoming the barriers to change, such as the perception of CVD prevention as a 'hard sell', is going to rely on improving the value proposition for all stakeholders. The study provided a detailed understanding of the work required to implement a complex cardiovascular disease prevention intervention within general practice. The findings highlighted the need for multiple strategies that engage all stakeholders. Normalisation process theory was a useful framework for guiding change implementation.

Urban public attitudes to the treatment of psychological problems and depression in general practice.

PubMed

Gavigan, P; Carr, A; McKeon, P

2000-10-01

A previous national study of public attitudes to depression indicated that only 17% spontaneously mentioned their general practitioner as someone who could help with depression, in contrast to 79% of respondents being willing to consult their G.P. in a similar U.K. survey. The present study undertook to examine the public perception of an urban sample to the treatment of depression in general practice and the factors associated with expressed unwillingness to consult. A random sample from the electoral register was drawn and 54 (89%) of 61 subjects selected were interviewed. While 85% of respondents were satisfied with their general practice care, only 24% to 52%, depending on the context and wording of the question, said that they would seek help from their general practitioner for depression. Factors associated with an expressed reluctance to consult were being male, dissatisfied with general practitioner care and believing that general practitioners were not qualified to treat depression.

Impact of health literacy, accessibility and coordination of care on patient's satisfaction with primary care in Germany.

PubMed

Altin, Sibel Vildan; Stock, Stephanie

2015-10-22

Although health policy makers call for the transformation of health care organizations to health literacy responsive ones, there is limited evidence on the care experiences of patients with limited health literacy skills (HL) in respect to health care quality. We explored if HL and patient-reported experiences regarding access to care and support in care-coordination in primary care organizations (PCO) have an impact on patients satisfaction with the care received by their personal general practitioner (GP). A nationwide representative survey was administered in a random sample of 1125 German adults. Binary logistic regression analyses were performed to determine whether HL and perceived access to and coordination of care were associated with satisfaction with care received in primary care adjusting for demographics and health status. In the unadjusted as well as adjusted model, better accessibility of the primary care practice (β= 1.858; 2.032 p < 0.001) frequent support in care coordination by the general practitioner (β = 2.680; 2.820 p < 0.001) as well as sufficient HL (β = 0.888; 1.228 p < 0.05) were independent predictors of a higher satisfaction with care received in the general practice. German adults with sufficient HL and positive experiences regarding care coordination and access to care are more satisfied with care received by their personal general practitioner. This result is from major importance for primary care organizations intending to transform their processes and structures to respond to the health literacy needs of their patients more effectively.

Are health professionals' perceptions of patient safety related to figures on safety incidents?

PubMed

Martijn, Lucie; Harmsen, Mirjam; Gaal, Sander; Mettes, Dirk; van Dulmen, Simone; Wensing, Michel

2013-10-01

The study aims to explore whether health care professionals' perceptions of patient safety in their practice were associated with the number of patient safety incidents identified in patient records. Seventy primary care practices of general practice, general dental practice, midwifery practices and allied health care practices were used in the study. A retrospective audit of 50 patient records was performed to identify patient safety incidents in each of the practices and a survey among health professionals to identify their perceptions of patient safety. All health professions felt that 'communication breakdowns inside the practice' as well as 'communication breakdowns outside the practice' and 'reporting of patient safety concerns' were a threat to patient safety in their work setting. We found little association between the perceptions of health professionals and the number of safety incidents. The only item with a significant relation to a higher number of safety incidents referred to the perception of 'communication problems outside the practice' as a threat to patient safety. This study indicates that the assessment of professionals' perceptions may be complementary to observed safety incidents, but not linked to an objective measure of patient safety. © 2012 John Wiley & Sons Ltd.

Practical Parenting Tips: Over 1,500 Helpful Hints for the First Five Years. Revised and Updated.

ERIC Educational Resources Information Center

Lansky, Vicki

Noting that other parents can be an excellent source of practical parenting advice, this book compiles over a thousand practical tips--those not generally found in baby care books or pediatrician's offices--with over 400 new tips compiled since the book's 1982 version. Major topics include: (1) new baby care, including cesarean deliveries,…

Cost analysis of nurse telephone consultation in out of hours primary care: evidence from a randomised controlled trial

PubMed Central

Lattimer, Val; Sassi, Franco; George, Steve; Moore, Michael; Turnbull, Joanne; Mullee, Mark; Smith, Helen

2000-01-01

Objective To undertake an economic evaluation of nurse telephone consultation using decision support software in comparison with usual general practice care provided by a general practice cooperative. Design Cost analysis from an NHS perspective using stochastic data from a randomised controlled trial. Setting General practice cooperative with 55 general practitioners serving 97 000 registered patients in Wiltshire, England. Subjects All patients contacting the service, or about whom the service was contacted during the trial year (January 1997 to January 1998). Main outcome measures Costs and savings to the NHS during the trial year. Results The cost of providing nurse telephone consultation was £81 237 per annum. This, however, determined a £94 422 reduction of other costs for the NHS arising from reduced emergency admissions to hospital. Using point estimates for savings, the cost analysis, combined with the analysis of outcomes, showed a dominance situation for the intervention over general practice cooperative care alone. If a larger improvement in outcomes is assumed (upper 95% confidence limit) NHS savings increase to £123 824 per annum. Savings of only £3728 would, however, arise in a scenario where lower 95% confidence limits for outcome differences were observed. To break even, the intervention would have needed to save 138 emergency hospital admissions per year, around 90% of the effect achieved in the trial. Additional savings of £16 928 for general practice arose from reduced travel to visit patients at home and fewer surgery appointments within three days of a call. Conclusions Nurse telephone consultation in out of hours primary care may reduce NHS costs in the long term by reducing demand for emergency admission to hospital. General practitioners currently bear most of the cost of nurse telephone consultation and benefit least from the savings associated with it. This indicates that the service produces benefits in terms of service quality, which are beyond the reach of this cost analysis. PMID:10764368

Email communication at the medical primary-secondary care interface: a qualitative exploration.

PubMed

Sampson, Rod; Barbour, Rosaline; Wilson, Philip

2016-07-01

There is little published research into the influence of email communication between primary and secondary care clinicians on patient care. To explore the use of email communication between clinicians across the primary- secondary care interface, and how this may relate to patient care. A qualitative study involving primary and secondary care services in the NHS Highland Health Board area, Scotland. Ten GPs and 12 hospital consultants were purposively sampled to reflect diversity. Eligible clinicians were invited to take part in a semi-structured interview. Data were analysed using a thematic analysis approach. Key themes that emerged for clinicians included general perceptions of email; using email in practice (managing workload, impact on patient journeys, and 'quick answers'); system issues (variability and governance); relational aspects; and email skills. Email communication between primary and secondary care clinicians generally has a positive impact on patient access to specialist expertise. Governance issues around the use of clinical email need to be defined. There may currently be a two-tier health service for those patients (and their GPs) requiring 'quick answers'. © British Journal of General Practice 2016.

Improving Patient Safety Culture in Primary Care: A Systematic Review.

PubMed

Verbakel, Natasha J; Langelaan, Maaike; Verheij, Theo J M; Wagner, Cordula; Zwart, Dorien L M

2016-09-01

Patient safety culture, described as shared values, attitudes and behavior of staff in a health-care organization, gained attention as a subject of study as it is believed to be related to the impact of patient safety improvements. However, in primary care, it is yet unknown, which effect interventions have on the safety culture. To review literature on the use of interventions that effect patient safety culture in primary care. Searches were performed in PubMed, EMBASE, CINAHL, and PsychINFO on March 4, 2013. Terms defining safety culture were combined with terms identifying intervention and terms indicating primary care. Inclusion followed if the intervention effected patient safety culture, and effect measures were reported. The search yielded 214 articles from which two were eligible for inclusion. Both studies were heterogeneous in their interventions and outcome; we present a qualitative summary. One study described the implementation of an electronic medical record system in general practices as part of patient safety improvements. The other study facilitated 2 workshops for general practices, one on risk management and another on significant event audit. Results showed signs of improvement, but the level of evidence was low because of the design and methodological problems. These studies in general practice provide a first understanding of improvement strategies and their effect in primary care. As the level of evidence was low, no clear preference can be determined. Further research is needed to help practices make an informed choice for an intervention.

Implementing practice management strategies to improve patient care: the EPIC project.

PubMed

Attwell, David; Rogers-Warnock, Leslie; Nemis-White, Joanna

2012-01-01

Healthcare gaps, the difference between usual care and best care, are evident in Canada, particularly with respect to our aging, ailing population. Primary care practitioners are challenged to identify, prevent and close care gaps in their practice environment given the competing demands of informed, litigious patients with complex medical needs, ever-evolving scientific evidence with new treatment recommendations across many disciplines and an enhanced emphasis on quality and accountability in healthcare. Patient-centred health and disease management partnerships using measurement, feedback and communication of practice patterns and outcomes have been shown to narrow care gaps. Practice management strategies such as the use of patient registries and recall systems have also been used to help practitioners better understand, follow and proactively manage populations of patients in their practice. The Enhancing Practice to Improve Care project was initiated to determine the impact of a patient-centred health and disease management partnership using practice management strategies to improve patient care and outcomes for patients with chronic kidney disease (CKD). Forty-four general practices from four regions of British Columbia participated and, indeed, demonstrated that care and outcomes for patients with CKD could be improved via the implementation of practice management strategies in a patient-centred partnership measurement model of health and disease management.

Judgements about fellow professionals and the management of patients receiving palliative care in primary care: a qualitative study

PubMed Central

Walshe, Catherine; Todd, Chris; Caress, Ann-Louise; Chew-Graham, Carolyn

2008-01-01

Background Policies emphasise the importance of collaborative working in community palliative care. Collaborations are generally formed through formal and informal referral processes, but little is known about what influences professionals' decisions to refer to such services. Aim To explore the influences on referrals within general and specialist community palliative care services. Design of study Qualitative, multiple-case study. Setting Three primary care trusts in the north-west of England. Method Multiple data collection methods were employed, including documentary analysis, observation of referral team meetings and interviews. This paper primarily reports data from interviews with 47 health professionals, including GPs, district nurses, and specialist palliative care professionals. Results Judgements — positive and negative — about aspects of fellow professionals' performances appeared to influence referral decisions and ongoing collaboration and care. Attributes upon which these judgements were based included professional responsiveness and communication, respect, working and workload management practices, perceived expertise, and notions of elite practice. The effects of such judgements on referral and healthcare practices were altered by professional ‘game playing’ to achieve professionals' desired outcomes. Conclusion Palliative care policies and protocols need to take account of these complex and subtle influences on referrals and collaboration. In particular, teamwork and partnership are encouraged within palliative care work, but critical judgements indicate that such partnerships may be difficult or fragile. It is likely that such judgemental attitudes and practices affect many aspects of primary care, not just palliative care. PMID:18494176

Trauma and emergency surgery: an evolutionary direction for trauma surgeons.

PubMed

Scherer, Lynette A; Battistella, Felix D

2004-01-01

The success of nonoperative management of injuries has diminished the operative experience of trauma surgeons. To enhance operative experience, our trauma surgeons began caring for all general surgery emergencies. Our objective was to characterize and compare the experience of our trauma surgeons with that of our general surgeons. We reviewed records to determine case diversity, complexity, time of operation, need for intensive care unit care, and payor mix for patients treated by the trauma and emergency surgery (TES) surgeons and elective practice general surgery (ELEC) surgeons over a 1-year period. TES and ELEC surgeons performed 253 +/- 83 and 234 +/- 40 operations per surgeon, respectively (p = 0.59). TES surgeons admitted more patients and performed more after-hours operations than their ELEC colleagues. Both groups had a mix of cases that was diverse and complex. Combining the care of patients with trauma and general surgery emergencies resulted in a breadth and scope of practice for TES surgeons that compared well with that of ELEC surgeons.

General practitioners' perceptions of the barriers and solutions to good-quality palliative care in dementia.

PubMed

Carter, Gillian; van der Steen, Jenny T; Galway, Karen; Brazil, Kevin

2015-04-16

The general practitioner (GP) is in a pivotal position to initiate and adapt care for their patients living with dementia. This study aimed to elicit GPs' perceptions of the potential barriers and solutions to the provision of good-quality palliative care in dementia in their practices. A postal survey of GPs across Northern Ireland was conducted with open-ended items soliciting for barriers in their practices and possible solutions; 40.6% (138/340) were returned completed. Barriers to palliative care in dementia were perceived to be a dementia knowledge deficit for healthcare staff and the public, a resource shortfall within the GP practice and community, poor team coordination alongside inappropriate dementia care provision, and disagreements from and within families. These findings have significant implications for educators and clinicians as enhanced dementia education and training were highlighted as a strong agenda for GPs with the suggestions of dementia awareness programmes for the public. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Interacting institutional logics in general dental practice☆

PubMed Central

Harris, Rebecca; Holt, Robin

2013-01-01

We investigate the organisational field of general dental practice and how agents change or maintain the institution of values associated with the everyday work of health care provision. Our dataset comprise archival literature and policy documents, interview data from field level actors, as well as service delivery level interview data and secondary data gathered (2011–12) from 16 English dental practices. Our analysis provides a typology of institutional logics (prevailing systems of value) experienced in the field of dental practice. Confirming current literature, we find two logics dominate how care is assessed: business-like health care and medical professionalism. We advance the literature by finding the business-like health care logic further distinguished by values of commercialism on the one hand and those of accountability and procedural diligence on the other. The logic of professionalism we also find is further distinguished into a commitment to clinical expertise and independence in delivering patient care on the one hand, and concerns for the autonomy and sustainability of a business enterprise on the other. PMID:23931946

Roles and identities in transition: boundaries of work and inter-professional relationships at the interface between telehealth and primary care.

PubMed

Segar, Julia; Rogers, Anne; Salisbury, Chris; Thomas, Clare

2013-11-01

Shifting the balance of care towards home and community is viewed as requiring interventions which enhance or complement primary care. Technology-based interventions are seen as key to the future in this work. Telehealthcare implicates a new agenda for inter-professional working across boundaries of healthcare. One such interface is between telehealthcare professionals and professionals located in primary care. This study reports the findings from a qualitative study forming part of a broader project examining the potential of developing and implementing telehealth interventions to support patients with long-term conditions. Semi-structured interviews were undertaken with telehealth nurse care managers, practice nurses and general practitioners in their respective work settings (39 interviews with 62 participants). Observation was undertaken at a telehealth call centre. The research took place between April 2010 and March 2011. Thematic analysis of qualitative data was undertaken. Telehealth nurse care managers' interviews suggested narrative constructions of new roles and identities to fit telehealth work, combining a holistic ideal and retro-appeal with 'traditional' values of nursing, which distinguished and distanced them from counterparts in general practices. Practice nurses and general practitioners were ambivalent and often sceptical about the contribution of telehealth to long-term condition work. Practice nurses' accounts suggested a sense of protectiveness about maintaining boundaries around established remits of managing long-term conditions; general practitioners, having devolved much of the care of long-term conditions to nurses, were keen to retain their positions as gatekeepers to resources. Perceptions of shifts of professional roles, new ways of working and how they are valued form a relevant contextual element to the introduction of telehealth interventions. A pre-emptive view and response to how professionals understand and approach increasingly complex and multi-faceted roles within primary care is likely to prepare and facilitate the introduction and integration of telehealth innovations into existing patient services. © 2013 John Wiley & Sons Ltd.

Characterizing emergency admissions of patients with sickle cell crisis in NHS brent: observational study

PubMed Central

Green, Stuart A; AlJuburi, Ghida; Majeed, Azeem; Okoye, Ogo; Amobi, Carole; Banarsee, Ricky; Phekoo, Karen J

2012-01-01

Objectives To characterize emergency admissions for patients with sickle cell crisis in NHS Brent and to determine which patients and practices may benefit most from primary care intervention. Design Observational study Setting Emergency departments attended by residents of the London borough of Brent Participants Patients with sickle cell disease registered with a general practitioner (GP) in the borough of Brent Main outcome measures Analysis of admissions between January 2008 and July 2010 that included length of stay (average and <2 days versus ≥2 days) by age group and registered GP practice. Results Thirty six percent of sickle cell disease admission spells resulted in a length of stay of less than two days. Seventy four percent of total bed days are associated with patients with more than one admission during the period of analysis, i.e. multiple admissions. Two general practices in Brent were identified as having the highest number of patients admitted to the emergency department for sickle cell crisis and may benefit most from primary care intervention. Discussion Patients with short length of stay and multiple admissions may be potentially amenable to primary care intervention. The practices which have the highest numbers of sickle cell disease patients who frequently seek emergency care will be earmarked for an education intervention designed to help further engage general practitioners in the care and management of their sickle cell patients. PMID:22768371

Characterizing emergency admissions of patients with sickle cell crisis in NHS brent: observational study.

PubMed

Green, Stuart A; Aljuburi, Ghida; Majeed, Azeem; Okoye, Ogo; Amobi, Carole; Banarsee, Ricky; Phekoo, Karen J

2012-06-01

To characterize emergency admissions for patients with sickle cell crisis in NHS Brent and to determine which patients and practices may benefit most from primary care intervention. Observational study Emergency departments attended by residents of the London borough of Brent Patients with sickle cell disease registered with a general practitioner (GP) in the borough of Brent Analysis of admissions between January 2008 and July 2010 that included length of stay (average and <2 days versus ≥2 days) by age group and registered GP practice. Thirty six percent of sickle cell disease admission spells resulted in a length of stay of less than two days. Seventy four percent of total bed days are associated with patients with more than one admission during the period of analysis, i.e. multiple admissions. Two general practices in Brent were identified as having the highest number of patients admitted to the emergency department for sickle cell crisis and may benefit most from primary care intervention. Patients with short length of stay and multiple admissions may be potentially amenable to primary care intervention. The practices which have the highest numbers of sickle cell disease patients who frequently seek emergency care will be earmarked for an education intervention designed to help further engage general practitioners in the care and management of their sickle cell patients.

Qualitative insights into practice time management: does 'patient-centred time' in practice management offer a portal to improved access?

PubMed

Buetow, S; Adair, V; Coster, G; Hight, M; Gribben, B; Mitchell, E

2002-12-01

Different sets of literature suggest how aspects of practice time management can limit access to general practitioner (GP) care. Researchers have not organised this knowledge into a unified framework that can enhance understanding of barriers to, and opportunities for, improved access. To suggest a framework conceptualising how differences in professional and cultural understanding of practice time management in Auckland, New Zealand, influence access to GP care for children with chronic asthma. A qualitative study involving selective sampling, semi-structured interviews on barriers to access, and a general inductive approach. Twenty-nine key informants and ten mothers of children with chronic, moderate to severe asthma and poor access to GP care in Auckland. Development of a framework from themes describing barriers associated with, and needs for, practice time management. The themes were independently identified by two authors from transcribed interviews and confirmed through informant checking. Themes from key informant and patient interviews were triangulated with each other and with published literature. The framework distinguishes 'practice-centred time' from 'patient-centred time.' A predominance of 'practice-centred time' and an unmet opportunity for 'patient-centred time' are suggested by the persistence of five barriers to accessing GP care: limited hours of opening; traditional appointment systems; practice intolerance of missed appointments; long waiting times in the practice; and inadequate consultation lengths. None of the barriers is specific to asthmatic children. A unified framework was suggested for understanding how the organisation of practice work time can influence access to GP care by groups including asthmatic children.

Cluster randomized trials utilizing primary care electronic health records: methodological issues in design, conduct, and analysis (eCRT Study).

PubMed

Gulliford, Martin C; van Staa, Tjeerd P; McDermott, Lisa; McCann, Gerard; Charlton, Judith; Dregan, Alex

2014-06-11

There is growing interest in conducting clinical and cluster randomized trials through electronic health records. This paper reports on the methodological issues identified during the implementation of two cluster randomized trials using the electronic health records of the Clinical Practice Research Datalink (CPRD). Two trials were completed in primary care: one aimed to reduce inappropriate antibiotic prescribing for acute respiratory infection; the other aimed to increase physician adherence with secondary prevention interventions after first stroke. The paper draws on documentary records and trial datasets to report on the methodological experience with respect to research ethics and research governance approval, general practice recruitment and allocation, sample size calculation and power, intervention implementation, and trial analysis. We obtained research governance approvals from more than 150 primary care organizations in England, Wales, and Scotland. There were 104 CPRD general practices recruited to the antibiotic trial and 106 to the stroke trial, with the target number of practices being recruited within six months. Interventions were installed into practice information systems remotely over the internet. The mean number of participants per practice was 5,588 in the antibiotic trial and 110 in the stroke trial, with the coefficient of variation of practice sizes being 0.53 and 0.56 respectively. Outcome measures showed substantial correlations between the 12 months before, and after intervention, with coefficients ranging from 0.42 for diastolic blood pressure to 0.91 for proportion of consultations with antibiotics prescribed, defining practice and participant eligibility for analysis requires careful consideration. Cluster randomized trials may be performed efficiently in large samples from UK general practices using the electronic health records of a primary care database. The geographical dispersal of trial sites presents a difficulty for research governance approval and intervention implementation. Pretrial data analyses should inform trial design and analysis plans. Current Controlled Trials ISRCTN 47558792 and ISRCTN 35701810 (both registered on 17 March 2010).

Cluster randomized trials utilizing primary care electronic health records: methodological issues in design, conduct, and analysis (eCRT Study)

PubMed Central

2014-01-01

Background There is growing interest in conducting clinical and cluster randomized trials through electronic health records. This paper reports on the methodological issues identified during the implementation of two cluster randomized trials using the electronic health records of the Clinical Practice Research Datalink (CPRD). Methods Two trials were completed in primary care: one aimed to reduce inappropriate antibiotic prescribing for acute respiratory infection; the other aimed to increase physician adherence with secondary prevention interventions after first stroke. The paper draws on documentary records and trial datasets to report on the methodological experience with respect to research ethics and research governance approval, general practice recruitment and allocation, sample size calculation and power, intervention implementation, and trial analysis. Results We obtained research governance approvals from more than 150 primary care organizations in England, Wales, and Scotland. There were 104 CPRD general practices recruited to the antibiotic trial and 106 to the stroke trial, with the target number of practices being recruited within six months. Interventions were installed into practice information systems remotely over the internet. The mean number of participants per practice was 5,588 in the antibiotic trial and 110 in the stroke trial, with the coefficient of variation of practice sizes being 0.53 and 0.56 respectively. Outcome measures showed substantial correlations between the 12 months before, and after intervention, with coefficients ranging from 0.42 for diastolic blood pressure to 0.91 for proportion of consultations with antibiotics prescribed, defining practice and participant eligibility for analysis requires careful consideration. Conclusions Cluster randomized trials may be performed efficiently in large samples from UK general practices using the electronic health records of a primary care database. The geographical dispersal of trial sites presents a difficulty for research governance approval and intervention implementation. Pretrial data analyses should inform trial design and analysis plans. Trial registration Current Controlled Trials ISRCTN 47558792 and ISRCTN 35701810 (both registered on 17 March 2010). PMID:24919485

Structuring group medical practices: tax planning aspects.

PubMed

Gassman, A S; Conetta, T F

1992-01-01

This article is the first in a series addressing the structuring of group medical practice entities, shareholder relationships, and general representation factors. In this article, a general background in federal tax planning is provided, including strategies for minimization of income tax payment and the potential problems that may be encountered when a group practice is not carefully structured.

The Co-Existence of Technology and Caring in the Theory of Technological Competency as Caring in Nursing.

PubMed

Locsin, Rozzano C

2017-01-01

The coexistence of technology and caring is best exemplified in nursing. The theory of Technological Competency as Caring in Nursing illuminates this coexistence as the essence of technology in health care premised on machine technologies as a generic concept of objects or things that are mechanical, organic, and electronic. With its timely development these technologies are continually imbued with artificial general intelligence. As such, the ultimate expression of machine technologies in nursing turns out to be autonomous robots (ARs) with future potentials of functions comparable to human persons. While theory-based nursing practice is essential to nursing care practice, quality human care, particularly with technologies assuming indispensable practice process mechanisms is critical. Some practice-based questions informing ARs and human person engagements in nursing care practice include, "Will ARs which are imbued with artificial intelligence replace nurses in their practice?" "What contributions to quality human health care will autonomous and artificially intelligent robots provide?" While these questions may reflect far-reaching ramifications of technologies in health care, it must also be acknowledged that these technologies are fundamental to the delivery of quality human health care now, and in the future. J. Med. Invest. 64: 160-164, February, 2017.

Determining specific competencies for General Internal Medicine residents (PGY 4 and PGY 5). What are they and are programs currently teaching them? A survey of practicing Canadian General Internists.

PubMed

Card, Sharon E; Pausjenssen, Anne M; Ottenbreit, Rachel C

2011-11-03

General Internal Medicine (GIM) has recently been approved as a subspecialty by the Royal College of Physicians and Surgeons of Canada. As such, there is a need to define areas of knowledge that a General Internist must learn in those two years of training. There is limited literature as to what competencies are needed in a GIM practice. Draft competencies for GIM (4th and 5th year residents in internal medicine) training were developed over eight years with input from many stakeholders. Practicing General Internists were surveyed and asked their perspective as to the level of importance of each of these competencies for GIM training. They were also asked if training gaps exist in current training programs. The survey was offered widely online in both English and French to gain perspectives from as many different contexts as possible. 157 General Internists, in practice on average for 15 years, responded from all of Canada's provinces and territories. Practice profiles were diverse (large urban centers to rural centers). The majority of the competencies surveyed were perceived as important to attain at least proficiency in. Perioperative care, risk reduction, and the management of common, emergent, and complex internal medicine problems were identified as key areas to focus training programs on, with respondents perceiving these should be mastered to an expert level. Training gaps were identified, most frequently in that of the manager role (example managing practice). This is the first study we are aware of to attempt to isolate the opinions of practicing Canadian General Internists as to the major competencies that should be mastered as a General Internist. We suggest that "generalism" in the context of GIM, does not mean a bit of knowledge about everything but that defined objectives for training in this 'newest' of Royal College subspecialties can be identified. This includes mastery of core areas such as perioperative care, risk reduction, and management of common, emergent and multiple internal medicine problems. The training gaps identified need to be addressed to ensure that General Internists continue to provide excellence in health care delivery.

[Vitamin D supplementation in the elderly: guidelines and practice].

PubMed

Chel, V G M; Elders, P J M; Tuijp, M L M; van den Berg, H H; van Drongelen, K I; Siedenburg, R C; Ooms, M E; Lips, P T A

2013-01-01

In 2008, the Health Council of the Netherlands published an advice on vitamin D supplementation for the elderly. Nevertheless, suspicion arose at the Ministry of Health, Welfare and Sport and the Netherlands Nutrition Centre that vitamin D supplementation in the elderly is still insufficient. We aimed to determine the extent to which general practitioners and elderly care physicians actually followed the advice of the Health Council. Questionnaire study. Brief questionnaires were sent to all elderly care physicians in the Netherlands. Some questions were also posed to general practitioners at a network meeting of the Academic Network of GP Practices of the VU University Medical Center in Amsterdam. More than two-thirds of the respondents, both elderly care physicians and general practitioners, are familiar with the guidelines of the Health Council of the Netherlands on vitamin D supplementation in the elderly, but about half do not prescribe vitamin D when the guideline advises to do so. When supplementation is prescribed, about half of the elderly care physicians and a fifth of the general practitioners uses an insufficient dose. The guidelines of the Health Council of the Netherlands on vitamin D supplementation in the elderly are not sufficiently followed by elderly care physicians and general practitioners. Awareness of and support for the vitamin D supplementation guidelines among health care providers is still limited.

The work of nurses in Australian general practice: A national survey.

PubMed

Joyce, Catherine M; Piterman, Leon

2011-01-01

Following recent reforms to Australia's health system, nurses now comprise a significant and growing sector of the Australian primary care workforce, but there is little data describing the services they provide. This study aimed to describe the patient consultations of nurses in Australian general practice, including patient characteristics, reasons for the consultation, treatments provided and other actions taken. The study was a national cross-sectional survey, with each participating nurse collecting information about 50 nurse-patient encounters. General practice settings in all regions of Australia. 108 nurses volunteered in response to advertisements and 104 returned completed study materials. Participants included Registered (Division 1) and Enrolled (Division 2) nurses working in a general practice setting. Data were collected between May 2007 and May 2008 using a profile questionnaire and a series of encounter forms. Information was gathered on reasons for encounter, patient characteristics, and actions taken. Data were classified using the International Classification of Primary Care. The final data set included 5,253 nurse-patient encounters. 37.2% of patients (95% CI 33.3-41.2) were aged 65 and over, and 57.1% were female (95% CI 54.9-59.5). The majority of encounters (90.7%) were with existing patients of the practice (95% CI 89.1-92.7). The most common reasons for encounter were general and unspecified problems (35.4 per 100 encounters; 95% CI 31.8-39.1), followed by skin-related problems (20.0; 95% CI 17.3-22.8), and cardiovascular problems (11.0; 95% CI 8.7-13.3). Common management actions included medical examinations (20.7 per 100 encounters), immunisations (22.5), diagnostic tests (10.6), and dressings (15.8). Approximately 30% of encounters involved advice-giving. The findings confirm the generalist nature of the General Practice Nurse role, with a wide range of patient types and clinical conditions. There is a clear influence of current funding and organisational arrangements on work patterns, with tasks that have specific funding (including immunisations and wound care) featuring prominently in nurses' work. Whilst nurses' rates for presenting conditions were similar to doctors at a general level, specific actions taken and problems managed differed. New policy reforms in Australia are supporting greater flexibility in the General Practice Nurse role, maximising efficient use of nurses' skills in the primary health care context. Copyright © 2010 Elsevier Ltd. All rights reserved.

The spiritual care meanings of adults residing in the midwest.

PubMed

Sellers, S C

2001-07-01

Only limited nursing knowledge exists as theoretical guidance for nurses in providing spiritual care. Using Leininger's theory of culture care diversity and universality, the purpose of this ethnonursing research study was to discover the embedded spiritual care meanings, expressions, lived experiences, and practices of adults residing in the Midwest and their perceptions of spiritual nursing care. Data were collected through interviews of 6 key and 12 general informants. Five universal spiritual themes were supported by the findings. Culture care modes were used to explicate spiritual knowledge that can be integrated into nursing practice.

Barriers and facilitators to integration of physician associates into the general practice workforce: a grounded theory approach.

PubMed

Jackson, Ben; Marshall, Michelle; Schofield, Susie

2017-11-01

Physician associates (PAs) are described as one solution to workforce capacity in primary care in the UK. Despite new investment in the role, how effective this will be in addressing unmet primary care needs is unclear. To investigate the barriers and facilitators to the integration of PAs into the general practice workforce. A modified grounded theory study in a region unfamiliar with the PA role. No a priori themes were assumed. Themes generated from stakeholder interviews informed a literature review and theoretical framework, and were then tested in focus groups with GPs, advanced nurse practitioners (ANPs), and patients. Recorded data were transcribed verbatim, and organised using NVivo version 10.2.2, with iterative analysis of emergent themes. A reflexive diary and independent verification of coding and analysis were included. There were 51 participants (30 GPs, 11 ANPs, and 10 patients) in eight focus groups. GPs, ANPs, and patients recognised that support for general practice was needed to improve access. GPs expressed concerns regarding PAs around managing medical complexity and supervision burden, non-prescriber status, and medicolegal implications in routine practice. Patients were less concerned about specific competencies as long as there was effective supervision, and were accepting of a PA role. ANPs highlighted their own negative experiences entering advanced clinical practice, and the need for support to counteract stereotypical and prejudicial attitudes CONCLUSION: This study highlights the complex factors that may impede the introduction of PAs into UK primary care. A conceptual model is proposed to help regulators and educationalists support this integration, which has relevance to other proposed new roles in primary care. © British Journal of General Practice 2017.

12. Children and Adolescents: Standards of Medical Care in Diabetes-2018.

PubMed

2018-01-01

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. © 2017 by the American Diabetes Association.

The impact of extensive loss of telecommunications on general practice: A case study in rural Victoria.

PubMed

Tran, Nancy H; Pedler, Daryl

2017-04-01

To describe the impact of major loss of telecommunications on general practice in a rural region of Australia. A multi-stage qualitative study. Purposively selected participants were invited to contribute to initial data collection using an online survey, followed by interviews with selected participants. Thematic analysis of the data was performed by both research team members. South-western Victoria, Australia. Individuals from organisations involved in Telstra recovery efforts, disaster management, health care and general practice staff. The survey collected freeform responses from participants. Semi-structured interviews further explored a variety of experiences from purposively selected participants. Organisations and practices in the region were prepared for major disasters, but not for the unusual and 'limited' disaster of losing telecommunications, including lack of Internet access and loss of telephone services. Although alternative measures were found for telecommunications, there was still a significant impact on many health-care-related activities and general practice functionality during the outage period. In particular, there was an increase in duties for administrative staff to compensate for loss of telecommunications. Patient traffic for many services decreased due to uncertainty about availability and continuation of business. The Warrnambool outage could be used as a case study illustrating the dramatic impact of communication loss. Major impacts include changes in patient traffic, increased administrative duties and slowing of patient care. When developing or assessing disaster management plans, general practices should consider the impact of telecommunication loss on functionality and prepare appropriate alternative, accessible and reliable measures. © 2016 National Rural Health Alliance Inc.

Roles and relationships between health professionals involved in insulin initiation for people with type 2 diabetes in the general practice setting: a qualitative study drawing on relational coordination theory.

PubMed

Manski-Nankervis, Jo-Anne; Furler, John; Blackberry, Irene; Young, Doris; O'Neal, David; Patterson, Elizabeth

2014-01-31

The majority of care for people with type 2 diabetes occurs in general practice, however when insulin initiation is required it often does not occur in this setting or in a timely manner and this may have implications for the development of complications. Increased insulin initiation in general practice is an important goal given the increasing prevalence of type 2 diabetes and a relative shortage of specialists. Coordination between primary and secondary care, and between medical and nursing personnel, may be important in achieving this. Relational coordination theory identifies key concepts that underpin effective interprofessional work: communication which is problem solving, timely, accurate and frequent and relationships between professional roles which are characterized by shared goals, shared knowledge and mutual respect. This study explores roles and relationships between health professionals involved in insulin initiation in order to gain an understanding of factors which may impact on this task being carried out in the general practice setting. 21 general practitioners, practice nurses, diabetes nurse educators and physicians were purposively sampled to participate in a semi-structured interview. Transcripts of the interviews were analysed using framework analysis. There were four closely interlinked themes identified which impacted on how health professionals worked together to initiate people with type 2 diabetes on insulin: 1. Ambiguous roles; 2. Uncertain competency and capacity; 3. Varying relationships and communication; and 4. Developing trust and respect. This study has shown that insulin initiation is generally recognised as acceptable in general practice. The role of the DNE and practice nurse in this space and improved communication and relationships between health professionals across organisations and levels of care are factors which need to be addressed to support this clinical work. Relational coordination provides a useful framework for exploring these issues.

Integrating counselling into general practice.

PubMed

Stone, L; Blashki, G

2000-03-01

General practice counselling has many significant differences to counselling in other settings. General practitioners have long term relationships with their patients involving physical as well as mental health care. General practitioners are often the first point of contact for distressed patients who may not perceive their problem to have a psychological basis. There are barriers to counselling including time management and cultural expectations of the consultation. To outline a practical biopsychosocial model for counselling in the general practice setting using the knowledge and skills unique to each GP. Theoretical and practical barriers to counselling commonly encountered in general practice are discussed. Assessing the problem in a biopsychosocial format highlights strengths and skills the patient already possesses and involves consideration of physical sensations, emotions, behaviours, key relationships, family, social roles and resources. Counselling in general practice requires flexibility and an ability to adapt available resources to address patient needs in an individually appropriate way.

Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial.

PubMed

Riis, Allan; Jensen, Cathrine Elgaard; Bro, Flemming; Maindal, Helle Terkildsen; Petersen, Karin Dam; Jensen, Martin Bach

2013-10-20

Evidence-based clinical practice guidelines may improve treatment quality, but the uptake of guideline recommendations is often incomplete and slow. Recently new low back pain guidelines are being launched in Denmark. The guidelines are considered to reduce personal and public costs. The aim of this study is to evaluate whether a complex, multifaceted implementation strategy of the low back pain guidelines will reduce secondary care referral and improve patient outcomes compared to the usual simple implementation strategy. In a two-armed cluster randomised trial, 100 general practices (clusters) and 2,700 patients aged 18 to 65 years from the North Denmark region will be included. Practices are randomly allocated 1:1 to a simple or a complex implementation strategy. Intervention practices will receive a complex implementation strategy, including guideline facilitator visits, stratification tools, and quality reports on low back pain treatment. Primary outcome is referral to secondary care. Secondary outcomes are pain, physical function, health-related quality of life, patient satisfaction with care and treatment outcome, employment status, and sick leave. Primary and secondary outcomes pertain to the patient level. Assessments of outcomes are blinded and follow the intention-to-treat principle. Additionally, a process assessment will evaluate the degree to which the intervention elements will be delivered as planned, as well as measure changes in beliefs and behaviours among general practitioners and patients. This study provides knowledge concerning the process and effect of an intervention to implement low back pain guidelines in general practice, and will provide insight on essential elements to include in future implementation strategies in general practice. Registered as NCT01699256 on ClinicalTrials.gov.

Analytical performance, agreement and user-friendliness of six point-of-care testing urine analysers for urinary tract infection in general practice

PubMed Central

Schot, Marjolein J C; van Delft, Sanne; Kooijman-Buiting, Antoinette M J; de Wit, Niek J; Hopstaken, Rogier M

2015-01-01

Objective Various point-of-care testing (POCT) urine analysers are commercially available for routine urine analysis in general practice. The present study compares analytical performance, agreement and user-friendliness of six different POCT urine analysers for diagnosing urinary tract infection in general practice. Setting All testing procedures were performed at a diagnostic centre for primary care in the Netherlands. Urine samples were collected at four general practices. Primary and secondary outcome measures Analytical performance and agreement of the POCT analysers regarding nitrite, leucocytes and erythrocytes, with the laboratory reference standard, was the primary outcome measure, and analysed by calculating sensitivity, specificity, positive and negative predictive value, and Cohen's κ coefficient for agreement. Secondary outcome measures were the user-friendliness of the POCT analysers, in addition to other characteristics of the analysers. Results The following six POCT analysers were evaluated: Uryxxon Relax (Macherey Nagel), Urisys 1100 (Roche), Clinitek Status (Siemens), Aution 11 (Menarini), Aution Micro (Menarini) and Urilyzer (Analyticon). Analytical performance was good for all analysers. Compared with laboratory reference standards, overall agreement was good, but differed per parameter and per analyser. Concerning the nitrite test, the most important test for clinical practice, all but one showed perfect agreement with the laboratory standard. For leucocytes and erythrocytes specificity was high, but sensitivity was considerably lower. Agreement for leucocytes varied between good to very good, and for the erythrocyte test between fair and good. First-time users indicated that the analysers were easy to use. They expected higher productivity and accuracy when using these analysers in daily practice. Conclusions The overall performance and user-friendliness of all six commercially available POCT urine analysers was sufficient to justify routine use in suspected urinary tract infections in general practice. PMID:25986635

Nurse prescribing in general practice: a qualitative study of job satisfaction and work-related stress.

PubMed

Cousins, Rosanna; Donnell, Christine

2012-04-01

Studies examining the impact nurse prescribing have largely focused on the efficacy of the service. It was suggested in pro-prescribing policy arguments that extending the nursing role to include prescribing would increase job satisfaction. This assertion has not been fully explored. To investigate the impact of independent prescribing for experienced nurse practitioners (NPs) working in general practice. In-depth interviews were conducted with six NPs who each had at least 3 years experience of independent prescribing in a busy inner city general practice. Analysis of interview data yielded two main themes: as independent prescribers NPs experienced increased levels of both job satisfaction and work-related stress. Increased satisfaction was associated with having greater autonomy and being able to provide more holistic care. Increased work-related stress emerged from greater job demands, perceived insufficient support and perceived effort-reward imbalance that centred upon the enhanced role not being recognized in terms of an increase in grade and pay. Independent prescribing increases job satisfaction for NPs in general practice, but there is also evidence of stressors associated with the role. It is important that NPs in general practice are encouraged and supported towards providing the effective patient-centred care in the community envisaged by current UK government. We acknowledge that the results presented in this paper are based on a sample limited to one city; however, it provides information that has important implications for the well being of NPs and ultimately patient care.

Prospective, observational study comparing automated and visual point-of-care urinalysis in general practice

PubMed Central

van Delft, Sanne; Goedhart, Annelijn; Spigt, Mark; van Pinxteren, Bart; de Wit, Niek; Hopstaken, Rogier

2016-01-01

Objective Point-of-care testing (POCT) urinalysis might reduce errors in (subjective) reading, registration and communication of test results, and might also improve diagnostic outcome and optimise patient management. Evidence is lacking. In the present study, we have studied the analytical performance of automated urinalysis and visual urinalysis compared with a reference standard in routine general practice. Setting The study was performed in six general practitioner (GP) group practices in the Netherlands. Automated urinalysis was compared with visual urinalysis in these practices. Reference testing was performed in a primary care laboratory (Saltro, Utrecht, The Netherlands). Primary and secondary outcome measures Analytical performance of automated and visual urinalysis compared with the reference laboratory method was the primary outcome measure, analysed by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) and Cohen's κ coefficient for agreement. Secondary outcome measure was the user-friendliness of the POCT analyser. Results Automated urinalysis by experienced and routinely trained practice assistants in general practice performs as good as visual urinalysis for nitrite, leucocytes and erythrocytes. Agreement for nitrite is high for automated and visual urinalysis. κ's are 0.824 and 0.803 (ranked as very good and good, respectively). Agreement with the central laboratory reference standard for automated and visual urinalysis for leucocytes is rather poor (0.256 for POCT and 0.197 for visual, respectively, ranked as fair and poor). κ's for erythrocytes are higher: 0.517 (automated) and 0.416 (visual), both ranked as moderate. The Urisys 1100 analyser was easy to use and considered to be not prone to flaws. Conclusions Automated urinalysis performed as good as traditional visual urinalysis on reading of nitrite, leucocytes and erythrocytes in routine general practice. Implementation of automated urinalysis in general practice is justified as automation is expected to reduce human errors in patient identification and transcribing of results. PMID:27503860

Prospective, observational study comparing automated and visual point-of-care urinalysis in general practice.

PubMed

van Delft, Sanne; Goedhart, Annelijn; Spigt, Mark; van Pinxteren, Bart; de Wit, Niek; Hopstaken, Rogier

2016-08-08

Point-of-care testing (POCT) urinalysis might reduce errors in (subjective) reading, registration and communication of test results, and might also improve diagnostic outcome and optimise patient management. Evidence is lacking. In the present study, we have studied the analytical performance of automated urinalysis and visual urinalysis compared with a reference standard in routine general practice. The study was performed in six general practitioner (GP) group practices in the Netherlands. Automated urinalysis was compared with visual urinalysis in these practices. Reference testing was performed in a primary care laboratory (Saltro, Utrecht, The Netherlands). Analytical performance of automated and visual urinalysis compared with the reference laboratory method was the primary outcome measure, analysed by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) and Cohen's κ coefficient for agreement. Secondary outcome measure was the user-friendliness of the POCT analyser. Automated urinalysis by experienced and routinely trained practice assistants in general practice performs as good as visual urinalysis for nitrite, leucocytes and erythrocytes. Agreement for nitrite is high for automated and visual urinalysis. κ's are 0.824 and 0.803 (ranked as very good and good, respectively). Agreement with the central laboratory reference standard for automated and visual urinalysis for leucocytes is rather poor (0.256 for POCT and 0.197 for visual, respectively, ranked as fair and poor). κ's for erythrocytes are higher: 0.517 (automated) and 0.416 (visual), both ranked as moderate. The Urisys 1100 analyser was easy to use and considered to be not prone to flaws. Automated urinalysis performed as good as traditional visual urinalysis on reading of nitrite, leucocytes and erythrocytes in routine general practice. Implementation of automated urinalysis in general practice is justified as automation is expected to reduce human errors in patient identification and transcribing of results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

The economics of employing a counsellor in general practice: analysis of data from a randomised controlled trial.

PubMed Central

Friedli, K; King, M B; Lloyd, M

2000-01-01

BACKGROUND: Counselling is currently adopted in many general practices, despite limited evidence of clinical and cost effectiveness. AIM: To compare direct and indirect costs of counsellors and general practitioners (GPs) in providing care to people with emotional problems. METHOD: We carried out a prospective, randomized controlled trial of non-directive counselling and routine general practice care in 14 general practices in north London. Counsellors adhered to a Rogerian model of counselling. The counselling sessions ranged from one to 12 sessions over 12 weeks. As reported elsewhere, there were no differences in clinical outcomes between the two groups. Therefore, we conducted a cost minimisation analysis. We present only the economic outcomes in this paper. Main outcome measures were cost data (service utilisation, travel, and work absence) at baseline, three months, and nine months. RESULTS: One hundred and thirty-six patients with emotional problems, mainly depression, took part. Seventy patients were randomised to the counsellors and 66 to the GPs. The average direct and indirect costs for the counsellor was 162.09 Pounds more per patient after three months compared with costs for the GP group; however, over the following six months the counsellor group was 87.00 Pounds less per patient than the GP group. Over the total nine-month period, the counsellor group remained more expensive per patient. CONCLUSIONS: Referral to counselling is no more clinically effective or expensive than GP care over a nine-month period in terms of direct plus indirect costs. However, further research is needed to establish indirect costs of introducing a counsellor into general practice. PMID:10897510

A survey on knowledge and self-reported formula handling practices of parents and child care workers in Palermo, Italy

PubMed Central

2009-01-01

Background Powdered infant formula (PIF) is not a sterile product, but this information appears to be poorly diffused among child caregivers. Parents and child care workers may behave in an unsafe manner when handling PIF. Methods This study involved parents and child care workers in the 24 municipal child care centres of Palermo. Knowledge and self-reported practices about PIF handling were investigated by a structured questionnaire. A Likert scale was used to measure the strength of the respondent's feelings. Association of knowledge and self-reported practices with demographic variables was also evaluated. Results 42.4% of parents and 71.0% of child care workers filled in the questionnaire. Significant differences were found between parents and child care workers for age and education. 73.2% of parents and 84.4% of child care workers were confident in sterility of PIF. Generally, adherence to safe procedures when reconstituting and handling PIF was more frequently reported by child care workers who, according to the existing legislation, are regularly subjected to a periodic training on food safety principles and practices. Age and education significantly influenced the answers to the questionnaire of both parents and child care workers. Conclusion The results of the study reveal that parents and child care workers are generally unaware that powdered formulas may contain viable microorganisms. However, child care workers consistently chose safer options than parents when answering the questions about adherence to hygienic practices. At present it seems unfeasible to produce sterile PIF, but the risk of growth of hazardous organisms in formula at the time of administration should be minimized by promoting safer behaviours among caregivers to infants in both institutional settings and home. PMID:20003304

When and why do doctors decide to become general practitioners? Implications for recruitment into UK general practice specialty training.

PubMed

Irish, Bill; Lake, Jonathan

2011-01-01

All applicants to round 1 of national recruitment into the general practice specialty recruitment process were surveyed as to the reasons for, and the timing of their career choices. Most applicants reported decision making after completing undergraduate training citing variety, continuity of care and work-life balance as their main drivers for a career in general practice. Applicants were statistically more likely to have undertaken a Foundation placement in general practice than their peers on a Foundation programme. Reasons for choice of deanery were largely related to location and social ties, rather than to the educational 'reputation' of its programmes.

Optimising value and quality in general practice within the primary health care sector through relationship marketing: a conceptual framework.

PubMed

Bansal, Manjit K

2004-01-01

Discusses the rationale of applying relationship marketing and service quality concepts within the primary health care sector. The use of relational strategies in general practice, by modelling the relationships between practitioners and patients from a marketing perspective, could potentially lead to sustained high quality service being provided, and to more efficient use of resources. This essentially conceptually focused paper addresses an area that has not yet been researched in detail, and furthers understanding of the relationships that facilitate exchange within general practice and service delivery in non-profit, resource-constrained conditions. Deeper understanding of the needs and expectations of patients and the way these can be delivered by general practice can only lead to improvements for all parties involved. The relationship marketing paradigm presents itself as a potentially exciting way of addressing issues associated with ensuring that the highest level of quality is delivered in this area of the UK National Health Service.

A policy of introducing a new contract and funding system of general practice in Estonia.

PubMed

Lember, Margus

2002-01-01

The socialist bloc of post-war Europe was obliged to follow the Soviet example with a hierarchical, centrally controlled health care system based on polyclinics and other facilities providing extensive specialist services at the first level of contact. All the countries of Central and Eastern Europe have now expressed their wish to totally change their health care systems. Changes in these countries include: the introduction of market economy mechanisms in health care, an increased focus on population health needs in guiding health care systems, and the possibility of introducing a more general type of care at primary level. Patient expectations of access, choice and convenience are factors in shaping new models of health care delivery. Appropriate timing is the key determinant of the success of reforms. In Estonia the beginning of the 1990s was the time when several interest groups in society supported changes in the health care system. The first step after regaining independence was the reintroduction of a Bismarck-type insurance system. In the late 1990s the primary care reforms have changed the initial plans and elements of a National Health Service were introduced, especially general practitioners' lists, capitation payment and gate-keeping principles. The family medicine reform in Estonia has two main objectives: introduction of general practice as a specialty into Estonian health care and changing the remuneration system of primary care doctors. The specific tasks are: to provide practising primary care doctors with opportunities for retraining to gain the specialty status of a general practitioner, to create a list system for the population to register with a primary care doctor, to introduce a partial gate-keeping system and to give the status of the independent contractor to primary care doctors.

The collaboration of general practitioners and nurses in primary care: a comparative analysis of concepts and practices in Slovenia and Spain.

PubMed

Hämel, Kerstin; Vössing, Carina

2017-09-01

Aim A comparative analysis of concepts and practices of GP-nurse collaborations in primary health centres in Slovenia and Spain. Cross-professional collaboration is considered a key element for providing high-quality comprehensive care by combining the expertise of various professions. In many countries, nurses are also being given new and more extensive responsibilities. Implemented concepts of collaborative care need to be analysed within the context of care concepts, organisational structures, and effective collaboration. Background review of primary care concepts (literature analysis, expert interviews), and evaluation of collaboration in 'best practice' health centres in certain regions of Slovenia and Spain. Qualitative content analysis of expert interviews, presentations, observations, and group discussions with professionals and health centre managers. Findings In Slovenian health centres, the collaboration between GPs and nurses has been strongly shaped by their organisation in separate care units and predominantly case-oriented functions. Conventional power structures between professions hinder effective collaboration. The introduction of a new cross-professional primary care concept has integrated advanced practice nurses into general practice. Conventional hierarchies still exist, but a shared vision of preventive care is gradually strengthening attitudes towards team-oriented care. Formal regulations or incentives for teamwork have yet to be implemented. In Spain, health centres were established along with a team-based care concept that encompasses close physician-nurse collaboration and an autonomous role for nurses in the care process. Nurses collaborate with GPs on more equal terms with conflicts centring on professional disagreements. Team development structures and financial incentives for team achievements have been implemented, encouraging teams to generate their own strategies to improve teamwork. Clearly defined structures, shared visions of care and team development are important for implementing and maintaining a good collaboration. Central prerequisites are advanced nursing education and greater acceptance of advanced nursing practice.

Understanding quit decisions in primary care: a qualitative study of older GPs

PubMed Central

Sansom, Anna; Calitri, Raff; Carter, Mary; Campbell, John

2016-01-01

Objective To investigate the reasons behind intentions to quit direct patient care among experienced general practitioners (GPs) aged 50–60 years. Design and setting Qualitative study based on semistructured interviews with GPs in the South West region of England. Transcribed interviews were analysed thematically. Participants 23 GPs aged 50–60 years: 3 who had retired from direct patient care before age 60, and 20 who intended to quit direct patient care within the next 5 years. Results The analysis identified four key themes: early retirement is a viable option for many GPs; GPs have employment options other than undertaking direct patient care; GPs report feeling they are doing an (almost) undoable job; and GPs may have other aspirations that pull them away from practice. Findings from this study confirmed those from earlier research, with high workload, ageing and health, family and domestic life, and organisational change all influencing GPs’ decisions about when to retire/quit direct patient care. However, in addition, GPs expressed feelings of insecurity and uncertainty regarding the future of general practice, low morale, and issues regarding accountability (appraisal and revalidation) and governance. Suggestions about how to help retain GPs within the active clinical workforce were offered, covering individual, practice and organisational levels. Conclusions This research highlights aspects of the current professional climate for GPs that are having an impact on retirement decisions. Any future changes to policy or practice to help retain experienced GPs will benefit from this informed understanding of GPs’ views. Key factors to take into account include: making the GP workload more manageable; managing change sympathetically; paying attention to GPs’ own health; improving confidence in the future of general practice; and improving GP morale. PMID:26895989

Outcomes and opportunities: a nurse-led model of chronic disease management in Australian general practice.

PubMed

Eley, Diann S; Patterson, Elizabeth; Young, Jacqui; Fahey, Paul P; Del Mar, Chris B; Hegney, Desley G; Synnott, Robyn L; Mahomed, Rosemary; Baker, Peter G; Scuffham, Paul A

2013-01-01

The Australian government's commitment to health service reform has placed general practice at the centre of its agenda to manage chronic disease. Concerns about the capacity of GPs to meet the growing chronic disease burden has stimulated the implementation and testing of new models of care that better utilise practice nurses (PN). This paper reports on a mixed-methods study nested within a larger study that trialled the feasibility and acceptability of a new model of nurse-led chronic disease management in three general practices. Patients over 18 years of age with type 2 diabetes, hypertension or stable ischaemic heart disease were randomised into PN-led or usual GP-led care. Primary outcomes were self-reported quality of life and perceptions of the model's feasibility and acceptability from the perspective of patients and GPs. Over the 12-month study quality of life decreased but the trend between groups was not statistically different. Qualitative data indicate that the PN-led model was acceptable and feasible to GPs and patients. It is possible to extend the scope of PN care to lead the routine clinical management of patients' stable chronic diseases. All GPs identified significant advantages to the model and elected to continue with the PN-led care after our study concluded.

Engaging participants in a complex intervention trial in Australian General Practice

PubMed Central

Perkins, David; Harris, Mark F; Tan, Jocelyn; Christl, Bettina; Taggart, Jane; Fanaian, Mahnaz

2008-01-01

Background The paper examines the key issues experienced in recruiting and retaining practice involvement in a large complex intervention trial in Australian General Practice. Methods Reflective notes made by research staff and telephone interviews with staff from general practices which expressed interest, took part or withdrew from a trial of a complex general practice intervention. Results Recruitment and retention difficulties were due to factors inherent in the demands and context of general practice, the degree of engagement of primary care organisations (Divisions of General Practice), perceived benefits by practices, the design of the trial and the timing and complexity of data collection. Conclusion There needs to be clearer articulation to practices of the benefits of the research to participants and streamlining of the design and processes of data collection and intervention to fit in with their work practices. Ultimately deeper engagement may require additional funding and ongoing participation through practice research networks. Trial Registration Current Controlled Trials ACTRN12605000788673 PMID:18700984

Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study.

PubMed

Griffiths, C; Kaur, G; Gantley, M; Feder, G; Hillier, S; Goddard, J; Packe, G

2001-10-27

To explore reasons for increased risk of hospital admission among south Asian patients with asthma. Qualitative interview study using modified critical incident technique and framework analysis. Newham, east London, a deprived area with a large mixed south Asian population. 58 south Asian and white adults with asthma (49 admitted to hospital with asthma, 9 not admitted); 17 general practitioners; 5 accident and emergency doctors; 2 out of hours general practitioners; 1 asthma specialist nurse. Patients' and health professionals' views on influences on admission, events leading to admission, general practices' organisation and asthma strategies, doctor-patient relationship, and cultural attitudes to asthma. South Asian and white patients admitted to hospital coped differently with asthma. South Asians described less confidence in controlling their asthma, were unfamiliar with the concept of preventive medication, and often expressed less confidence in their general practitioner. South Asians managed asthma exacerbations with family advocacy, without systematic changes in prophylaxis, and without systemic corticosteroids. Patients describing difficulty accessing primary care during asthma exacerbations were registered with practices with weak strategies for asthma care and were often south Asian. Patients with easy access described care suggesting partnerships with their general practitioner, had better confidence to control asthma, and were registered with practices with well developed asthma strategies that included policies for avoiding hospital admission. The different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission in south Asian patients. Interventions that increase confidence to control asthma, confidence in the general practitioner, understanding of preventive treatment, and use of systemic corticosteroids in exacerbations may reduce hospital admissions. Development of more sophisticated asthma strategies by practices with better access and partnerships with patients may also achieve this.

Development of a Self-Report Checklist to Assess Dementia Care by Nurses in Hospital Settings.

PubMed

Ikegami, Chikako; Ota, Katsumasa

2018-03-01

Nurses working at general hospitals face difficulties in providing dementia care. The current study examined aged care nurses' dementia care practices in the hospital setting and developed a dementia care checklist that nurses can use to review their own care practice. A self-administered questionnaire was given to 676 participants; responses were collected from 595 participants. Exploratory factor analysis identified six factors (e.g., patient understanding prompted by concern and interest for the patient, respect for patients' voluntary behavior, early detection of abnormalities) among the questionnaire's 28 items. This analysis provided a framework for the checklist and verified that it had satisfactory internal consistency and construct validity. The frequency of care practices varied with participants' knowledge of dementia care requirements, satisfaction with their own dementia care practice, confidence in their ability to judge patients' physical condition, and cooperation with colleagues. This checklist might improve dementia care in hospital settings. [Res Gerontol Nurs. 2018; 11(2):91-102.]. © 2018 Ikegami and Ota.

Pediatric information seeking behaviour, information needs, and information preferences of health care professionals in general emergency departments: Results from the Translating Emergency Knowledge for Kids (TREKK) Needs Assessment.

PubMed

Scott, Shannon D; Albrecht, Lauren; Given, Lisa M; Hartling, Lisa; Johnson, David W; Jabbour, Mona; Klassen, Terry P

2018-01-01

The majority of children requiring emergency care are treated in general emergency departments (EDs) with variable levels of pediatric care expertise. The goal of the Translating Emergency Knowledge for Kids (TREKK) initiative is to implement the latest research in pediatric emergency medicine in general EDs to reduce clinical variation. To determine national pediatric information needs, seeking behaviours, and preferences of health care professionals working in general EDs. An electronic cross-sectional survey was conducted with health care professionals in 32 Canadian general EDs. Data were collected in the EDs using the iPad and in-person data collectors. Total of 1,471 surveys were completed (57.1% response rate). Health care professionals sought information on children's health care by talking to colleagues (n=1,208, 82.1%), visiting specific medical/health websites (n=994, 67.7%), and professional development opportunities (n=941, 64.4%). Preferred child health resources included protocols and accepted treatments for common conditions (n=969, 68%), clinical pathways and practice guidelines (n=951, 66%), and evidence-based information on new diagnoses and treatments (n=866, 61%). Additional pediatric clinical information is needed about multisystem trauma (n=693, 49%), severe head injury (n=615, 43%), and meningitis (n=559, 39%). Health care professionals preferred to receive child health information through professional development opportunities (n=1,131, 80%) and printed summaries (n=885, 63%). By understanding health care professionals' information seeking behaviour, information needs, and information preferences, knowledge synthesis and knowledge translation initiatives can be targeted to improve pediatric emergency care. The findings from this study will inform the following two phases of the TREKK initiative to bridge the research-practice gap in Canadian general EDs.

Impact of an educational program on knowledge and practice of health care staff toward pharmaceutical waste management in Gaza, Palestine.

PubMed

Tabash, Mohammed I; Hussein, Rim A; Mahmoud, Aleya H; El-Borgy, Mohamed D; Abu-Hamad, Bassam A

2016-04-01

In health care facilities, pharmaceutical waste is generally discharged down the drain or sent to landfill. Poor knowledge about their potential downstream impacts may be a primary factor for improper disposal behavior. The objective of this study was to determine the impact of an intervention program on knowledge and practice of health care staff regarding pharmaceutical waste management. The study was designed as a pre/posttest intervention study. Total sample size was 530 in the pre-intervention phase, and then a subsample of 69 individuals was selected for the intervention and the post-intervention phases. Paired-sample t test was used to assess the difference between pretest and follow-up test results. A statistically significant improvement in knowledge and practice was achieved (P<0.001). Poor knowledge and poor practice levels (scores<50%) were found to improve to satisfactory levels (scores≥75%). Therefore, educational programs could be considered as an effective tool for changing health care staff practice in pharmaceutical waste management. In health care facilities, pharmaceutical waste is generally discharged down the drain or sent to landfill. A lack of knowledge about the potential impacts of this type of waste may be a leading factor in improper disposal behavior. Following an educational program, statistically significant improvement in knowledge and practice of health care staff as regards to pharmaceutical waste management (PWM) was achieved. It is thus recommended that authorities implement training-of-trainers (TOT) programs to educate health care staff on PWM and organize refreshment workshops regularly.

Supporting self-care in general practice

PubMed Central

Greaves, Colin J; Campbell, John L

2007-01-01

There is both a clear need and a political will to improve self-care in long-term conditions: demand for self-care support interventions is rising. This article discusses current approaches to supporting self-care in primary care, evidence in favour of self-care support, and issues for GPs to consider in planning self-care support systems. In planning care pathways, important choices need to be made about whether to use individual or group-based approaches and what intensity of intervention is appropriate to match patient needs. Investment may also be needed in both health professional competences and practice systems to optimise their ability to support patient self-care. Self-care support is a key approach for the future of UK health care. Practices that are well trained and well organised to support self-care will respond better to the complex challenges of achieving improvements in the outcomes of long-term conditions. PMID:17925140

Interpretive Medicine

PubMed Central

Reeve, Joanne

2010-01-01

Patient-centredness is a core value of general practice; it is defined as the interpersonal processes that support the holistic care of individuals. To date, efforts to demonstrate their relationship to patient outcomes have been disappointing, whilst some studies suggest values may be more rhetoric than reality. Contextual issues influence the quality of patient-centred consultations, impacting on outcomes. The legitimate use of knowledge, or evidence, is a defining aspect of modern practice, and has implications for patient-centredness. Based on a critical review of the literature, on my own empirical research, and on reflections from my clinical practice, I critique current models of the use of knowledge in supporting individualised care. Evidence-Based Medicine (EBM), and its implementation within health policy as Scientific Bureaucratic Medicine (SBM), define best evidence in terms of an epistemological emphasis on scientific knowledge over clinical experience. It provides objective knowledge of disease, including quantitative estimates of the certainty of that knowledge. Whilst arguably appropriate for secondary care, involving episodic care of selected populations referred in for specialist diagnosis and treatment of disease, application to general practice can be questioned given the complex, dynamic and uncertain nature of much of the illness that is treated. I propose that general practice is better described by a model of Interpretive Medicine (IM): the critical, thoughtful, professional use of an appropriate range of knowledges in the dynamic, shared exploration and interpretation of individual illness experience, in order to support the creative capacity of individuals in maintaining their daily lives. Whilst the generation of interpreted knowledge is an essential part of daily general practice, the profession does not have an adequate framework by which this activity can be externally judged to have been done well. Drawing on theory related to the recognition of quality in interpretation and knowledge generation within the qualitative research field, I propose a framework by which to evaluate the quality of knowledge generated within generalist, interpretive clinical practice. I describe three priorities for research in developing this model further, which will strengthen and preserve core elements of the discipline of general practice, and thus promote and support the health needs of the public. PMID:21805819

Are general practitioners characteristics associated with the quality of type 2 diabetes care in general practice? Results from the Norwegian ROSA4 study from 2014.

PubMed

Tran, Anh Thi; Bakke, Åsne; Berg, Tore J; Gjelsvik, Bjørn; Mdala, Ibrahimu; Nøkleby, Kjersti; Shakil Rai, Anam; Cooper, John G; Claudi, Tor; Løvaas, Karianne; Thue, Geir; Sandberg, Sverre; Jenum, Anne K

2018-06-01

To explore the associations between general practitioners (GPs) characteristics such as gender, specialist status, country of birth and country of graduation and the quality of care for patients with type 2 diabetes (T2DM). Cross-sectional survey. The 277 GPs provided care for 10082 patients with T2DM in Norway in 2014. The GPs characteristics were self-reported: 55% were male, 68% were specialists in General Practice, 82% born in Norway and 87% had graduated in Western Europe. Of patients, 81% were born in Norway and 8% in South Asia. Data regarding diabetes care were obtained from electronic medical records and manually verified. Performance of recommended screening procedures, prescribed medication and level of HbA1c, blood pressure and LDL-cholesterol stratified according to GPs characteristics, adjusted for patient and GP characteristics. Female GPs, specialists, GPs born in Norway and GPs who graduated in Western Europe performed recommended procedures more frequently than their counterparts. Specialists achieved lower mean HbA1c (7.14% vs. 7.25%, p < 0.01), a larger proportion of their patients achieved good glycaemic control (HbA1c = 6.0%-7.0%) (49.1% vs. 44.4%, p = 0.018) and lower mean systolic blood pressure (133.0 mmHg vs. 134.7 mmHg, p < 0.01) compared with non-specialists. GPs who graduated in Western Europe achieved lower diastolic blood pressure than their counterparts (76.6 mmHg vs. 77.8 mmHg, p < 0.01). Several quality indicators for type 2 diabetes care were better if the GPs were specialists in General Practice. Key Points Research on associations between General Practitioners (GPs) characteristics and quality of care for patients with type 2 diabetes is limited. Specialists in General Practice performed recommended procedures more frequently, achieved better HbA1c and blood pressure levels than non-specialists. GPs who graduated in Western Europe performed screening procedures more frequently and achieved lower diastolic blood pressure compared with their counterparts. There were few significant differences in the quality of care between GP groups according to their gender and country of birth.

Nurses attitudes and practices towards provision of survivorship care for people with a haematological cancer on completion of treatment.

PubMed

Chan, Raymond Javan; Button, Elise; Thomas, Alison; Gates, Priscilla; Yates, Patsy

2018-05-01

The purpose of this study is to assess cancer nurses' perceptions of responsibility, confidence levels and practice in relation to survivorship care for people with a haematological malignancy on completion of treatment. A prospective cross-sectional survey was conducted. An online survey was distributed to members of two Australian professional bodies. A total of 310 cancer nurses participated in the study, representing a response rate of 28%. The participants generally agreed that all survivorship care items were part of their role. Of the 17 survivorship care items, the three items receiving the lowest confidence scores were discussing fertility issues, discussing employment and financial issues and discussing how to identify signs of cancer recurrence. The least performed survivorship care items were discussing fertility issues, communicating survivorship care with primary healthcare team (i.e. general practitioners) and discussing sexuality issues. Older age, more years of experience, having a post-graduate qualification and working in non-metropolitan area were associated with higher levels of perception of responsibilities and confidence (p < 0.05). The top ranked barriers to survivorship care were reported to be lack of end-of-treatment consultation dedicated to survivorship care, time and an appropriate physical space for delivering care. Cancer nurses perceive key aspects of survivorship care to be part of their role, however there remains variations in practice and confidence with respect to implementation of survivorship care practices. Interventions that focus on enhancing the capability of cancer nurses and eliminating barriers identified in this study have the potential to improve quality survivorship care provision.

Religious Practices and Self-Care in Iranian Patients with Type 2 Diabetes.

PubMed

Heidari, Saeide; Rezaei, Mahboubeh; Sajadi, Mahbobeh; Ajorpaz, Neda Mirbagher; Koenig, Harold G

2017-04-01

This study aimed to examine the relationship between religious practices and self-care of patients with type 2 diabetes. A descriptive cross-sectional survey was conducted on 154 diabetic patients who were referred to two general teaching hospitals in Qom City (Iran). Data were collected using demographic questionnaire, private and public religious practices, and summary of diabetes self-care activities questionnaires. Data were analyzed using descriptive statistics and statistical tests including independent t test, and Pearson correlation coefficient. Significant positive correlations were observed between religious practices and self-care activities in diabetic patients (p < 0.05). Significant positive correlations were also found between some religious practices and self-care activities subscales (p < 0.05). Healthcare providers should be aware of the role that religion plays in the lives of diabetic patients and be able to take religious factors into account when developing care plans. Doing so will enhance a more patient-centered approach and thereby support patients in their role as self-care decision-makers.

Effect of an Education Programme for South Asians with Asthma and Their Clinicians: A Cluster Randomised Controlled Trial (OEDIPUS)

PubMed Central

Griffiths, Chris; Bremner, Stephen; Islam, Kamrul; Sohanpal, Ratna; Vidal, Debi-Lee; Dawson, Carolyn; Foster, Gillian; Ramsay, Jean; Feder, Gene; Taylor, Stephanie; Barnes, Neil; Choudhury, Aklak; Packe, Geoff; Bayliss, Elizabeth; Trathen, Duncan; Moss, Philip; Cook, Viv; Livingstone, Anna Eleri; Eldridge, Sandra

2016-01-01

Background People with asthma from ethnic minority groups experience significant morbidity. Culturally-specific interventions to reduce asthma morbidity are rare. We tested the hypothesis that a culturally-specific education programme, adapted from promising theory-based interventions developed in the USA, would reduce unscheduled care for South Asians with asthma in the UK. Methods A cluster randomised controlled trial, set in two east London boroughs. 105 of 107 eligible general practices were randomised to usual care or the education programme. Participants were south Asians with asthma aged 3 years and older with recent unscheduled care. The programme had two components: the Physician Asthma Care Education (PACE) programme and the Chronic Disease Self Management Programme (CDSMP), targeted at clinicians and patients with asthma respectively. Both were culturally adapted for south Asians with asthma. Specialist nurses, and primary care teams from intervention practices were trained using the PACE programme. South Asian participants attended an outpatient appointment; those registered with intervention practices received self-management training from PACE-trained specialist nurses, a follow-up appointment with PACE-trained primary care practices, and an invitation to attend the CDSMP. Patients from control practices received usual care. Primary outcome was unscheduled care. Findings 375 south Asians with asthma from 84 general practices took part, 183 registered with intervention practices and 192 with control practices. Primary outcome data were available for 358/375 (95.5%) of participants. The intervention had no effect on time to first unscheduled attendance for asthma (Adjusted Hazard Ratio AHR = 1.19 95% CI 0.92 to 1.53). Time to first review in primary care was reduced (AHR = 2.22, (1.67 to 2.95). Asthma-related quality of life and self-efficacy were improved at 3 months (adjusted mean difference -2.56, (-3.89 to -1.24); 0.44, (0.05 to 0.82) respectively. Conclusions A multi-component education programme adapted for south Asians with asthma did not reduce unscheduled care but did improve follow-up in primary care, self-efficacy and quality of life. More effective interventions are needed for south Asians with asthma. PMID:28030569

American Internal Medicine in the 21st Century

PubMed Central

Huddle, Thomas S; Centor, Robert; Heudebert, Gustavo R

2003-01-01

American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant-generalist ideal even as primary care further displaces that ideal. We discuss the origins and importance of the consultant-generalist ideal of internal medicine as exemplified by Osler, and its continued appeal in spite of the predominant role played by clinical science and accompanying subspecialism in determining the academic leadership of American internal medicine since the 1920s. Organizing departmental clinical work along subspecialty lines diminished the importance of the consultant-generalist ideal in academic departments of medicine after 1950. General internists, when they joined the divisions of general internal medicine that appeared in departments of medicine in the 1970s, could sometimes emulate Osler in practicing a general medicine of complexity, but often found themselves in a more limited role doing primary care. As we enter the 21st century, managed care threatens what remains of the Oslerian ideal, both in departments of medicine and in clinical practice. Twenty-first century American internists will have to adjust their conditions of work should they continue to aspire to practice Oslerian internal medicine. PMID:12950486

Assessing the representativeness of physician and patient respondents to a primary care survey using administrative data.

PubMed

Li, Allanah; Cronin, Shawna; Bai, Yu Qing; Walker, Kevin; Ammi, Mehdi; Hogg, William; Wong, Sabrina T; Wodchis, Walter P

2018-05-30

QUALICOPC is an international survey of primary care performance. QUALICOPC data have been used in several studies, yet the representativeness of the Canadian QUALICOPC survey is unknown, potentially limiting the generalizability of findings. This study examined the representativeness of QUALICOPC physician and patient respondents in Ontario using health administrative data. This representativeness study linked QUALICOPC physician and patient respondents in Ontario to health administrative databases at the Institute for Clinical Evaluative Sciences. Physician respondents were compared to other physicians in their practice group and all Ontario primary care physicians on demographic and practice characteristics. Patient respondents were compared to other patients rostered to their primary care physicians, patients rostered to their physicians' practice groups, and a random sample of Ontario residents on sociodemographic characteristics, morbidity, and health care utilization. Standardized differences were calculated to compare the distribution of characteristics across cohorts. QUALICOPC physician respondents included a higher proportion of younger, female physicians and Canadian medical graduates compared to other Ontario primary care physicians. A higher proportion of physician respondents practiced in Family Health Team models, compared to the provincial proportion for primary care physicians. QUALICOPC patient respondents were more likely to be older and female, with significantly higher levels of morbidity and health care utilization, compared with the other patient groups examined. However, when looking at the QUALICOPC physicians' whole rosters, rather than just the patient survey respondents, the practice profiles were similar to those of the other physicians in their practice groups and Ontario patients in general. Comparisons revealed some differences in responding physicians' demographic and practice characteristics, as well as differences in responding patients' characteristics compared to the other patient groups tested, which may have resulted from the visit-based sampling strategy. Ontario QUALICOPC physicians had similar practice profiles as compared to non-participating physicians, providing some evidence that the participating practices are representative of other non-participating practices, and patients selected by visit-based sampling may also be representative of visiting patients in other practices. Those using QUALICOPC data should understand this limited representativeness when generalizing results, and consider the potential for bias in their analyses.

Effectiveness and cost-effectiveness of implementing HIV testing in primary care in East London: protocol for an interrupted time series analysis.

PubMed

Leber, Werner; Beresford, Lee; Nightingale, Claire; Barbosa, Estela Capelas; Morris, Stephen; El-Shogri, Farah; McMullen, Heather; Boomla, Kambiz; Delpech, Valerie; Brown, Alison; Hutchinson, Jane; Apea, Vanessa; Symonds, Merle; Gilliham, Samantha; Creighton, Sarah; Shahmanesh, Maryam; Fulop, Naomi; Estcourt, Claudia; Anderson, Jane; Figueroa, Jose; Griffiths, Chris

2017-12-14

HIV remains underdiagnosed. Guidelines recommend routine HIV testing in primary care, but evidence on implementing testing is lacking. In a previous study, the Rapid HIV Assessment 2 (RHIVA2) cluster randomised controlled trial, we showed that providing training and rapid point-of-care HIV testing at general practice registration (RHIVA2 intervention) in Hackney led to cost-effective, increased and earlier diagnosis of HIV. However, interventions effective in a trial context may be less so when implemented in routine practice. We describe the protocol for an MRC phase IV implementation programme, evaluating the impact of rolling out the RHIVA2 intervention in a post-trial setting. We will use a longitudinal study to examine if the post-trial implementation in Hackney practices is effective and cost-effective, and a cross-sectional study to compare Hackney with two adjacent boroughs providing usual primary care (Newham) and an enhanced service promoting HIV testing in primary care (Tower Hamlets). Service evaluation using interrupted time series and cost-effectiveness analyses. We will include all general practices in three contiguous high HIV prevalence East London boroughs. All adults aged 16 and above registered with the practices will be included. The interventions to be examined are: a post-trial RHIVA2 implementation programme (including practice-based education and training, external quality assurance, incentive payments for rapid HIV testing and incorporation of rapid HIV testing in the sexual health Local Enhanced Service) in Hackney; the general practice sexual health Network Improved Service in Tower Hamlets and usual care in Newham. Coprimary outcomes are rates of HIV testing and new HIV diagnoses. The chair of the Camden and Islington NHS Research Ethics Committee, London, has endorsed this programme as an evaluation of routine care. Study results will be published in peer-reviewed journals and reported to commissioners. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Practice-based learning can improve osteoporosis care.

PubMed

Hess, Brian J; Johnston, Mary M; Iobst, William F; Lipner, Rebecca S

2013-10-01

To examine physician engagement in practice-based learning using a self-evaluation module to assess and improve their care of individuals with or at risk of osteoporosis. Retrospective cohort study. Internal medicine and subspecialty clinics. Eight hundred fifty U.S. physicians with time-limited certification in general internal medicine or a subspecialty. Performance rates on 23 process measures and seven practice system domain scores were obtained from the American Board of Internal Medicine (ABIM) Osteoporosis Practice Improvement Module (PIM), an Internet-based self-assessment module that physicians use to improve performance on one targeted measure. Physicians remeasured performance on their targeted measures by conducting another medical chart review. Variability in performance on measures was found, with observed differences between general internists, geriatricians, and rheumatologists. Some practice system elements were modestly associated with measure performance; the largest association was between providing patient-centered self-care support and documentation of calcium intake and vitamin D estimation and counseling (correlation coefficients from 0.20 to 0.28, Ps < .002). For all practice types, the most commonly selected measure targeted for improvement was documentation of vitamin D level (38% of physicians). On average, physicians reported significant and large increases in performance on measures targeted for improvement. Gaps exist in the quality of osteoporosis care, and physicians can apply practice-based learning using the ABIM PIM to take action to improve the quality of care. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Quality of care for people with multimorbidity - a case series.

PubMed

Schiøtz, Michaela L; Høst, Dorte; Christensen, Mikkel B; Domínguez, Helena; Hamid, Yasmin; Almind, Merete; Sørensen, Kim L; Saxild, Thomas; Holm, Rikke Høgsbro; Frølich, Anne

2017-11-18

Multimorbidity is becoming increasingly prevalent and presents challenges for healthcare providers and systems. Studies examining the relationship between multimorbidity and quality of care report mixed findings. The purpose of this study was to investigate quality of care for people with multimorbidity in the publicly funded healthcare system in Denmark. To investigate the quality of care for people with multimorbidity different groups of clinicians from the hospital, general practice and the municipality reviewed records from 23 persons with multimorbidity and discussed them in three focus groups. Before each focus group, clinicians were asked to review patients' medical records and assess their care by responding to a questionnaire. Medical records from 2013 from hospitals, general practice, and health centers in the local municipality were collected and linked for the 23 patients. Further, two clinical pharmacologists reviewed the appropriateness of medications listed in patient records. The review of the patients' records conducted by three groups of clinicians revealed that around half of the patients received adequate care for the single condition which prompted the episode of care such as a hospitalization, a visit to an outpatient clinic or the general practitioner. Further, the care provided to approximately two-thirds of the patients did not take comorbidities into account and insufficiently addressed more diffuse symptoms or problems. The review of the medication lists revealed that the majority of the medication lists contained inappropriate medications and that there were incongruity in medication listed in the primary and secondary care sector. Several barriers for providing high quality care were identified. These included relative short consultation times in general practice and outpatient clinics, lack of care coordinators, and lack of shared IT-system proving an overview of the treatment. Our findings reveal quality of care deficiencies for people with multimorbidity. Suggestions for care improvement for people with multimorbidity includes formally assigned responsibility for care coordination, a change in the financial incentive structure towards a system rewarding high quality care and care focusing on prevention of disease exacerbation, as well as implementing shared medical record systems.

Generalist solutions to complex problems: generating practice-based evidence - the example of managing multi-morbidity

PubMed Central

2013-01-01

Background A growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare? Discussion Strengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem. We need practice-based evidence to fill this gap. By recognising generalist practice as a ‘complex intervention’ (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem. Summary Answers to the complex problem of multi-morbidity won’t come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity. PMID:23919296

Generalist solutions to complex problems: generating practice-based evidence--the example of managing multi-morbidity.

PubMed

Reeve, Joanne; Blakeman, Tom; Freeman, George K; Green, Larry A; James, Paul A; Lucassen, Peter; Martin, Carmel M; Sturmberg, Joachim P; van Weel, Chris

2013-08-07

A growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare? Strengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem. We need practice-based evidence to fill this gap. By recognising generalist practice as a 'complex intervention' (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem. Answers to the complex problem of multi-morbidity won't come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity.

A process for developing standards to promote quality in general practice.

PubMed

Khoury, Julie; Krejany, Catherine J; Versteeg, Roald W; Lodewyckx, Michaela A; Pike, Simone R; Civil, Michael S; Jiwa, Moyez

2018-06-02

Since 1991, the Royal Australian College of General Practitioners' (RACGP) Standards for General Practices (the Standards) have provided a framework for quality care, risk management and best practice in the operation of Australian general practices. The Standards are also linked to incentives for general practice remuneration. These Standards were revised in 2017. The objective of this study is to describe the process undertaken to develop the fifth edition Standards published in 2017 to inform future standards development both nationally and internationally. A modified Delphi process was deployed to develop the fifth edition Standards. Development was directed by the RACGP and led by an expert panel of GPs and representatives of stakeholder groups who were assisted and facilitated by a team from RACGP. Each draft was released for stakeholder feedback and tested twice before the final version was submitted for approval by the RACGP board. Four rounds of consultation and two rounds of piloting were carried out over 32 months. The Standards were redrafted after each round. One hundred and fifty-two individuals and 225 stakeholder groups participated in the development of the Standards. Twenty-three new indicators were recommended and grouped into three sections in a new modular structure that was different from the previous edition. The Standards represent the consensus view of national stakeholders on the indicators of quality and safety in Australian general practice and primary care.

[Association between productivity, list size, patient and practice characteristics in general practice].

PubMed

Olsen, Kim Rose; Sørensen, Torben Højmark; Gyrd-Hansen, Dorte

2010-04-19

Due to shortage of general practitioners, it may be necessary to improve productivity. We assess the association between productivity, list size and patient- and practice characteristics. A regression approach is used to perform productivity analysis based on national register data and survey data for 1,758 practices. Practices are divided into four groups according to list size and productivity. Statistical tests are used to assess differences in patient- and practice characteristics. There is a significant, positive correlation between list size and productivity (p < 0.01). Nevertheless, 19% of the practices have a list size below and a productivity above mean sample values. These practices have relatively demanding patients (older, low socioeconomic status, high use of pharmaceuticals) and they are frequently located in areas with limited access to specialized care and have a low use of assisting personnel. 13% of the practices have a list size above and a productivity below mean sample values. These practices have relatively less demanding patients, are located in areas with good access to specialized care, and have a high use of assisting personnel. Lists and practice characteristics have substantial influence on both productivity and list size. Adjusting list size to external factors seems to be an effective tool to increase productivity in general practice.

Ethnic differences in Type 2 diabetes care and outcomes in Auckland: a multiethnic community in New Zealand.

PubMed

Robinson, Tom; Simmons, David; Scott, David; Howard, Eileen; Pickering, Karen; Cutfield, Rick; Baker, John; Patel, Ashwin; Wellingham, John; Morton, Sara

2006-06-02

In New Zealand, Maori and Pacific (mostly of Samoan, Tongan, Niuean, or Cook Islands origin) people with Type 2 diabetes are more likely to suffer poor outcomes than other New Zealanders. Responsibility for addressing this outcome differential is falling on primary care and general practice in particular. This paper compares the general practice care provided to people with Type 2 diabetes in South and West Auckland, according to ethnicity. An external audit of general practice diabetes care is carried out in South and West Auckland by the Diabetes Care Support Service. The results of 5917 routine patient audits carried out in 2003 are included in this study. Number of visits, recording of important information, risk factors, and treatments are compared between different ethnic groups. Maori and Pacific people with diabetes who attend a regular GP had a higher average number of consultations than Europeans (5.7, 5.4, and 4.8 visits per year respectively). They were as likely as Europeans to have undergone important regular examinations and investigations. Maori were more likely than Europeans to be on some treatments. However, Maori and Pacific people were more likely to have a range of adverse risk factors for diabetes complications than Europeans. These include being a smoker (35, 18, and 13% respectively), having an HbA1c greater than 8% (50, 56, 23%), and having microalbuminuria (55, 50, 27%). Although there were no large differences in the process measures of general practice diabetes care provided to different ethnic groups in South and West Auckland, Maori and Pacific people were not achieving the same outcomes of care in terms of risk factors for diabetes complications. Many of these risk factors are influenced by other factors in the wider community; however the New Zealand health system needs to consider how it can better address these differences.

Acute care teaching in the undergraduate nursing curriculum.

PubMed

McGaughey, Jennifer

2009-01-01

To incorporate basic aspects of acute care into the undergraduate nursing programme by providing an opportunity for the development of knowledge and skills in the early recognition and assessment of deteriorating patients on general hospital wards. Acute care initiatives implemented in the hospital setting to improve the identification and management of 'at risk' patients have focused on the provision of education for trained or qualified staff. However, to ensure student nurses are 'fit to practice' at the point of registration, it has been recommended that acute care theory and skills are incorporated into the undergraduate nursing curriculum. PRACTICE DEVELOPMENT INITIATIVE: An 'Integrated Nursing Care' module was incorporated into year 3 of the undergraduate nursing programme to introduce students to acute care theory and practice. Module content focuses on the early detection and management of acute deterioration in patients with respiratory, cardiac, neurological or renal insufficiencies. We used a competency-based framework to ensure the application of theory to practice through the use of group seminars. High-fidelity patient-simulated clinical scenarios were a key feature. The United Kingdom Resuscitation Council Intermediate Life Support course is also an important component of the module. Incorporating the Integrated Nursing Care module into the undergraduate nursing curriculum provides pre-registration students the opportunity to develop their knowledge and skills in acute care. The provision of undergraduate education in care of the acutely ill patient in hospital is essential to improve nurses' competence and confidence in assessing and managing deteriorating patients in general wards at the point of registration.

Nurse-led motivational interviewing to change the lifestyle of patients with type 2 diabetes (MILD-project): protocol for a cluster, randomized, controlled trial on implementing lifestyle recommendations

PubMed Central

Jansink, Renate; Braspenning, Jozé; van der Weijden, Trudy; Niessen, Louis; Elwyn, Glyn; Grol, Richard

2009-01-01

Background The diabetes of many patients is managed in general practice; healthcare providers aim to promote healthful behaviors, such as healthful diet, adequate physical activity, and smoking cessation. These measures may decrease insulin resistance, improve glycemic control, lipid abnormalities, and hypertension. They may also prevent cardiovascular disease and complications of diabetes. However, professionals do not adhere optimally to guidelines for lifestyle counseling. Motivational interviewing to change the lifestyle of patients with type 2 diabetes is intended to improve diabetes care in accordance with the national guidelines for lifestyle counseling. Primary care nurses will be trained in motivational interviewing embedded in structured care in general practice. The aim of this paper is to describe the design and methods of a study evaluating the effects of the nurses' training on patient outcomes. Methods/Design A cluster, randomized, controlled trial involving 70 general practices (35 practices in the intervention arm and 35 in the control arm) starting in March 2007. A total of 700 patients with type 2 diabetes will be recruited. The patients in the intervention arm will receive care from the primary care nurse, who will receive training in an implementation strategy with motivational interviewing as the core component. Other components of this strategy will be adaptation of the diabetes protocol to local circumstances, introduction of a social map for lifestyle support, and educational and supportive tools for sustaining motivational interviewing. The control arm will be encouraged to maintain usual care. The effect measures will be the care process, metabolic parameters (glycosylated hemoglobin, blood pressure and lipids), lifestyle (diet, physical activity, smoking, and alcohol), health-related quality of life, and patients' willingness to change behaviors. The measurements will take place at baseline and after 14 months. Discussion Applying motivational interviewing for patients with diabetes in primary care has been studied, but to our knowledge, no other study has yet evaluated the implementation and sustainability of motivating and involving patients in day-to-day diabetes care in general practice. If this intervention proves to be effective and cost-effective, large-scale implementation of this nurse-oriented intervention will be considered and anticipated. Trial registration Current Controlled Trials ISRCTN68707773. PMID:19183462

Family-centred care delivery: comparing models of primary care service delivery in Ontario.

PubMed

Mayo-Bruinsma, Liesha; Hogg, William; Taljaard, Monica; Dahrouge, Simone

2013-11-01

To determine whether models of primary care service delivery differ in their provision of family-centred care (FCC) and to identify practice characteristics associated with FCC. Cross-sectional study. Primary care practices in Ontario (ie, 35 salaried community health centres, 35 fee-for-service practices, 32 capitation-based health service organizations, and 35 blended remuneration family health networks) that belong to 4 models of primary care service delivery. A total of 137 practices, 363 providers, and 5144 patients. Measures of FCC in patient and provider surveys were based on the Primary Care Assessment Tool. Statistical analyses were conducted using linear mixed regression models and generalized estimating equations. Patient-reported FCC scores were high and did not vary significantly by primary care model. Larger panel size in a practice was associated with lower odds of patients reporting FCC. Provider-reported FCC scores were significantly higher in community health centres than in family health networks (P = .035). A larger number of nurse practitioners and clinical services on-site were both associated with higher FCC scores, while scores decreased as the number of family physicians in a practice increased and if practices were more rural. Based on provider and patient reports, primary care reform strategies that encourage larger practices and more patients per family physician might compromise the provision of FCC, while strategies that encourage multidisciplinary practices and a range of services might increase FCC.

Hepatitis C infection among injecting drug users in general practice: a cluster randomised controlled trial of clinical guidelines' implementation.

PubMed

Cullen, Walter; Stanley, June; Langton, Deirdre; Kelly, Yvonne; Staines, Anthony; Bury, Gerard

2006-11-01

Hepatitis C is a common infection among injecting drug users and has important implications for general practice. Although several clinical guidelines concerning the infection have been published, their effectiveness has yet to be tested. To assess the effectiveness of a general practice-based complex intervention to support the implementation of clinical guidelines for hepatitis C management among current or former drug users attending general practice. Cluster randomised controlled trial. General practices in the Eastern Regional Health Authority area of Ireland. Twenty-six practices were randomly allocated within strata to receive the intervention under study or to provide care as usual for a period of 6 months. There was screening for patients attending general practice for methadone maintenance treatment for hepatitis C and referral of anti-HCV antibody positive patients to a specialist hepatology department for assessment. At study completion, patients in the intervention group were significantly more likely to have been screened for hepatitis C than those in the control group, odds ratio adjusted for clustering 3.76 (95% confidence interval [CI] = 1.3 to 11.3) and this association remained significant after adjusting for other potentially confounding variables, using multiple logistic regression, with the odds ratio adjusted for clustering 4.53 (95% CI = 1.39 to 14.78). Although anti-HCV antibody positive patients in the intervention group were more likely to have been referred to a hepatology clinic, this was not statistically significant (P = 0.06). General practice has an important role in the care of people at risk of hepatitis C and when appropriately supported can effectively implement current best practice.

Cross-sectional survey of older patients' views regarding multidisciplinary care for chronic conditions in general practice.

PubMed

Bonney, Andrew; Magee, Christopher; Pearson, Russell

2014-01-01

The ageing population and increasing prevalence of chronic illness have contributed to the need for significant primary care reform, including increased use of multidisciplinary care and task substitution. This cross-sectional study explores conditions under which older patients would accept having health professionals other than their general practitioner (GP) involved in their care for chronic disease management (CDM). Ten practices were randomly sampled from a contiguous major city and inner regional area. Questionnaires were distributed to consecutive patients aged 60 years and over in each practice. Agency theory was used to inform analyses. Statistical analysis was undertaken using Wald's test, growth modelling and linear regression, controlling for the clustered design. The response rate was 53% (n=272). Most respondents (79%) had at least one chronic health condition. Respondents were more comfortable with GP than with practice nurse management in the CDM scenario (Wald's test=105.49, P<0.001). Comfort with practice nurse CDM was positively associated with increased contact with their GP at the time of the visit (β=0.41, P<0.001), negatively associated with the number of the respondent's chronic conditions (β=-0.13, P=0.030) and not associated with the frequency of other health professional visits. Agency theory suggests that patients employ continuity of care to optimise factors important in CDM: information symmetry and goal alignment. Our findings are consistent with the theory and lend support to ensuring that interpersonal continuity of care is not lost in health care reform. Further research exploring patients' acceptance of differing systems of care is required.

A primer to natural hair care practices in black patients.

PubMed

Bosley, Rawn E; Daveluy, Steven

2015-02-01

Natural hairstyles have increased in popularity in the United States among individuals of African and Afro-Caribbean descent. Dermatologists should be aware of general principles of natural hair care in this patient population, including basic hair care terminology, types of natural hairstyles, methods of washing, and product selection. A basic knowledge of natural hair care practices in black patients will assist dermatologists in the management and treatment of many conditions associated with traumatic hairstyling in this patient population.

Effect of care management program structure on implementation: a normalization process theory analysis.

PubMed

Holtrop, Jodi Summers; Potworowski, Georges; Fitzpatrick, Laurie; Kowalk, Amy; Green, Lee A

2016-08-15

Care management in primary care can be effective in helping patients with chronic disease improve their health status, however, primary care practices are often challenged with implementation. Further, there are different ways to structure care management that may make implementation more or less successful. Normalization process theory (NPT) provides a means of understanding how a new complex intervention can become routine (normalized) in practice. In this study, we used NPT to understand how care management structure affected how well care management became routine in practice. Data collection involved semi-structured interviews and observations conducted at 25 practices in five physician organizations in Michigan, USA. Practices were selected to reflect variation in physician organizations, type of care management program, and degree of normalization. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with NPT as a guiding framework. Seventy interviews and 25 observations were completed. Two key structures for care management organization emerged: practice-based care management where the care managers were embedded in the practice as part of the practice team; and centralized care management where the care managers worked independently of the practice work flow and was located outside the practice. There were differences in normalization of care management across practices. Practice-based care management was generally better normalized as compared to centralized care management. Differences in normalization were well explained by the NPT, and in particular the collective action construct. When care managers had multiple and flexible opportunities for communication (interactional workability), had the requisite knowledge, skills, and personal characteristics (skill set workability), and the organizational support and resources (contextual integration), a trusting professional relationship (relational integration) developed between practice providers and staff and the care manager. When any of these elements were missing, care management implementation appeared to be affected negatively. Although care management can introduce many new changes into delivery of clinical practice, implementing it successfully as a new complex intervention is possible. NPT can be helpful in explaining differences in implementing a new care management program with a view to addressing them during implementation planning.

The evolution of nursing in Australian general practice: a comparative analysis of workforce surveys ten years on.

PubMed

Halcomb, Elizabeth J; Salamonson, Yenna; Davidson, Patricia M; Kaur, Rajneesh; Young, Samantha Am

2014-03-25

Nursing in Australian general practice has grown rapidly over the last decade in response to government initiatives to strengthen primary care. There are limited data about how this expansion has impacted on the nursing role, scope of practice and workforce characteristics. This study aimed to describe the current demographic and employment characteristics of Australian nurses working in general practice and explore trends in their role over time. In the nascence of the expansion of the role of nurses in Australian general practice (2003-2004) a national survey was undertaken to describe nurse demographics, clinical roles and competencies. This survey was repeated in 2009-2010 and comparative analysis of the datasets undertaken to explore workforce changes over time. Two hundred eighty four nurses employed in general practice completed the first survey (2003/04) and 235 completed the second survey (2009/10). Significantly more participants in Study 2 were undertaking follow-up of pathology results, physical assessment and disease specific health education. There was also a statistically significant increase in the participants who felt that further education/training would augment their confidence in all clinical tasks (p < 0.001). Whilst the impact of legal implications as a barrier to the nurses' role in general practice decreased between the two time points, more participants perceived lack of space, job descriptions, confidence to negotiate with general practitioners and personal desire to enhance their role as barriers. Access to education and training as a facilitator to nursing role expansion increased between the two studies. The level of optimism of participants for the future of the nurses' role in general practice was slightly decreased over time. This study has identified that some of the structural barriers to nursing in Australian general practice have been addressed over time. However, it also identifies continuing barriers that impact practice nurse role development. Understanding and addressing these issues is vital to optimise the effectiveness of the primary care nursing workforce.

Analysis of 1263 deaths in four general practices.

PubMed Central

Holden, J; O'Donnell, S; Brindley, J; Miles, L

1998-01-01

BACKGROUND: The death of a patient is a significant event that occurs often enough in general practice for it to have the potential to tell us much about the care we provide. There are few large series in the literature and we still know little about the collaborative use of this outcome measure. AIM: To determine the pattern of deaths and potentially preventable factors in our practices. METHOD: We completed a standard data collection form after each death in four general practices over a 40-month period. The results were discussed at quarterly meetings. RESULTS: A total of 1263 deaths occurred among our registered patients during the period of the audit. Preventable factors contributing to deaths were considered to be attributable to: patients (40%): mainly cigarette smoking, poor compliance, and alcohol problems; general practice teams (5%): mainly delayed referral, diagnosis and treatment, and failure to prescribe aspirin to patients with vascular disease; hospitals (6%): mainly delayed diagnosis and perceived treatment problems; the environment (3%): mainly falls, principally resulting in fractured neck of femur. CONCLUSION: A simple audit of deaths along the lines that we describe gives important information about the care provided by general practice teams and those in hospital practice. It has both educational value and is a source of ideas for service improvement and further study, particularly when carried out over several years. PMID:9800400

42 CFR 409.35 - Criteria for “practical matter”.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Criteria for “practical matter”. (a) General considerations. In making a “practical matter” determination...) Examples of circumstances that meet practical matter criteria—(1) Beneficiary's condition. Inpatient care would be required “as a practical matter” if transporting the beneficiary to and from the nearest...

42 CFR 409.35 - Criteria for “practical matter”.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Criteria for “practical matter”. (a) General considerations. In making a “practical matter” determination...) Examples of circumstances that meet practical matter criteria—(1) Beneficiary's condition. Inpatient care would be required “as a practical matter” if transporting the beneficiary to and from the nearest...

42 CFR 409.35 - Criteria for “practical matter”.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Criteria for “practical matter”. (a) General considerations. In making a “practical matter” determination...) Examples of circumstances that meet practical matter criteria—(1) Beneficiary's condition. Inpatient care would be required “as a practical matter” if transporting the beneficiary to and from the nearest...

42 CFR 409.35 - Criteria for “practical matter”.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Criteria for “practical matter”. (a) General considerations. In making a “practical matter” determination...) Examples of circumstances that meet practical matter criteria—(1) Beneficiary's condition. Inpatient care would be required “as a practical matter” if transporting the beneficiary to and from the nearest...

Measuring the burden of herpes zoster and post herpetic neuralgia within primary care in rural Crete, Greece

PubMed Central

2011-01-01

Background Research has indicated that general practitioners (GPs) have good clinical judgment in regards to diagnosing and managing herpes zoster (HZ) within clinical practice in a country with limited resources for primary care and general practice. The objective of the current study was to assess the burden of HZ and post herpetic neuralgia (PHN) within rural general practices in Crete, Greece. Methods The current study took place within a rural setting in Crete, Greece during the period of November 2007 to November 2009 within the catchment area in which the Cretan Rural Practice-based Research Network is operating. In total 19 GP's from 14 health care units in rural Crete were invited to participate, covering a total turnover patient population of approximately 25, 000 subjects. For the purpose of this study an electronic record database was constructed and used as the main tool for monitoring HZ and PHN incidence. Stress related data was also collected with the use of the Short Anxiety Screening Test (SAST). Results The crude incidence rate of HZ was 1.4/1000 patients/year throughout the entire network of health centers and satellite practices, while among satellite practices alone it was calculated at 1.3/1000 patients/year. Additionally, the standardised incidence density within satellite practices was calculated at 1.6/1000 patients/year. In regards to the stress associated with HZ and PHN, the latter were found to have lower levels of anxiety, as assessed through the SAST score (17.4 ± 3.9 vs. 21.1 ± 5.7; p = 0.029). Conclusions The implementation of an electronic surveillance system was feasible so as to measure the burden of HZ and PHN within the rural general practice setting in Crete. PMID:22145678

Qualitative insights into practice time management: does 'patient-centred time' in practice management offer a portal to improved access?

PubMed Central

Buetow, S; Adair, V; Coster, G; Hight, M; Gribben, B; Mitchell, E

2002-01-01

BACKGROUND: Different sets of literature suggest how aspects of practice time management can limit access to general practitioner (GP) care. Researchers have not organised this knowledge into a unified framework that can enhance understanding of barriers to, and opportunities for, improved access. AIM: To suggest a framework conceptualising how differences in professional and cultural understanding of practice time management in Auckland, New Zealand, influence access to GP care for children with chronic asthma. DESIGN OF STUDY: A qualitative study involving selective sampling, semi-structured interviews on barriers to access, and a general inductive approach. SETTING: Twenty-nine key informants and ten mothers of children with chronic, moderate to severe asthma and poor access to GP care in Auckland. METHOD: Development of a framework from themes describing barriers associated with, and needs for, practice time management. The themes were independently identified by two authors from transcribed interviews and confirmed through informant checking. Themes from key informant and patient interviews were triangulated with each other and with published literature. RESULTS: The framework distinguishes 'practice-centred time' from 'patient-centred time.' A predominance of 'practice-centred time' and an unmet opportunity for 'patient-centred time' are suggested by the persistence of five barriers to accessing GP care: limited hours of opening; traditional appointment systems; practice intolerance of missed appointments; long waiting times in the practice; and inadequate consultation lengths. None of the barriers is specific to asthmatic children. CONCLUSION: A unified framework was suggested for understanding how the organisation of practice work time can influence access to GP care by groups including asthmatic children. PMID:12528583

Extended training to prepare GPs for future workforce needs: a qualitative investigation of a 1-year fellowship in urgent care.

PubMed

Dale, Jeremy; Russell, Rachel; Harkness, Frances; Wilkie, Veronica; Aiello, Matthew

2017-09-01

It has been argued that UK general practice specialist training should be extended to better prepare GPs for the challenges facing 21st-century health care. Evidence is needed to inform how this should occur. To investigate the experience of recently trained GPs undertaking a 1-year full-time fellowship programme designed to provide advanced skills training in urgent care, integrated care, leadership, and academic practice; and its impact on subsequent career development. Semi-structured interviews conducted longitudinally over 2 years augmented by observational data in the West Midlands, England. Participants were interviewed on at least three occasions: twice while undertaking the fellowship, and at least once post-completion. Participants' clinical and academic activities were observed. Data were analysed using a framework approach. Seven GPs participated in the pilot scheme. The fellowship was highly rated and felt to be balanced in terms of the opportunities for skill development, academic advancement, and confidence building. GPs experienced enhanced employability on completing the scheme, and at follow-up were working in a variety of primary care/urgent care interface clinical and leadership roles. Participants believed it was making general practice a more attractive career option for newly qualified doctors. The 1-year fellowship provides a defined framework for training GPs to work in an enhanced manner across organisational interfaces with the skills to support service improvement and integration. It appears to be well suited to preparing GPs for portfolio roles, but its wider applicability and impact on NHS service delivery needs further investigation. © British Journal of General Practice 2017.

Nursing competency standards in primary health care: an integrative review.

PubMed

Halcomb, Elizabeth; Stephens, Moira; Bryce, Julianne; Foley, Elizabeth; Ashley, Christine

2016-05-01

This paper reports an integrative review of the literature on nursing competency standards for nurses working in primary health care and, in particular, general practice. Internationally, there is growing emphasis on building a strong primary health care nursing workforce to meet the challenges of rising chronic and complex disease. However, there has been limited emphasis on examining the nursing workforce in this setting. Integrative review. A comprehensive search of relevant electronic databases using keywords (e.g. 'competencies', 'competen*' and 'primary health care', 'general practice' and 'nurs*') was combined with searching of the Internet using the Google scholar search engine. Experts were approached to identify relevant grey literature. Key websites were also searched and the reference lists of retrieved sources were followed up. The search focussed on English language literature published since 2000. Limited published literature reports on competency standards for nurses working in general practice and primary health care. Of the literature that is available, there are differences in the reporting of how the competency standards were developed. A number of common themes were identified across the included competency standards, including clinical practice, communication, professionalism and health promotion. Many competency standards also included teamwork, education, research/evaluation, information technology and the primary health care environment. Given the potential value of competency standards, further work is required to develop and test robust standards that can communicate the skills and knowledge required of nurses working in primary health care settings to policy makers, employers, other health professionals and consumers. Competency standards are important tools for communicating the role of nurses to consumers and other health professionals, as well as defining this role for employers, policy makers and educators. Understanding the content of competency standards internationally is an important step to understanding this growing workforce. © 2016 John Wiley & Sons Ltd.

Predicting declines in perceived relationship continuity using practice deprivation scores: a longitudinal study in primary care.

PubMed

Levene, Louis S; Baker, Richard; Walker, Nicola; Williams, Christopher; Wilson, Andrew; Bankart, John

2018-06-01

Increased relationship continuity in primary care is associated with better health outcomes, greater patient satisfaction, and fewer hospital admissions. Greater socioeconomic deprivation is associated with lower levels of continuity, as well as poorer health outcomes. To investigate whether deprivation scores predicted variations in the decline over time of patient-perceived relationship continuity of care, after adjustment for practice organisational and population factors. An observational study in 6243 primary care practices with more than one GP, in England, using a longitudinal multilevel linear model, 2012-2017 inclusive. Patient-perceived relationship continuity was calculated using two questions from the GP Patient Survey. The effect of deprivation on the linear slope of continuity over time was modelled, adjusting for nine confounding variables (practice population and organisational factors). Clustering of measurements within general practices was adjusted for by using a random intercepts and random slopes model. Descriptive statistics and univariable analyses were also undertaken. Relationship continuity declined by 27.5% between 2012 and 2017, and at all deprivation levels. Deprivation scores from 2012 did not predict variations in the decline of relationship continuity at practice level, after accounting for the effects of organisational and population confounding variables, which themselves did not predict, or weakly predicted with very small effect sizes, the decline of continuity. Cross-sectionally, continuity and deprivation were negatively correlated within each year. The decline in relationship continuity of care has been marked and widespread. Measures to maximise continuity will need to be feasible for individual practices with diverse population and organisational characteristics. © British Journal of General Practice 2018.

Selected problems associated with the treatment and care for patients with colostomy - part 2.

PubMed

Muzyczka, Katarzyna; Kachaniuk, Hanna; Szadowska-Szlachetka, Zdzisława; Charzyńska-Gula, Marianna; Kocka, Katarzyna; Bartoszek, Agnieszka; Celej-Szuster, Jolanta

2013-01-01

Generally, ostomy is a purposeful connection of the lumen of the intestine with abdominal integuments by surgery. The study presents practical solutions related to care for the colostomy patient, i.e. an ostomy on the large intestine. The following issues will be discussed: regulating the defecation cycle, risk connected with improper selection of ostomy equipment, instruction on colostomy irrigation with practical advice and irrigation equipment supply. The knowledge of these rules and mastering them in practice is to provide ostomy patients not only with highest-standard care and help but also to prepare them for dealing with problems independently, i.e. for self-care.

Digital communication between clinician and patient and the impact on marginalised groups: a realist review in general practice

PubMed Central

Huxley, Caroline J; Atherton, Helen; Watkins, Jocelyn Anstey; Griffiths, Frances

2015-01-01

Background Increasingly, the NHS is embracing the use of digital communication technology for communication between clinicians and patients. Policymakers deem digital clinical communication as presenting a solution to the capacity issues currently faced by general practice. There is some concern that these technologies may exacerbate existing inequalities in accessing health care. It is not known what impact they may have on groups who are already marginalised in their ability to access general practice. Aim To assess the potential impact of the availability of digital clinician–patient communication on marginalised groups’ access to general practice in the UK. Design and setting Realist review in general practice. Method A four-step realist review process was used: to define the scope of the review; to search for and scrutinise evidence; to extract and synthesise evidence; and to develop a narrative, including hypotheses. Results Digital communication has the potential to overcome the following barriers for marginalised groups: practical access issues, previous negative experiences with healthcare service/staff, and stigmatising reactions from staff and other patients. It may reduce patient-related barriers by offering anonymity and offers advantages to patients who require an interpreter. It does not impact on inability to communicate with healthcare professionals or on a lack of candidacy. It is likely to work best in the context of a pre-existing clinician–patient relationship. Conclusion Digital communication technology offers increased opportunities for marginalised groups to access health care. However, it cannot remove all barriers to care for these groups. It is likely that they will remain disadvantaged relative to other population groups after their introduction. PMID:26622034

Safer Prescribing and Care for the Elderly (SPACE): feasibility of audit and feedback plus practice mail-out to patients with high-risk prescribing.

PubMed

Wallis, Katharine; Tuckey, Rebecca

2017-06-01

INTRODUCTION High-risk prescribing in general practice is common and places patients at increased risk of adverse events. AIM The Safer Prescribing and Care for the Elderly (SPACE) intervention, comprising audit and feedback plus practice mail-out to patients with high-risk prescribing, was designed to promote medicines review and support safer prescribing. This study aims to test the SPACE intervention feasibility in general practice. METHODS This feasibility study involved an Auckland Primary Health Organisation (PHO), a clinical advisory pharmacist, two purposively sampled urban general practices, and seven GPs. The acceptability and utility of the SPACE intervention were assessed by semi- structured interviews involving study participants, including 11 patients with high-risk prescribing. Interviews were audio-recorded, transcribed verbatim and analysed using a general inductive approach to identify emergent themes. RESULTS The pharmacist said the SPACE intervention facilitated communication with GPs, and provided a platform for their clinical advisory role at no extra cost to the PHO. GPs said the feedback session with the pharmacist was educational but added to time pressures. GPs selected 29 patients for the mail-out. Some GPs were concerned the mail-out might upset patients, but patients said they felt cared for. Some patients intended to take the letter to their next appointment and discuss their medicines with their GP; others said there were already many things to discuss and not enough time. Some patients were confused by the medicines information brochure. DISCUSSION The SPACE intervention is feasible in general practice. The medicines information brochure needs simplification. Further research is needed to test the effect of SPACE on high-risk prescribing.

A collaborative project to improve identification and management of patients with chronic kidney disease in a primary care setting in Greater Manchester.

PubMed

Humphreys, John; Harvey, Gill; Coleiro, Michelle; Butler, Brook; Barclay, Anna; Gwozdziewicz, Maciek; O'Donoghue, Donal; Hegarty, Janet

2012-08-01

Research has demonstrated a knowledge and practice gap in the identification and management of chronic kidney disease (CKD). In 2009, published data showed that general practices in Greater Manchester had a low detection rate for CKD. A 12-month improvement collaborative, supported by an evidence-informed implementation framework and financial incentives. 19 general practices from four primary care trusts within Greater Manchester. Number of recorded patients with CKD on practice registers; percentage of patients on registers achieving nationally agreed blood pressure targets. The collaborative commenced in September 2009 and involved three joint learning sessions, interspersed with practice level rapid improvement cycles, and supported by an implementation team from the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Greater Manchester. At baseline, the 19 collaborative practices had 4185 patients on their CKD registers. At final data collection in September 2010, this figure had increased by 1324 to 5509. Blood pressure improved from 34% to 74% of patients on practice registers having a recorded blood pressure within recommended guidelines. Evidence-based improvement can be implemented in practice for chronic disease management. A collaborative approach has been successful in enabling teams to test and apply changes to identify patients and improve care. The model has proved to be more successful for some practices, suggesting a need to develop more context-sensitive approaches to implementation and actively manage the factors that influence the success of the collaborative.

Views of newly-qualified GPs about their training and preparedness: lessons for extended generalist training.

PubMed

Sabey, Abigail; Hardy, Holly

2015-04-01

General practice is becoming increasingly complex due to an ageing population with multiple morbidities and the shift of services from secondary to primary care, yet GP training remains largely the same. Extended training is now recommended, initially proposed as a fourth GP specialty trainee year, but more recently as a broad-based 4-year specialty training programme. To explore the views of newly-qualified GPs about their training and preparedness for specific aspects of the GP's role. Qualitative study with newly-qualified GPs who qualified with Severn Deanery between 2007 and 2010. Semi-structured interviews with 18 GPs between November 2011 and April 2012. Gaining experience in a variety of primary care environments widens insight into patient populations as well as helping GPs develop adaptability and confidence, although this is not routinely part of GP training. However, alongside variety, having continuity with patients in practice remains important. Opportunities to be involved in the management of a practice or to take on substantial leadership roles also vary widely and this may limit preparedness and development of generalist skills. Extended training could help prepare GPs for the current challenges of general practice. It could ensure all trainees are exposed to a greater variety of primary care settings including those outside GP practice, as well as experience of business, finance, and leadership roles. Collectively, these changes have the potential to produce GPs with both generalist and enhanced skills, who are better prepared to work collaboratively across the organisational boundaries between primary, secondary, and community care. © British Journal of General Practice 2015.

Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England

PubMed Central

Sansom, Anna; Terry, Rohini; Fletcher, Emily; Salisbury, Chris; Long, Linda; Richards, Suzanne H; Aylward, Alex; Welsman, Jo; Sims, Laura; Campbell, John L; Dean, Sarah G

2018-01-01

Objective To identify factors influencing general practitioners’ (GPs’) decisions about whether or not to remain in direct patient care in general practice and what might help to retain them in that role. Design Qualitative, in-depth, individual interviews exploring factors related to GPs leaving, remaining in and returning to direct patient care. Setting South West England, UK. Participants 41 GPs: 7 retired; 8 intending to take early retirement; 11 who were on or intending to take a career break; 9 aged under 50 years who had left or were intending to leave direct patient care and 6 who were not intending to leave or to take a career break. Plus 19 stakeholders from a range of primary care-related professional organisations and roles. Results Reasons for leaving direct patient care were complex and based on a range of job-related and individual factors. Three key themes underpinned the interviewed GPs’ thinking and rationale: issues relating to their personal and professional identity and the perceived value of general practice-based care within the healthcare system; concerns regarding fear and risk, for example, in respect of medical litigation and managing administrative challenges within the context of increasingly complex care pathways and environments; and issues around choice and volition in respect of personal social, financial, domestic and professional considerations. These themes provide increased understanding of the lived experiences of working in today’s National Health Service for this group of GPs. Conclusion Future policies and strategies aimed at retaining GPs in direct patient care should clarify the role and expectations of general practice and align with GPs’ perception of their own roles and identity; demonstrate to GPs that they are valued and listened to in planning delivery of the UK healthcare; target GPs’ concerns regarding fear and risk, seeking to reduce these to manageable levels and give GPs viable options to support them to remain in direct patient care. PMID:29326195

[Emergencies and urgent consultation in non-urban Swiss general practices].

PubMed

Meyer, R L; Marty, F

2007-03-07

The upcoming shortage of general practitioners in Switzerland will be a big challenge for medical out-of-hours services. Regionally ver different exists only few datas about organisational matters of and problems seen in "out-of-hours" care and "urgent consultations". Our Pilot present the prevalence of "out-of-hours care" in a general practitioner setting describes and classifies the problems seen using ICPC-2.

Deep water running and general practice in primary care for non-specific low back pain versus general practice alone: randomized controlled trial.

PubMed

Cuesta-Vargas, A I; Adams, N; Salazar, J A; Belles, A; Hazañas, S; Arroyo-Morales, M

2012-07-01

There is equivocal evidence regarding the benefits of aquatic aerobic exercise for non-specific chronic low back pain (NSCLBP) in addition to standard care in general practice consisting of education and advice. The purpose of this study was to compare the addition of deep water running (DWR) to standard general practice (GP) on NSCLBP versus GP care alone on pain, physical and mental health and disability. In this single-blind randomised controlled trial, 58 subjects with NSCLBP were recruited from primary care. The control group received GP care consisting of a physician's consultation and educational booklet only. The experimental group received additional 30-min sessions of DWR three times a week for 15 weeks at the individualized aerobic threshold. Measurements were made pre- and post-intervention and at 1-year follow-up. Both groups showed improvement. The difference between treatment effects at longest follow-up of 1 year was -26.0 (-40.9 to -11.1) mm on the VAS (p < 0.05), -2.5 (-5.7 to -0.2) points in RMQ for disability (p < 0.05), 3.3 (10.0 to 24.7) points on physical health in the physical summary component of the Spanish Short Form 12 (SF-12; p < 0.05) and 5.8 (8.6 to 34.7) points on the mental summary component of the SF-12 (p < 0.05), in favour of the DWR group. For patients with NSCLBP, the addition of DWR to GP was more effective in reducing pain and disability than standard GP alone, suggesting the effectiveness and acceptability of this approach with this group of patients.

Engaging general practice nurses in chronic disease self-management support in Australia: insights from a controlled trial in chronic obstructive pulmonary disease.

PubMed

Walters, Julia A E; Courtney-Pratt, Helen; Cameron-Tucker, Helen; Nelson, Mark; Robinson, Andrew; Scott, Jenn; Turner, Paul; Walters, E Haydn; Wood-Baker, Richard

2012-01-01

The growing burden of chronic disease will increase the role of primary care in supporting self-management and health behaviour change. This role could be undertaken to some extent by the increased practice nurse workforce that has occurred over recent years. Mixed methods were used to investigate the potential for general practice nurses to adopt this role during a 12-month randomised controlled study of telephone-delivered health mentoring in Tasmanian practices. Nurses (general practice and community health) were trained as health mentors to assist chronic obstructive pulmonary disease patients to identify and achieve personal health related goals through action plans. Of 21% of invited practices that responded, 19 were allocated to health mentoring; however, general practice nurses were unable to train as health mentors in 14 (74%), principally due to lack of financial compensation and/or workload pressure. For five general practice nurses trained as health mentors, their roles had previously included some chronic disease management, but training enhanced their understanding and skills of self-management approaches and increased the focus on patient partnership, prioritising patients' choices and achievability. Difficulties that led to early withdrawal of health mentors were competing demands, insufficient time availability, phone calls having lower priority than face-to-face interactions and changing employment. Skills gained were rated as valuable, applicable to all clinical practice and transferable to other health care settings. Although these results suggest that training can enhance general practice nurses' skills to deliver self-management support in chronic disease, there are significant system barriers that need to be addressed through funding models and organisational change.

Improving access for patients – a practice manager questionnaire

PubMed Central

Meade, James G; Brown, James S

2006-01-01

Background The administrative and professional consequences of access targets for general practices, as detailed in the new GMS contract, are unknown. This study researched the effect of implementing the access targets of the new GP contract on general practice appointment systems, and practice manager satisfaction in a UK primary health care setting. Methods A four-part postal questionnaire was administered. The questionnaire was modified from previously validated questionnaires and the findings compared with data obtained from the Western Health and Social Services Board (WHSSB) in N Ireland. Practice managers from the 59 general practices in the WHSSB responded to the questionnaire. Results There was a 94.9% response rate. Practice managers were generally satisfied with the introduction of access targets for patients. Some 57.1% of responding practices, most in deprived areas (Odds ratio 3.13 -95% CI 1.01 – 9.80, p = 0.0256) had modified their appointment systems. Less booking flexibility was reported among group practices (p = 0.006), urban practices (p < 0.001) and those with above average patient list sizes (p < 0.001). Receptionists had not received training in patient appointment management in a quarter of practices. Practices with smaller list sizes were more likely than larger ones to utilise nurses in seeing extra patients (p = 0.007) or to undertake triage procedures (p = 0.062). Conclusion The findings demonstrated the ability of general practices within the WHSSB to adjust to a demanding component of the new GP contract. Issues relating to the flexibility of patient appointment booking systems, receptionists' training and the development of the primary care nursing role were highlighted by the study. PMID:16784530

Promoting Mental Health and Preventing Mental Illness in General Practice.

PubMed

Thomas, Steve; Jenkins, Rachel; Burch, Tony; Calamos Nasir, Laura; Fisher, Brian; Giotaki, Gina; Gnani, Shamini; Hertel, Lise; Marks, Marina; Mathers, Nigel; Millington-Sanders, Catherine; Morris, David; Ruprah-Shah, Baljeet; Stange, Kurt; Thomas, Paul; White, Robert; Wright, Fiona

2016-01-01

This paper calls for the routine integration of mental health promotion and prevention into UK General Practice in order to reduce the burden of mental and physical disorders and the ensuing pressure on General Practice. The proposals & the resulting document (https://ethicscharity.files.wordpress.com/2015/09/rcgp_keymsg_150925_v5.pdf) arise from an expert 'Think Tank' convened by the London Journal of Primary Care, Educational Trust for Health Improvement through Cognitive Strategies (ETHICS Foundation) and the Royal College of General Practitioners. It makes 12 recommendations for General Practice: (1) Mental health promotion and prevention are too important to wait. (2) Work with your community to map risk factors, resources and assets. (3) Good health care, medicine and best practice are biopsychosocial rather than purely physical. (4) Integrate mental health promotion and prevention into your daily work. (5) Boost resilience in your community through approaches such as community development. (6) Identify people at increased risk of mental disorder for support and screening. (7) Support early intervention for people of all ages with signs of illness. (8) Maintain your biopsychosocial skills. (9) Ensure good communication, interdisciplinary team working and inter-sectoral working with other staff, teams and agencies. (10) Lead by example, taking action to promote the resilience of the general practice workforce. (11) Ensure mental health is appropriately included in the strategic agenda for your 'cluster' of General Practices, at the Clinical Commissioning Groups, and the Health and Wellbeing Board. (12) Be aware of national mental health strategies and localise them, including action to destigmatise mental illness within the context of community development.

Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract.

PubMed

Checkland, Kath; Harrison, Stephen; McDonald, Ruth; Grant, Suzanne; Campbell, Stephen; Guthrie, Bruce

2008-07-01

In 2004 a new contract was introduced for General Practitioners in the UK, which introduced a significant element of 'pay-for-performance', including both clinical and organisational targets. The introduction of this contract has caused interest across the world, particularly amongst those responsible for commissioning primary care services. It can be argued that the clinical targets in the contract (known as the Quality and Outcomes Framework, QOF) represent a move towards a more biomedical model of health and illness, which is contrary to the ideal of providing holistic (or biopsychosocial) care that has been traditionally espoused by GPs. This paper reports results from two linked studies (in England and Scotland) investigating the early stages of the new contract. We describe the way in which four practices with different organisational approaches and espoused identities have all changed their practice structures, consultations and clinical care in response to QOF in ways which will result in patients receiving a more biomedical type of care. In spite of these observed changes, respondents continued to maintain discursive claims to holism. We discuss how this disconnection between rhetoric and reality can be maintained, and consider its implications for the future development of GPs' claims to a professional identity.

Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice

PubMed Central

Brangan, Emer; Wye, Lesley; Checkland, Kath; Lasserson, Daniel; Morris, Richard; Tammes, Peter; Purdy, Sarah

2017-01-01

Objectives To describe how processes of primary care access influence decisions to seek help at the emergency department (ED). Design Ethnographic case study combining non-participant observation, informal and formal interviewing. Setting Six general practitioner (GP) practices located in three commissioning organisations in England. Participants and methods Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29). Results Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like ‘urgent’ and ‘emergency’ was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use. Conclusions This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around ‘inappropriate’ patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups. PMID:28473509

Divisions of general practice in Australia: how do they measure up in the international context?

PubMed Central

Smith, Judith; Sibthorpe, Beverly

2007-01-01

Background Since the late 1980s, there has been evidence of an international trend towards more organised primary care. This has taken a number of forms including the emergence of primary care organisations. Underpinning such developments is an inherent belief in evidence that suggests that well-developed primary care is associated with improved health outcomes and greater cost-effectiveness within health systems. In Australia, primary care organisations have emerged as divisions of general practice. These are professionally-led, regionally-based, and largely government-funded voluntary associations of general practitioners that seek to co-ordinate local primary care services, and improve the quality of care and health outcomes for local communities. Discussion In this paper, we examine and debate the development of divisions in the international context, using six roles of primary care organisations outlined in published research. The six roles that are used as the basis for the critique are the ability of primary care organisations to: improve health outcomes; manage demand and control costs; engage primary care physicians; enable greater integration of health services; develop more accessible services in community and primary care settings; and enable greater scrutiny and assurance of quality of primary care services. Summary We conclude that there has been an evolutionary approach to divisions' development and they now appear embedded as geographically-based planning and development organisations within the Australian primary health care system. The Australian Government has to date been cautious in its approach to intervention in divisions' direction and performance. However, options for the next phase include: making greater use of contracts between government and divisions; introducing and extending proposed national quality targets for divisions, linked with financial or other incentives for performance; government sub-contracting with state-based organisations to act as purchasers of care; pursuing a fund-holding approach within divisions; and developing divisions as a form of health maintenance organisation. The challenge for the Australian Government, should it wish to see divisions' role expand, is to find mechanisms to enable this without compromising the relatively strong GP engagement that increasingly distinguishes divisions of general practice within the international experience of primary care organisations. PMID:17626642

Non-face-to-face consultations and communications in primary care: the role and perspective of general practice managers in Scotland.

PubMed

Hanna, Lisa; May, Carl; Fairhurst, Karen

2011-01-01

Practice managers play an important role in the organisation and delivery of primary care, including uptake and implementation of technologies. Little is currently known about practice managers' attitudes to the use of information and communication technologies, such as email or text messaging, to communicate or consult with patients. To investigate practice managers' attitudes to non-face-to-face consultation/communication technologies in the routine delivery of primary care and their role in the introduction and normalisation of these technologies. We carried out a mixed-methods study in Scotland, UK. We invited all practice managers in Scotland to take part in a postal questionnaire survey. A maximum variation sample of 20 survey respondents participated subsequently in in-depth qualitative interviews. Practice managers supported the use of new technologies for routine tasks to manage workload and maximise convenience for patients, but a range of contextual factors such as practice list size, practice deprivation area and geographical location affected whether managers would pursue the introduction of these technologies in the immediate future. The most common objections were medico-legal concerns and lack of perceived patient demand. Practice managers are likely to play a central role in the introduction of new consultation/communication technologies within general practice. They hold varying views on the appropriateness of these technologies, influenced by a complex mix of contextual characteristics. Managers from areas in which the ethos of the practice prioritises personalised care in service delivery are less enthusiastic about the adoption of remote consultation/communication technologies.

Developing a general ward nursing dashboard.

PubMed

Russell, Margot; Hogg, Maggie; Leach, Stuart; Penman, Mags; Friel, Susan

2014-12-15

The seventh and final article in the series on Leading Better Care explores some of the challenges in clinical practice relating to the use of data and making information meaningful to senior charge nurses and ward sisters. It describes the collaborative approach taken by NHS Lanarkshire, which involved nursing staff, programme leads and the eHealth team in the development of a general ward nursing dashboard as a means of ensuring safe, effective person-centred care. The article also illustrates how this web-based data-reporting programme is used to support clinical practice.

Newborn Care Practices among Mother-Infant Dyads in Urban Uganda

PubMed Central

Kayom, Violet Okaba; Kakuru, Abel; Kiguli, Sarah

2015-01-01

Background. Most information on newborn care practices in Uganda is from rural communities which may not be generalized to urban settings. Methods. A community based cross-sectional descriptive study was conducted in the capital city of Uganda from February to May 2012. Quantitative and qualitative data on the newborn care practices of eligible mothers were collected. Results. Over 99% of the mothers attended antenatal care at least once and the majority delivered in a health facility. Over 50% of the mothers applied various substances to the cord of their babies to quicken the healing. Although most of the mothers did not bathe their babies within the first 24 hours of birth, the majority had no knowledge of skin to skin care as a thermoprotective method. The practice of bathing babies in herbal medicine was common (65%). Most of the mothers breastfed exclusively (93.2%) but only 60.7% initiated breastfeeding within the first hour of life, while a significant number (29%) used prelacteal feeds. Conclusion. The inadequate newborn care practices in this urban community point to the need to intensify the promotion of universal coverage of the newborn care practices irrespective of rural or urban communities and irrespective of health care seeking indicators. PMID:26713096

Hypertension and Diabetes Self-care Activities: A Hospital Based Pilot Survey in Benin City, Nigeria.

PubMed

Egbi, O G; Ofili, A N; Oviasu, E

2015-06-01

The burden of hypertension and diabetes is on the increase globally with its attendant complications. Although self-care activities are critical to the successful management of both conditions, there are only a few reports on such activities, especially in this part of the world. This pilot study was therefore undertaken to assess the self-care activities among hypertensive and diabetic patients in Benin City. Hypertensive and diabetic patients were consecutively recruited from the out- patient department of the University of Benin Teaching Hospital. The questionnaires were developed based on past assessment scales such as the Hypertension Self-Care Activity Level Effects (H-SCALE) and the Summary of Diabetes Self-Care Assessment (SDSCA) for hypertensive and diabetic participants respectively. A total of 85(32 hypertensive, 24 diabetic and 29 co-morbid hypertensive diabetic) participants completed the study. Only 14 (16.5%) subjects had good self-care practice, 39 (45.9%) had fair practice while poor self-care practice was found in 32 (37.6%) subjects. Adherence to medications, clinic adherence, use of self-monitoring devices, regular exercising and dietician contact were generally low. However, only a relatively few subjects smoked tobacco or took significant alcohol. The health-related self-care practice among the patients was generally not good. There was no significant difference in the overall level of self-care among hypertensive, diabetic patients or those with co-morbid conditions. There is need for more aggressive health education aimed at improving the current health-related self-care habits among these patients.

Integrated care: theory to practice.

PubMed

Stokes, Jonathan; Checkland, Kath; Kristensen, Søren Rud

2016-10-01

'Integrated care' is pitched as the solution to current health system challenges. In the literature, what integrated care actually involves is complex and contested. Multi-disciplinary team case management is frequently the primary focus of integrated care when implemented internationally. We examine the practical application of integrated care in the NHS in England to exemplify the prevalence of the case management focus. We look at the evidence for effectiveness of multi-disciplinary team case management, for the focus on high-risk groups and for integrated care more generally. We suggest realistic expectations of what integration of care alone can achieve and additional research questions. © The Author(s) 2016.

An evaluation of experiences and views of Scottish leadership training opportunities amongst primary care professionals.

PubMed

Power, Ailsa; Allbutt, Helen; Munro, Lucy; MacLeod, Marion; Kennedy, Susan; Cameron, Donald; Scoular, Ken; Orr, Graham; Gillies, John

2017-05-01

To determine experiences of leadership training of six primary care professions in Scotland and consider future development. A questionnaire on previous leadership course attendance and future intentions was distributed to community pharmacists, general dental practitioners, general practitioners, practice nurses, practice managers and optometrists. Analysis comprised descriptive statistics for closed questions and management of textual data. Formal leadership training participation was fairly low except for practice managers. Leadership was perceived to facilitate development of staff, problem-solving and team working. Preference for future delivery was similar across the six professions with e-modules and small group learning being preferred. Time and financial pressures to undertake courses were common barriers for professionals. Leadership is key to improve quality, safety and efficiency of care and help deliver innovative services and transformative change. To date, leadership provision for primary care professionals has typically been patchy, uni-disciplinary in focus and undertaken outwith work environments. Future development must reflect needs of busy primary care professionals and the reality of team working to deliver integrated services at local level.

Health care use of patients with osteoarthritis of the hip or knee after implementation of a stepped-care strategy: an observational study.

PubMed

Smink, Agnes J; Dekker, Joost; Vliet Vlieland, Thea P M; Swierstra, Bart A; Kortland, Joke H; Bijlsma, Johannes W J; Teerenstra, Steven; Voorn, Theo B; Bierma-Zeinstra, Sita M A; Schers, Henk J; van den Ende, Cornelia H M

2014-06-01

To enhance guideline-based nonsurgical management of osteoarthritis (OA), a multidisciplinary stepped-care strategy has been implemented in clinical practice. This study aimed to describe health care use after implementation of this strategy and to identify factors related to such use at multiple levels. For this 2-year observational prospective cohort, patients with symptomatic hip or knee OA were included by their general practitioner. Activities aligned with patients and health care providers were executed to implement the strategy. Health care use was described as the cumulative percentage of "users" for each modality recommended in the strategy. Determinants were identified at the level of the patient, general practitioner, and practice using backward stepwise logistic multilevel regression models. Three hundred thirteen patients were included by 70 general practitioners of 38 practices. Their mean ± SD age was 64 ± 10 years and 120 (38%) were men. The most frequently used modalities were education, acetaminophen, lifestyle advice, and exercise therapy, which were used by 242 (82%), 250 (83%), 214 (73%), and 187 (63%) patients, respectively. Fourteen percent of the overweight patients reported being treated by a dietician. Being female, having an active coping style, using the booklet "Care for Osteoarthritis," and having limitations in functioning were recurrently identified as determinants of health care use. After implementation of the stepped-care strategy, most recommended nonsurgical modalities seem to be well used. Health care could be further improved by providing dietary therapy in overweight patients and making more efforts to encourage patients with a passive coping style to use nonsurgical modalities. Copyright © 2014 by the American College of Rheumatology.

Cost-effectiveness of a multicomponent primary care program targeting frail elderly people.

PubMed

Ruikes, Franca G H; Adang, Eddy M; Assendelft, Willem J J; Schers, Henk J; Koopmans, Raymond T C M; Zuidema, Sytse U

2018-05-16

Over the last 20 years, integrated care programs for frail elderly people aimed to prevent functional dependence and reduce hospitalization and institutionalization. However, results have been inconsistent and merely modest. To date, evidence on the cost-effectiveness of these programs is scarce. We evaluated the cost-effectiveness of the CareWell program, a multicomponent integrated care program for frail elderly people. Economic evaluation from a healthcare perspective embedded in a cluster controlled trial of 12 months in 12 general practices in (the region of) Nijmegen. Two hundred and four frail elderly from 6 general practices in the intervention group received care according to the CareWell program, consisting of multidisciplinary team meetings, proactive care planning, case management, and medication reviews; 165 frail elderly from 6 general practices in the control group received usual care. In cost-effectiveness analyses, we related costs to daily functioning (Katz-15 change score i.e. follow up score minus baseline score) and quality adjusted life years (EQ-5D-3 L). Adjusted mean costs directly related to the intervention were €456 per person. Adjusted mean total costs, i.e. intervention costs plus healthcare utilization costs, were €1583 (95% CI -4647 to 1481) higher in the intervention group than in the control group. Incremental Net Monetary Benefits did not show significant differences between groups, but on average tended to favour usual care. The CareWell primary program was not cost-effective after 12 months. From a cost-effectiveness perspective, widespread implementation of the program in its current form cannot be recommended. The study was registered in the ClinicalTrials.govProtocol Registration System: ( NCT01499797 ; December 26, 2011). Retrospectively registered.

Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals?

PubMed

Cumming, Jacqueline; Mays, Nicholas; Gribben, Barry

2008-11-06

In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005. Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices. The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.

Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals?

PubMed Central

Cumming, Jacqueline; Mays, Nicholas; Gribben, Barry

2008-01-01

Background In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005. Results Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices. Conclusion The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care. PMID:18990236

Making the links between domestic violence and child safeguarding: an evidence-based pilot training for general practice.

PubMed

Szilassy, Eszter; Drinkwater, Jess; Hester, Marianne; Larkins, Cath; Stanley, Nicky; Turner, William; Feder, Gene

2017-11-01

We describe the development of an evidence-based training intervention on domestic violence and child safeguarding for general practice teams. We aimed - in the context of a pilot study - to improve knowledge, skills, attitudes and self-efficacy of general practice clinicians caring for families affected by domestic violence. Our evidence sources included: a systematic review of training interventions aiming to improve professional responses to children affected by domestic violence; content mapping of relevant current training in England; qualitative assessment of general practice professionals' responses to domestic violence in families; and a two-stage consensus process with a multi-professional stakeholder group. Data were collected between January and December 2013. This paper reports key research findings and their implications for practice and policy; describes how the research findings informed the training development and outlines the principal features of the training intervention. We found lack of cohesion and co-ordination in the approach to domestic violence and child safeguarding. General practice clinicians have insufficient understanding of multi-agency work, a limited competence in gauging thresholds for child protection referral to children's services and little understanding of outcomes for children. While prioritising children's safety, they are more inclined to engage directly with abusive parents than with affected children. Our research reveals uncertainty and confusion surrounding the recording of domestic violence cases in families' medical records. These findings informed the design of the RESPONDS training, which was developed in 2014 to encourage general practice clinicians to overcome barriers and engage more extensively with adults experiencing abuse, as well as responding directly to the needs of children. We conclude that general practice clinicians need more support in managing the complexity of this area of practice. We need to integrate and further evaluate responses to the needs of children exposed to domestic violence into general practice-based domestic violence training. © 2016 The Authors. Health and Social Care in the Community Published by John Wiley & Sons Ltd.

Economic influences on GPs' decisions to provide out-of-hours care.

PubMed

Geue, Claudia; Skåtun, Diane; Sutton, Matt

2009-01-01

Introduction of the new general medical services contract offered UK general practices the option to discontinue providing out-of-hours (OOH) care. This aimed to improve GP recruitment and retention by offering a better work-life balance, but put primary care organisations under pressure to ensure sustainable delivery of these services. Many organisations arranged this by re-purchasing provision from individual GPs. To analyse which factors influence an individual GP's decision to re-provide OOH care when their practice has opted out. Cross-sectional questionnaire survey. Rural and urban general practices in Scotland, UK. A postal survey was sent to all GPs working in Scotland in 2006, with analyses weighted for differential response rates. Analysis included logistic regression of individuals' decisions to re-provide OOH care based on personal characteristics, work and non-work time commitments, income from other sources, and contracting primary care organisation. Of the 1707 GPs in Scotland whose practice had opted out, 40.6% participated in OOH provision. Participation rates of GPs within primary care organisations varied from 16.7% to 74.7%. Males with young children were substantially more likely to participate than males without children (odds ratio [OR] 2.44, 95% confidence interval [CI] = 1.36 to 4.40). GPs with higher-earning spouses were less likely to participate. This effect was reinforced if GPs had spouses who were also GPs (OR 0.52, 95% CI = 0.37 to 0.74). GPs with training responsibilities (OR 1.36, 95% CI = 1.09 to 1.71) and other medical posts (OR 1.38, 95% CI = 1.09 to 1.75) were more likely to re-provide OOH services. The opportunity to opt out of OOH care has provided flexibility for GPs to raise additional income, although primary care organisations vary in the extent to which they offer these opportunities. Examining intrinsic motivation is an area for future study.

[Collaboration between Medicine and Psychology: Evolving Mentalities in Belgium and Evolution of the Health Care System in Canada].

PubMed

Chomienne, Marie-Hélène; Vanneste, Patrick; Grenier, Jean; Hendrick, Stephan

Objectives 1) To give a portrait of the evolving mentalities prevailing in Belgium on the collaboration between psychologists and general practitioners, and identify the barriers to the development of the collaboration between those two health professionals 2) To report on the primary care reform in Canada, its role in fostering collaborative practice in primary mental health and on the strategies needed to improve collaboration.Methods Literature search using PubMed and Google Scholar.Results Because of the unmet need of psychologists in primary care, general practitioners and psychologists have a propensity to work together. However to facilitate the collaborative process there needs to be system changes and clear definition of scopes of practices. Both countries are at different levels of implementing change. In Belgium for example it is only very recently that the autonomous practice of clinical psychology has been acknowledged. In Canada although the primary care reform has put forward and supported collaborative care, focus on mental health is insufficient. Early reports on collaborative care in the new models of care inconsistently report improved health outcomes. Strategies to improve collaborative care are looking at teaching future health professionals on how to work together by integrating inter-professional education.Conclusion Both the health care system and graduate training need to support foster and teach collaborative care.

Integrated care for asthma: a clinical, social, and economic evaluation. Grampian Asthma Study of Integrated Care (GRASSIC)

PubMed Central

1994-01-01

OBJECTIVES--To evaluate integrated care for asthma in clinical, social, and economic terms. DESIGN--Pragmatic randomised trial. SETTING--Hospital outpatient clinics and general practices throughout the north east of Scotland. PATIENTS--712 adults attending hospital outpatient clinics with a diagnosis of asthma confirmed by a chest physician and pulmonary function reversibility of at least 20%. MAIN OUTCOME MEASURES--Use of bronchodilators and inhaled and oral steroids; number of general practice consultations and hospital admissions for asthma; sleep disturbance and other restrictions on normal activity; psychological aspects of health including perceived asthma control; patient satisfaction; and financial costs. RESULTS--After one year there were no significant overall differences between those patients receiving integrated asthma care and those receiving conventional outpatient care for any clinical or psychosocial outcome. For pulmonary function, forced expiratory volume was 76% of predicted for integrated care patients and 75% for conventional outpatients (95% confidence interval for difference -3.6% to 5.0%). Patients who had experienced integrated care were more likely to select it as their preferred course of future management (75% (251/333) v 62% (207/333) (6% to 20%)); they saved 39.52 pounds a year. This was largely because patients in conventional outpatient care consulted their general practitioner as many times as those in integrated care, who were not also visiting hospital. CONCLUSION--Integrated care for moderately severe asthma patients is clinically as effective as conventional outpatient care, cost effective, and an attractive management option for patients, general practitioners, and hospital consultants. PMID:8148678

General practice recruitment for people at risk of schizophrenia: the Buckingham experience.

PubMed

Falloon, I R

2000-11-01

The process of detecting people at high risk of schizophrenia from a community sample is a major challenge for prevention of psychotic disorders. The aim of this paper is to describe early detection procedures that can be implemented in primary care settings. A selected literature review is supplemented by experiences and data obtained during the Buckingham Integrated Mental Health Care Project. General medical practitioners have been favoured as the agents most likely to prove helpful in detecting the key risk factors that predict the onset of schizophrenic disorders, as well as in recognising the earliest signs and symptoms of these conditions. However, the practical problems of screening for multiple and subtle risk factors in general practice are substantial, and general practitioners (GPs) often have difficulty recognising the earliest signs of a psychotic episode. A range of strategies to assist GPs detect early signs of psychosis in their patients are considered. It is feasible to implement primary care setting early detection procedures for people at risk of schizophrenia. Implementation is aided by the use of a brief screening questionnaire, training sessions and case supervision; and increased collaboration with mental health services and other community agencies.

How psychosocial factors affect well-being of practice assistants at work in general medical care?--a questionnaire survey.

PubMed

Goetz, Katja; Berger, Sarah; Gavartina, Amina; Zaroti, Stavria; Szecsenyi, Joachim

2015-11-11

Well-being at work is an important aspect of a workforce strategy. The aim of the study was to explore and evaluate psychosocial factors and health and work-related outcomes of practices assistants depending on their employment status in general medical practices. This observational study was based on a questionnaire survey to evaluate psychosocial aspects at work in general medical practices. A standardized questionnaire was used, the Copenhagen Psychosocial Questionnaire (COPSOQ). Beside descriptive analyses linear regression analyses were performed for each health and work-related outcome scale of the COPSOQ. 586 practice assistants out of 794 respondents (73.8 %) from 234 general medical practices completed the questionnaire. Practice assistants reported the highest scores for the psychosocial factor 'sense of community' (mean = 85.9) and the lower score for 'influence at work' (mean = 41.2). Moreover, practice assistants who worked part-time rated their psychosocial factors at work and health-related outcomes more positively than full-time employees. Furthermore, the two scales of health related outcomes 'burnout' and 'job satisfaction' showed strong associations between different psychosocial factors and socio-demographic variables. Psychosocial factors at work influence well-being at work and could be strong risk factors for poor health and work-related outcomes. Effective management of these issues could have an impact on the retention and recruitment of health care staff.

Advanced training for primary care and general practice nurses: enablers and outcomes of postgraduate education.

PubMed

Hallinan, Christine M; Hegarty, Kelsey L

2016-01-01

The aims of the present study were to understand enablers to participation in postgraduate education for primary care nurses (PCNs), and to explore how postgraduate education has advanced their nursing practice. Cross-sectional questionnaires were mailed out in April 2012 to current and past students undertaking postgraduate studies in primary care nursing at The University of Melbourne, Victoria, Australia. Questionnaires were returned by 100 out of 243 nurses (response rate 41%). Ninety-one per cent (91/100) of the respondents were first registered as nurses in Australia. Fifty-seven per cent were hospital trained and 43% were university educated to attain their initial nurse qualification. The respondents reported opportunities to expand scope of practice (99%; 97/98), improve clinical practice (98%; 97/99), increase work satisfaction (93%; 91/98) and increase practice autonomy (92%; 89/97) as factors that most influenced participation in postgraduate education in primary care nursing. Major enablers for postgraduate studies were scholarship access (75%; 71/95) and access to distance education (74%; 72/98). Many respondents reported an increased scope of practice (98%; 95/97) and increased job satisfaction (71%; 70/98) as an education outcome. Only 29% (28/97) cited an increase in pay-rate as an outcome. Of the 73 PCNs currently working in general practice, many anticipated an increase in time spent on the preparation of chronic disease management plans (63%; 45/72), multidisciplinary care plans (56%; 40/72) and adult health checks (56%; 40/72) in the preceding 12 months. Recommendations emerging from findings include: (1) increased access to scholarships for nurses undertaking postgraduate education in primary care nursing is imperative; (2) alternative modes of course delivery need to be embedded in primary care nursing education; (3) the development of Australian primary care policy, including policy on funding models, needs to more accurately reflect the educational level of PCNs, PCN role expansion and the extent of interprofessional collaboration that is evident from research undertaken to date. Nurses with postgraduate education have the potential to increase their scope of practice, take on a greater teaching role and provide more preventive and chronic disease services in primary care. Policies aimed at increasing access to education for nurses working in primary care would strengthen the primary care nursing profession, and enhance the delivery of primary health care services in Australia.

Accountable care organizations and prostate cancer care.

PubMed

Hollenbeck, Brent K; Kaufman, Samuel R; Borza, Tudor; Yan, Phyllis; Herrel, Lindsey A; Miller, David C; Luckenbaugh, Amy N; Skolarus, Ted A; Shahinian, Vahakn B

2017-11-01

Accountable care organizations have the potential to increase the value of healthcare by improving population health and enhanced financial stewardship. How practice context modifies effects on a specialty-focused disease, such as prostate cancer care, has implications for their success. We performed a retrospective cohort study of newly diagnosed men with prostate cancer between 2012 and 2013 using national Medicare data. Practice affiliation (small single-specialty, large single-specialty, multispecialty groups) and accountable care organization alignment were measured at the patient level. Generalized linear multivariable models were fitted to derive adjusted rates of treatment and spending for the 12-month period after diagnosis according to accountable care organization alignment and practice affiliation. Of 15,640 patients with newly diagnosed prostate cancer, 1,100 (7.0%) were aligned with accountable care organizations. Patients in these organizations had similar use of curative treatment to those not in accountable care organizations (71.4% vs. 70.0%, respectively; p=0.33), which did not vary with practice affiliation (p=0.39). Adjusted spending was higher among patients in accountable care organizations ($20,916 vs. $19,773, p=0.03); however, this relationship was independent of the practice affiliation (p=0.90). Higher accountable care organization penetration within a practice was associated with increased spending (p<0.05) but not with treatment (p=0.87). Prostate cancer patients aligned with accountable care organizations had similar rates of treatment, but increased spending, in the year following diagnosis. These findings were similar across practice affiliations. Better specialist engagement by accountable care organizations may be necessary for them to alter practice patterns for specialty care.

Critical care nurses' knowledge and practice of delirium assessment.

PubMed

Rowley-Conwy, Gabby

2017-04-13

The aim of this study was to examine perceived barriers to assessment of delirium for critical care nurses, and the impact of education on their knowledge and practice. Delirium is a significant problem in critical care, leading to increased morbidity and mortality. Many authors have found variations in assessment by critical care nurses, but there has been limited analysis of the reasons for this. Education on the topic improves knowledge and practice, but the best approach has not been examined. A questionnaire survey design. A self-reported questionnaire was distributed to critical care nurses (n=31) at a district general hospital. Data were analysed with descriptive statistics. Knowledge and practice were variable, but correlation was seen between nursing band and years of experience with better scores. Any type of education led to significantly improved scores. Several barriers to assessment were found, with the most common being lack of knowledge and difficulty in assessing intubated patients. It is essential to improve practice in delirium assessment and management. Education is vital to improve the knowledge and practice of critical care nurses regarding delirium.

Nursing practice environment, quality of care, and morale of hospital nurses in Japan.

PubMed

Anzai, Eriko; Douglas, Clint; Bonner, Ann

2014-06-01

The purpose of this study was to describe Japanese hospital nurses' perceptions of the nursing practice environment and examine its association with nurse-reported ability to provide quality nursing care, quality of patient care, and ward morale. A cross-sectional survey design was used including 223 nurses working in 12 acute inpatient wards in a large Japanese teaching hospital. Nurses rated their work environment favorably overall using the Japanese version of the Practice Environment Scale of the Nursing Work Index. Subscale scores indicated high perceptions of physician relations and quality of nursing management, but lower scores for staffing and resources. Ward nurse managers generally rated the practice environment more positively than staff nurses except for staffing and resources. Regression analyses found the practice environment was a significant predictor of quality of patient care and ward morale, whereas perceived ability to provide quality nursing care was most strongly associated with years of clinical experience. These findings support interventions to improve the nursing practice environment, particularly staffing and resource adequacy, to enhance quality of care and ward morale in Japan. © 2013 Wiley Publishing Asia Pty Ltd.

[Tests and scales: restrains to use them by general practitioners. Descriptive transversal study].

PubMed

Cario, Camille; Levesque, Jean-Louis; Bouche, Gauthier

2010-12-20

Tests, even though recommended, are only few used by general practitioners (GP's). The aim of this study was to understand the reasons of this underuse. Descriptive transversal study, to explore knowledge, use and restrains to using ten tests related in the first 50 results of consultation in general practice. We questioned 121 GP's from Charente, selected ad random. The oldest tests (MMS, MNA, Fagerström, mini-GDS, IPSS, depression) are known by more than half of the GP's. Only one third is familiar with more recent tests devoted to ambulatory care (TSTS, FACE, venous thromboembolic risk), which are also used less (20% at most). Systematic use of all tests mixed up, never exceeds 30% of all GP's. The principal restrain to use these tests is lack of training (53%), which seems indeed to be inefficient in this domain; 20 to 60% of GP's who know the tests, do not use them, mainly because of doubts regarding their usefulness (38%). What really is the utility of these tests in ambulatory care? Their validity in general practice shows some gaps: their validation results seldom on studies conducted in primary care, impact studies to evaluate the benefits for patients are lacking, and tests designed for specific use by GP's are rare and lacking in validity. Development of research in primary care in this field would be desirable in order to develop relevant, feasible and acceptable tools to help decision making in general practice.

Considerations for Providing Ambulatory Pharmacy Services for Pediatric Patients.

PubMed

Lampkin, Stacie J; Gildon, Brooke; Benavides, Sandra; Walls, Kelly; Briars, Leslie

2018-01-01

Pediatric clinical pharmacists are an integral part of the health care team. By practicing in an ambulatory care clinic, they can reduce the risk of medication errors, improve health outcomes, and enhance patient care. Unfortunately, because of limited data, misconceptions surrounding the role of pharmacists, and reimbursement challenges, there may be difficulty in establishing or expanding pediatric clinical pharmacy services to an ambulatory care setting. The purpose of this paper is to provide an overview of considerations for establishing or expanding pharmacy services in a pediatric ambulatory care clinic. The primer will discuss general and pediatric-specific pharmacy practice information, as well as potential barriers, and recommendations for identifying a practice site, creating a business plan, and integrating these services into a clinic setting.

Gathering, strategizing, motivating and celebrating: the team huddle in a teaching general practice.

PubMed

Walsh, Allyn; Moore, Ainsley; Everson, Jennifer; DeCaire, Katharine

2018-03-01

To understand how implementing a daily team huddle affected the function of a complex interprofessional team including learners. A qualitative descriptive study using semi-structured interviews in focus groups. An academic general practice teaching practice. All members of one interprofessional team, including nurses, general practitioners, junior doctors, and support staff. Focus group interviews using semi-structured guidance were transcribed and the results analysed using qualitative content analysis. Four interrelated themes were identified: communication and knowledge sharing; efficiency of care; relationship and team building; and shared responsibility for team function. The implementation of the daily team huddle was seen by participants to enhance the collaboration within the team and to contribute to work life enjoyment. Participants perceived that problems were anticipated and solved quickly. Clinical updates and information about patients benefited the team including learners. Junior doctors quickly understood the scope of practice of other team members, but some felt reluctant to offer clinical opinions. The implementation of a daily team huddle was viewed as worthwhile by this large interprofessional general practice team. The delivery of patient care was more efficient, knowledge was readily distributed, and problem solving was shared across the team, including junior doctors.

Perceptions of pharmacists' role in the health care team through student-pharmacist led point-of-care screenings and its future application in health care.

PubMed

Bastianelli, Karen M S; Nelson, Lucas; Palombi, Laura

The public is largely unaware of changing pharmacy roles and continues to underutilize pharmacists as mainly a dispensing service, often overlooking direct patient care components. This paper evaluates the public perceptions of pharmacists' through student led point-of-care screenings and comprehensive medication reviews. An IRB approved longitudinal retrospective study design was used to survey participants who attended College of Pharmacy sponsored health fairs in 2013. The survey contained questions related to patient understanding of the current pharmacy scope of practice, patient's reported level of comfort with the expanding roles of pharmacy, insurance coverage, demographics, income and whom the patients report that they seek first for medical related advice. One hundred participants were surveyed. By a large majority, the health care practitioner that patients reported that they currently sought out for general health information was a physician. All of the participants reported that they considered pharmacists as reliable sources of general health information. Of the 96 participants that completed the survey question regarding their willingness to seek out a pharmacist in the future to have their blood pressure, blood sugar, cholesterol, and/or bone density checked, 89 (92.7%) surveyed answered yes. Only 50 patients (50%) reported being aware that pharmacists have the capability to perform these point-of-care screenings. Participants responded that they felt "comfortable" (78 patients, 83.4%) followed by "trusting" (36 patients, 38.7%). The patients surveyed recognized pharmacists as the medication experts; however, many did not understand the capacity to which pharmacists' scope of practice allows them to deliver care to patients. In this study, almost all of the patients stated that they would consider seeking out a pharmacist to receive point-of-care screenings, but only half were aware that a pharmacist is capable of conducting these screenings. All felt that pharmacists are a reliable source of general health information and medication related needs, regardless of the patients' education level or household income. With the shortage of primary care providers, expansion of the scope of pharmaceutical practice is necessary. Although the public may not fully understand pharmacists' scope of practice, they are comfortable with pharmacists' knowledge related to general health needs outside of medications. The reported public comfort and trust of pharmacist knowledge and skills justify expanding the scope of pharmaceutical practice. Copyright © 2017 Elsevier Ltd. All rights reserved.

Relationship between quality of care and choice of clinical computing system: retrospective analysis of family practice performance under the UK's quality and outcomes framework.

PubMed

Kontopantelis, Evangelos; Buchan, Iain; Reeves, David; Checkland, Kath; Doran, Tim

2013-08-02

To investigate the relationship between performance on the UK Quality and Outcomes Framework pay-for-performance scheme and choice of clinical computer system. Retrospective longitudinal study. Data for 2007-2008 to 2010-2011, extracted from the clinical computer systems of general practices in England. All English practices participating in the pay-for-performance scheme: average 8257 each year, covering over 99% of the English population registered with a general practice. Levels of achievement on 62 quality-of-care indicators, measured as: reported achievement (levels of care after excluding inappropriate patients); population achievement (levels of care for all patients with the relevant condition) and percentage of available quality points attained. Multilevel mixed effects multiple linear regression models were used to identify population, practice and clinical computing system predictors of achievement. Seven clinical computer systems were consistently active in the study period, collectively holding approximately 99% of the market share. Of all population and practice characteristics assessed, choice of clinical computing system was the strongest predictor of performance across all three outcome measures. Differences between systems were greatest for intermediate outcomes indicators (eg, control of cholesterol levels). Under the UK's pay-for-performance scheme, differences in practice performance were associated with the choice of clinical computing system. This raises the question of whether particular system characteristics facilitate higher quality of care, better data recording or both. Inconsistencies across systems need to be understood and addressed, and researchers need to be cautious when generalising findings from samples of providers using a single computing system.

Nurse practice environment, workload, burnout, job outcomes, and quality of care in psychiatric hospitals: a structural equation model approach.

PubMed

Van Bogaert, Peter; Clarke, Sean; Willems, Riet; Mondelaers, Mieke

2013-07-01

To study the relationships between nurse practice environment, workload, burnout, job outcomes and nurse-reported quality of care in psychiatric hospital staff. Nurses' practice environments in general hospitals have been extensively investigated. Potential variations across practice settings, for instance in psychiatric hospitals, have been much less studied. A cross-sectional design with a survey. A structural equation model previously tested in acute hospitals was evaluated using survey data from a sample of 357 registered nurses, licensed practical nurses, and non-registered caregivers from two psychiatric hospitals in Belgium between December 2010-April 2011. The model included paths between practice environment dimensions and outcome variables, with burnout in a mediating position. A workload measure was also tested as a potential mediator between the practice environment and outcome variables. An improved model, slightly modified from the one validated earlier in samples of acute care nurses, was confirmed. This model explained 50% and 38% of the variance in job outcomes and nurse-reported quality of care respectively. In addition, workload was found to play a mediating role in accounting for job outcomes and significantly improved a model that ultimately explained 60% of the variance in these variables. In psychiatric hospitals as in general hospitals, nurse-physician relationship and other organizational dimensions such as nursing and hospital management were closely associated with perceptions of workload and with burnout and job satisfaction, turnover intentions, and nurse-reported quality of care. Mechanisms linking key variables and differences across settings in these relationships merit attention by managers and researchers. © 2012 Blackwell Publishing Ltd.

How do general practitioners experience providing care to refugees with mental health problems? A qualitative study from Denmark

PubMed Central

2013-01-01

Background Refugees are a particularly vulnerable group in relation to the development of mental illness and many may have been subjected to torture or other traumatic experiences. General practitioners are gatekeepers for access to several parts of the psychiatric system and knowledge of their patients’ refugee background is crucial to secure adequate care. The aim of this study is to investigate how general practitioners experience providing care to refugees with mental health problems. Methods The study was conducted as part of an EU project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). Semi-structured interviews were carried out with nine general practitioners in the vicinity of Copenhagen purposively selected from areas with a high proportion of immigrants. The analysis of the interviews is inspired by qualitative content analysis. Results One of the main themes identified in the analysis is communication. This includes the use of professional interpreters and that communication entails more than sharing a common language. Quality of care is another theme that emerges and includes awareness of possible trauma history, limited possibilities for refugees to participate in certain treatments due to language barriers and feelings of hopelessness in the general practitioners. The general practitioners may also choose different referral pathways for refugees and they report that their patients lack understanding regarding the differences between psychological problems and physical symptoms. Conclusion General practitioners experience that providing care to refugees differs from providing care for patients from the majority population. The different strategies employed by the general practitioners in the health care treatment of refugees may be the result of the great diversity in the organisation of general practice in Denmark and the lack of a national strategy in the health care management of refugees. The findings from this study suggest that the development of conversational models for general practitioners including points to be aware of in the treatment of refugee patients may serve as a support in the management of refugee patients in primary care. PMID:23356401

'…a one stop shop in their own community': Medical abortion and the role of general practice.

PubMed

Newton, Danielle; Bayly, Chris; McNamee, Kathleen; Bismark, Marie; Hardiman, Annarella; Webster, Amy; Keogh, Louise

2016-12-01

The introduction to Australia of modern medical abortion methods, which require less specialist expertise and equipment than the more traditional surgical methods, have brought an as yet unrealised potential to improve access to abortion services. To investigate the potential for expanding the role of general practice in the provision of medical abortion in Victoria. In 2015, in-depth interviews were conducted with 19 experts in abortion service provision in Victoria. A semi-structured interview schedule was used to guide the interviews. Interviews were transcribed verbatim and transcripts analysed thematically. Participants were largely very supportive of the provision of early medical abortion in general practice as a way of increasing abortion access for women, particularly in rural and regional communities. Access to abortion was seen as an essential component of women's comprehensive health care and therefore general practitioners (GPs) were perceived as ideally placed to provide this service. However, this would require development and implementation of new service models, careful consideration of GP and nurse roles, strengthening of partnerships with other health professionals and services in the community, and enhanced training, support and mentoring for clinicians. The application of these findings by relevant health services and agencies has the potential to increase provision of medical abortion services in general practice settings, better meeting the health-care needs of women seeking this service. © 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

A cluster randomised controlled trial evaluating the effectiveness of a structured pulmonary rehabilitation education programme for improving the health status of people with chronic obstructive pulmonary disease (COPD): The PRINCE Study protocol.

PubMed

Murphy, Kathy; Casey, Dympna; Devane, Declan; Cooney, Adeline; McCarthy, Bernard; Mee, Lorraine; Nichulain, Martina; Murphy, Andrew W; Newell, John; O' Shea, Eamon

2011-01-18

A key strategy in improving care for people with chronic obstructive pulmonary disease (COPD) is the provision of pulmonary rehabilitation programmes. Pulmonary rehabilitation programmes have been successful in improving patients' sense of dyspnoea and Health Related Quality of Life. However, the effectiveness of structured education pulmonary rehabilitation programmes delivered at the level of the general practice on the health status of people with COPD remains uncertain and there is a need for a robust and fair assessment of this. The PRINCE study will evaluate the effectiveness of a Structured Education Pulmonary Rehabilitation Programme (SEPRP), delivered at the level of the general practice, on the health status of people with COPD. The PRINCE Trial is a two-armed, single blind cluster randomised trial conducted in the primary care setting in Ireland. Randomisation to control and intervention is at the level of the General Practice. Participants in the intervention arm will receive a SEPRP and those allocated to the control arm will receive usual care. Delivery of the SEPRP will be by a practice nurse and physiotherapist in the General Practice (GP) site. The primary outcome measure of the study will be health status as measured by the Chronic Respiratory Questionnaire (CRQ). Blinded outcome assessment will be undertaken at baseline and at twelve-fourteen weeks after completion of the programme. A comparison of outcomes between the intervention and control sites will be made to examine if differences exist and, if so, to what extent between control and experimental groups. Sample size calculations estimate that 32 practices with a minimum of 10 participants per practice are required, in total, to be randomised to control and intervention arms for power of at least 80% with alpha levels of 0.05, to determine a clinically significant change of 0.5 units in the CRQ. A cost effectiveness analysis will also be conducted. The results of this trial are directly applicable to primary care settings in Ireland. Should a SEPRP delivered by practice nurses and physiotherapists in primary care be found to be effective in improving patients' sense of dyspnoea and HRQoL, then the findings would be applicable to many thousands of individuals in Ireland and beyond.

Meeting the educational needs of general practitioners for epilepsy.

PubMed

Chappell, B; Smithson, H

1999-05-01

Epilepsy care in general practice has been criticized, but what do GPs feel they deal with most and complete satisfactorily? If criticism is justified, education should be useful in improving epilepsy care, but what do general practitioners want to learn and how do they want to learn it? Questionnaires about these issues were sent to randomly chosen general practitioners throughout the United Kingdom. One hundred and twenty-four out of 200 (62%) responded. They were not biased by age, sex, type of practice or previous interest in epilepsy. Drug treatment and regular review were the two areas of care GPs said they dealt with most, but only half felt they dealt with them well. Sixty-six percent wanted to learn more about drug treatment, 46% about lifestyle advice, 45% about non-drug treatment, 44% about diagnosis and only 16% did not want to learn more about any aspect of care. Weekdays and evenings were the preferred times for study. Courses up to one full day away from practices were popular, distance learning and personal education plans were not, except for a group of younger GPs. When attending courses multi-disciplinary lectures rated highly and nearly three-quarters preferred to attend courses where epilepsy was covered in conjunction with other conditions. Future epilepsy education for GPs should recognize these findings if attendance and positive outcomes are to be maximized. Copyright 1999 BEA Trading Ltd.

Themes and methods of research presented at European General Practice Research Network conferences.

PubMed

Kruschinski, Carsten; Lange, Maaike; Lionis, Christos; van Weel, Chris; Hummers-Pradier, Eva

2010-08-01

The World Organization of Family Doctors (Wonca) defined core characteristics of general practice and general practitioners' competencies. It is unclear to which extent research has addressed these issues so far. To determine themes and research methods of general practice research as reflected by presentations at the European General Practice Research Network (EGPRN) meetings. Descriptive and retrospective study. All abstracts presented at each of the 14 EGPRN conferences between June 2001 and October 2007 were analysed for content and study design/methodology. Categories for content were developed inductively; a predefined hierarchical scheme was used for study designs. A total of N=614 abstracts were classified. The main research topics were related to GP/health service issues (n=232), clinical (n=148) and patient-related themes (n=118). Original data (n=558) were mainly derived from cross-sectional designs (38.7%). Intervention studies (11.0%), longitudinal designs including case-control and cohort studies (13.3%) as well as instrumental research (2.2%) were less common. More than one-fourth of all original studies were qualitative studies (27.6%). Stratified analysis revealed that cross-sectional designs were less frequent in the second half of conferences. Analysis by country showed that, in contrast to different quantitative designs, the proportion of qualitative studies was comparable. To test effectiveness of diagnostic and therapeutic interventions under primary care conditions, a higher proportion of experimental studies would be preferable. This could increase the acceptance of general practitioners' specific approaches and provide clear guidance on approaches and procedures, especially in health care systems not predominantly based on primary care.

Fundamentals of liver surgery for the practicing general surgeon.

PubMed

Cofer, Joseph B; Adams, Reid B

2010-05-01

This review focuses on the common general surgical referral problem of an undefined liver lesion. Understanding the clinical context in which the patient presents allows one to narrow the differential diagnosis and develop a focused evaluation plan. Most often, MRI is the most helpful initial study to define the likely diagnosis. If the appropriate radiologic expertise exists locally, most of the diagnostic evaluation, if not all, is feasible by a practicing general surgeon. Likewise, understanding the fundamentals of liver anatomy and physiology will facilitate the general surgeons' ability to evaluate the patient's imaging and liver reserve to decide whether local surgical care can be done safely. If local care is not available or safe, referral to a hepatobiliary specialist is appropriate. Ultimately, it is most important for the general surgeon contemplating surgery on the liver to understand his or her own limitations and the limits of their institutions' capabilities in providing pre- and postoperative care. It is particularly important to understand the pitfalls associated with decision-making for complex hepatobiliary problems and when considering an operation on anybody with significant intrinsic liver disease. When faced with these scenarios, the practicing general surgeon should always raise the question: "Is this patient better served at a hepatobiliary center or one that offers liver transplant?" If yes, a phone call, if not a referral, to a tertiary center to discuss the case is reasonable before embarking on a potentially hazardous operation.

Childbearing and child care in surgery.

PubMed

Mayer, K L; Ho, H S; Goodnight, J E

2001-06-01

The responsibility for childbearing and child care has a major effect on general surgical residency and subsequent surgical practice. A survey of all graduates from a university general surgical training program between 1989 and 2000. Twenty-seven women and 44 men completed general surgical training at our university during the period, and 42 (59%) responded to our survey. The age at completion of the residency was 34.0 +/- 2.2 years for men and 33.9 +/- 2.8 years for women. During residency, 64% (14/22) of the men and 15% (3/20) of the women had children. At the time of the survey, 21 (95%) of the men and 8 (40%) of the women had children. Most residents (24 [57%] of 42) relied on their spouse for child care. During surgical practice, 18 (43%) indicated that they rely on their spouse; 19 (45%) use day care, home care, or both; and (8%) of 26 are unsatisfied with their current child care arrangement. During training, 38% (5/13) of men and 67% (2/3) of women took time off for maternity leave, paternity leave, or child care. Two of 3 surgeons would like to have had more time off during residency; most men (70%, or 7 of 10) recommended a leave of 1 to 3 months, and all women preferred a 3-month maternity or child care leave of absence. During surgical practice, only 12% (2/17) of men but 64% (7/11) of women have taken time off for either childbearing or child care. Half of the respondents (21/42) have a formal leave of absence policy at work, 52% (11/21) of which are paid leave programs. Although the workweek of our practicing graduates is 69 +/- 16 hours for men and 64 +/- 12 hours for women, 62% (26/42) spend more than 20 hours per week parenting. More than 80% (27/32) would consider a part-time surgical practice for more parenting involvement; one third of the responders suggested that 30 hours a week constitutes a reasonable part-time practice, one third preferred fewer than 30 hours, and one third favored more than 30 hours per week. Data are presented as mean +/- SD. Childbearing and child care may have an enormous impact on one's decision to pursue a career in surgery. To attract and retain the best candidates for future surgeons, formal policies on the availability of child care services in the residency program and the workplace should be studied and implemented. Furthermore, national studies are needed to define appropriate, acceptable workweeks for part-time or flexible practices and the duration of leaves of absence for childbearing or child care.

Safe sleep practices and sudden infant death syndrome risk reduction: NICU and well-baby nursery graduates.

PubMed

Fowler, Aja J; Evans, Patricia W; Etchegaray, Jason M; Ottenbacher, Allison; Arnold, Cody

2013-11-01

Our primary objective was to compare parents of infants cared for in newborn intensive care units (NICUs) and infants cared for in well-baby ("general") nurseries with regard to knowledge and practice of safe sleep practices/sudden infant death syndrome risk reduction measures and guidelines. Our secondary objective was to obtain qualitative data regarding reasons for noncompliance in both populations. Sixty participants (30 from each population) completed our survey measuring safe sleep knowledge and practice. Parents of NICU infants reported using 2 safe sleep practices-(a) always placing baby in crib to sleep and (b) always placing baby on back to sleep-significantly more frequently than parents of well infants. Additional findings and implications for future studies are discussed.

Is the faculty of family planning and reproductive health care guidance on emergency contraception being followed in general practice? An audit in the West Midlands, UK.

PubMed

Bannister, Lisa; Macve, Joanna; Pinkey, Benjamin; Webberley, Helen

2007-07-01

In 2003, the Faculty of Family Planning and Reproductive Health Care (FFPRHC) of the Royal College of Obstetricians and Gynaecologists published guidance on emergency contraception (EC). A literature search revealed no published work describing doctors' actions when prescribing EC. In order to assess the extent to which the FFPRHC Guidance is being followed in general practice, an audit of the medical notes of women requesting EC between January 2003 and December 2004 in six general practice surgeries located in the West Midlands, UK was conducted. From the medical notes, discussions between health care professionals and patients requesting EC regarding ongoing contraceptive needs, the risk of sexually transmitted infections (STIs) and the availability of the emergency intrauterine device (IUD) were recorded. A total of 718 emergency contraceptive pill consultations were analysed. The median age for presentation was 24 years. The 20-24 years age group accounted for the most consultations (30.9%). In 40% of consultations there was no evidence of future contraceptive needs having been discussed. Only 20 (2.8%) consultation notes contained evidence that STIs had been discussed. Chlamydia tests were undertaken in only 15/718 (1.7%) consultations. In only 10 (1.4%) of the consultations was the IUD discussed with the patient as an alternative form of EC. This audit suggests that the FFPRHC Guidance on EC is not being followed in general practice, and therefore patients requesting EC may not be receiving the highest standard of care.

Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data

PubMed Central

Cowling, Thomas E; Harris, Matthew; Watt, Hilary; Soljak, Michael; Richards, Emma; Gunning, Elinor; Bottle, Alex; Macinko, James; Majeed, Azeem

2016-01-01

Background The UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes. Objective To determine whether primary care access is associated with the route of emergency admission—via a GP versus via an A and E department. Methods Retrospective analysis of national administrative data from English hospitals for 2011–2012. Adults admitted in an emergency (unscheduled) for ≥1 night via a GP or an A and E department formed the study population. The measure of primary care access—the percentage of patients able to get a general practice appointment on their last attempt—was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics. Results The analysis included 2 322 112 emergency admissions (81.9% via an A and E department). With a 5 unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ≥95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139 673 fewer GP admissions (456 232 vs 316 559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England. Conclusions Among hospital inpatients admitted as an emergency, patients registered to more accessible general practices were more likely to have been admitted via a GP (vs an A and E department). This furthers evidence suggesting that access to general practice is related to use of emergency hospital services in England. The relative merits of the two admission routes remain unclear. PMID:26306608

A cohort study of influences, health outcomes and costs of patients' health-seeking behaviour for minor ailments from primary and emergency care settings.

PubMed

Watson, M C; Ferguson, J; Barton, G R; Maskrey, V; Blyth, A; Paudyal, V; Bond, C M; Holland, R; Porteous, T; Sach, T H; Wright, D; Fielding, S

2015-02-18

To compare health-related and cost-related outcomes of consultations for symptoms suggestive of minor ailments in emergency departments (EDs), general practices and community pharmacies. Observational study; prospective cohort design. EDs (n=2), general practices (n=6) and community pharmacies (n=10) in a mix of rural/urban and deprived/affluent areas across North East Scotland and East Anglia. Participants Adults (≥18 years) presenting between 09:00 and 18:00 (Monday-Friday) in general practices and 09:00-18:00 (Monday-Saturday) in pharmacies and EDs with ≥1 of the following: musculoskeletal pain; eye discomfort; gastrointestinal disturbance; or upper respiratory tract-related symptoms. Participants completed three questionnaires: baseline (prior to index consultation); satisfaction with index consultation and follow-up (2 weeks after index consultation). Symptom resolution, quality of life, costs, satisfaction and influences on care-seeking behaviour. 377 patients participated, recruited from EDs (81), general practices (162) and community pharmacies (134). The 2-week response rate was 70% (264/377). Symptom resolution was similar across all three settings: ED (37.3%), general practice (35.7%) and pharmacy (44.3%). Mean overall costs per consultation were significantly lower for pharmacy (£29.30 (95% CI £21.60 to £37.00)) compared with general practice (£82.34 (95% CI £63.10 to £101.58)) and ED (£147.09 (95% CI £125.32 to £168.85)). Satisfaction varied across settings and by measure used. Compared with pharmacy and general practice use, ED use was significantly (p<0.001) associated with first episode and short duration of symptom(s), as well as higher levels of perceived seriousness and urgency for seeking care. Convenience of location was the most common reason for choice of consultation setting. These results suggest similar health-related outcomes and substantially lower costs with pharmacy consultations for minor ailments. Effective strategies are now needed to shift demand for minor ailment management away from EDs and general practices to the community pharmacy setting. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

National Service Frameworks and UK general practitioners: street-level bureaucrats at work?

PubMed

Checkland, Kath

2004-11-01

This paper argues that the past decade has seen significant changes in the nature of medical work in general practice in the UK. Increasing pressure to use normative clinical guidelines and the move towards explicit quantitative measures of performance together have the potential to alter the way in which health care is delivered to patients. Whilst it is possible to view these developments from the well-established sociological perspectives of deprofessionalisation and proletarianisation, this paper takes a view of general practice as work, and uses the ideas of Lipsky to analyse practice-level responses to some of these changes. In addition to evidence-based clinical guidelines, National Service Frameworks, introduced by the UK government in 1997, also specify detailed models of service provision that health care providers are expected to follow. As part of a larger study examining the impact of National Service Frameworks in general practice, the response of three practices to the first four NSFs were explored. The failure of NSFs to make a significant impact is compared to the practices' positive responses to purely clinical guidelines such as those developed by the British Hypertension Society. Lipsky's concept of public service workers as 'street-level bureaucrats' is discussed and used as a framework within which to view these findings.

Satisfying the patient in primary care: a postal survey following a recent consultation.

PubMed

Long, Sarah; Jiwa, Moyez

2004-05-01

Factors over and above the skills of the health care professional appear to impact on how well patients can cope with an illness following a consultation in general practice. These other factors appear to relate to the organisation and fabric of the doctor's practice. This study reports a systematic analysis of responses to a questionnaire survey of patients following a telephone consultation in a general practice setting. This study aims to explore how views on specific aspects of a general practice service contrast among patients. A structured anonymised postal questionnaire was sent to 916 patients within 24 h of a telephone consultation with a doctor or nurse in five general practices in North Trent, UK. No reminders were sent. Included on the questionnaire were free-text questions that invited opinions on areas for improvement for the patients' registered practice. These were analysed qualitatively using content analysis by two independent researchers. The overall response rate was 52% although responses from young men were under-represented in the survey. One in three responders expressed a need for improvements in the appointments, more access and less delay before practice. Five themes and a number of sub-themes were identified. Patients wanted more appointments. Other themes included a desire for better communication, more patient friendly policies and facilities. Analysis suggests that it would be very difficult to satisfy the contrasting and divergent needs of all patients. Communication with patients in general practice is influenced by the fabric, policies and reception staff in the practice as much as by the skills and resources of the care provider. Seeking patients' opinions about the practice within the context of a recent telephone consultation unearthed conflicting desires that cannot be satisfied given existing resources in the National Health Service (NHS). Patients favour a speedy, convenient and above all, tailored service. This may be impossible to deliver universally. Attention to the non-doctor aspects of the service may enhance the ability of practitioners to enable patients to cope with illness. The data suggest that patients are not universally satisfied with the service provided and that it would be naive to attempt to please them all.

Caring for people with dementia in hospital: findings from a survey to identify barriers and facilitators to implementing best practice dementia care.

PubMed

Tropea, Joanne; LoGiudice, Dina; Liew, Danny; Roberts, Carol; Brand, Caroline

2017-03-01

Best practice dementia care is not always provided in the hospital setting. Knowledge, attitudes and motivation, practitioner behavior, and external factors can influence uptake of best practice and quality care. The aim of this study was to determine hospital staff perceived barriers and enablers to implementing best practice dementia care. A 17-item survey was administered at two Australian hospitals between July and September 2014. Multidisciplinary staff working in the emergency departments and general medical wards were invited to participate in the survey. The survey collected data about the respondents' current role, work area, and years of experience, their perceived level of confidence and knowledge in dementia care and common symptoms of dementia, barriers and enablers to implementing best practice dementia care, job satisfaction in caring for people with dementia, and to rate the hospital's capacity and available resources to support best practice dementia care. A total of 112 survey responses were received. The environment, inadequate staffing levels and workload, time, and staff knowledge and skills were identified as barriers to implementing best practice dementia care. Most respondents rated their knowledge of dementia care and common symptoms of dementia, and confidence in recognizing whether a person has dementia, as moderate or high dementia. Approximately, half the respondents rated access to training and equipment as low or very low. The survey findings highlighted hospital staff perceived barriers to implementing best practice dementia care that can be used to inform locally tailored improvement interventions.

Factors influencing decision of general practitioners and managers to train and employ a nurse practitioner or physician assistant in primary care: a qualitative study.

PubMed

van der Biezen, Mieke; Derckx, Emmy; Wensing, Michel; Laurant, Miranda

2017-02-07

Due to the increasing demand on primary care, it is not only debated whether there are enough general practitioners (GPs) to comply with these demands but also whether specific tasks can be performed by other care providers. Although changing the workforce skill mix care by employing Physician Assistants (PAs) and Nurse Practitioners (NPs) has proven to be both effective and safe, the implementation of those professionals differs widely between and within countries. To support policy making regarding PAs/NPs in primary care, the aim of this study is to provide insight into factors influencing the decision of GPs and managers to train and employ a PA/NP within their organisation. A qualitative study was conducted in 2014 in which 7 managers of out-of-hours primary care services and 32 GPs who owned a general practice were interviewed. Three main topic areas were covered in the interviews: the decision-making process in the organisation, considerations and arguments to train and employ a PA/NP, and the tasks and responsibilities of a PA/NP. Employment of PAs/NPs in out-of-hours services was intended to substitute care for minor ailments in order to decrease GPs' caseload or to increase service capacity. Mangers formulated long-term planning and role definitions when changing workforce skill mix. Lastly, out-of-hours services experienced difficulties with creating team support among their members regarding the employment of PAs/NPs. In general practices during office hours, GPs indented both substitution and supplementation for minor ailments and/or target populations through changing the skill mix. Supplementation was aimed at improving quality of care and extending the range of services to patients. The decision-making in general practices was accompanied with little planning and role definition. The willingness to employ PAs/NPs was highly influenced by an employees' motivation to start the master's programme and GPs' prior experience with PAs/NPs. Knowledge about the PA/NP profession and legislations was often lacking. Role standardisations, long-term political planning and support from professional associations are needed to support policy makers in implementing skill mix in primary care.

Effect of telecare on use of health and social care services: findings from the Whole Systems Demonstrator cluster randomised trial

PubMed Central

Steventon, Adam; Bardsley, Martin; Billings, John; Dixon, Jennifer; Doll, Helen; Beynon, Michelle; Hirani, Shashi; Cartwright, Martin; Rixon, Lorna; Knapp, Martin; Henderson, Catherine; Rogers, Anne; Hendy, Jane; Fitzpatrick, Ray; Newman, Stanton

2013-01-01

Objective: to assess the impact of telecare on the use of social and health care. Part of the evaluation of the Whole Systems Demonstrator trial. Participants and setting: a total of 2,600 people with social care needs were recruited from 217 general practices in three areas in England. Design: a cluster randomised trial comparing telecare with usual care, general practice being the unit of randomisation. Participants were followed up for 12 months and analyses were conducted as intention-to-treat. Data sources: trial data were linked at the person level to administrative data sets on care funded at least in part by local authorities or the National Health Service. Main outcome measures: the proportion of people admitted to hospital within 12 months. Secondary endpoints included mortality, rates of secondary care use (seven different metrics), contacts with general practitioners and practice nurses, proportion of people admitted to permanent residential or nursing care, weeks in domiciliary social care and notional costs. Results: 46.8% of intervention participants were admitted to hospital, compared with 49.2% of controls. Unadjusted differences were not statistically significant (odds ratio: 0.90, 95% CI: 0.75–1.07, P = 0.211). They reached statistical significance after adjusting for baseline covariates, but this was not replicated when adjusting for the predictive risk score. Secondary metrics including impacts on social care use were not statistically significant. Conclusions: telecare as implemented in the Whole Systems Demonstrator trial did not lead to significant reductions in service use, at least in terms of results assessed over 12 months. International Standard Randomised Controlled Trial Number Register ISRCTN43002091. PMID:23443509

Pilot study of six Colorado dental hygiene independent practices.

PubMed

Astroth, D B; Cross-Poline, G N

1998-01-01

The purpose of this pilot study was to gather demographic data about six Colorado dental hygienists who were practicing independently and their practices as well as assess productivity and service mix, evaluate structure and process, and compare the findings in these practices to those of a study of California Health Manpower Pilot Project #139. A convenience sample of six dental hygiene independent practices was studied. A 21-item survey was distributed by mail to obtain demographic and practice information. Weekly surveys tracking patient visits and services provided were completed for three months. A general office audit to evaluate structure and a record audit of 22 patient records to evaluate process were conducted during visits at each practice site. The overall responses for each phase of this study were tabulated and frequencies were calculated using the SPSS/PC+ statistical package. The dental hygienists had practiced for an average of 13 years prior to establishing their practices. Four of the six practices were office-based, one was institution-based, and one was office- and institution-based. Health history, extraoral/intraoral examination, periodontal probing, adult prophylaxis, and oral hygiene instruction were provided during a majority of patient visits. The general office audit revealed compliance with infection control, office protocols for emergency situations, and practice management protocols. The patient record audit indicated a high standard for process of care for the practice sites. The six practices revealed a variety of backgrounds among the dental hygienists and diverse practice characteristics regarding both the populations served and practice settings. The services provided were consistent with allowable services for unsupervised practice. Compliance with specific guidelines was verified during the general office and patient record audits. Consistent with the findings of California Health Manpower Pilot Project #139, the care provided by the Colorado dental hygiene independent practitioners in this study and the environment in which the care was provided do not exhibit any undue risk to the health and safety of the public.

Quality of tuberculosis care in India: a systematic review.

PubMed

Satyanarayana, S; Subbaraman, R; Shete, P; Gore, G; Das, J; Cattamanchi, A; Mayer, K; Menzies, D; Harries, A D; Hopewell, P; Pai, M

2015-07-01

While Indian studies have assessed care providers' knowledge and practices, there is no systematic review on the quality of tuberculosis (TB) care. We searched multiple sources to identify studies (2000-2014) on providers' knowledge and practices. We used the International Standards for TB Care to benchmark quality of care. Of the 47 studies included, 35 were questionnaire surveys and 12 used chart abstraction. None assessed actual practice using standardised patients. Heterogeneity in the findings precluded meta-analysis. Of 22 studies evaluating provider knowledge about using sputum smears for diagnosis, 10 found that less than half of providers had correct knowledge; 3 of 4 studies assessing self-reported practices by providers found that less than a quarter reported ordering smears for patients with chest symptoms. In 11 of 14 studies that assessed treatment, less than one third of providers knew the standard regimen for drug-susceptible TB. Adherence to standards in practice was generally lower than correct knowledge of those standards. Eleven studies with both public and private providers found higher levels of appropriate knowledge/practice in the public sector. Available evidence suggests suboptimal quality of TB care, particularly in the private sector. Improvement of quality of care should be a priority for India.

Sources of influence on medical practice

PubMed Central

Fernandez, L. A.; Martin, J. M.; del Castillo, J. d. D. L.; Gaspar, O. S.; Millan, J. I.; Lozano, M. J.; Keenoy, E. D.

2000-01-01

OBJECTIVES—To explore the opinion of general practitioners on the importance and legitimacy of sources of influence on medical practice.
METHODS—General practitioners (n=723) assigned to Primary Care Teams (PCTs) in two Spanish regions were randomly selected to participate in this study. A self administered questionnaire was sent by mail and collected by hand. The dependent variable collected the opinion on different sources that exert influence on medical practice. Importance was measured with a 9 item scale while legitimacy was evaluated with 16 items measured with a 1 to 7 point Likert scale.
RESULTS—The most important and legitimate sources of influence according to general practitioners were: training courses and scientific articles, designing self developed protocols and discussing with colleagues. The worst evaluated were: financial incentives and the role played by the pharmaceutical industry.
CONCLUSIONS—The development of medical practice is determined by many factors, grouped around three big areas: organisational setting, professional system and social setting. The medical professional system is the one considered as being the most important and legitimate by general practitioners. Other strategies of influence, considered to be very important by the predominant management culture (financial incentives), are not considered to be so by general practitioners. These results, however, are not completely reliable as regards the real network of influences existing in medical practice, which reflect instead different "value systems".


Keywords: primary health care; physicians' practice patterns; medical practice management; physicians' incentive plans PMID:10890875

Selected problems associated with the treatment and care for patients with colostomy – part 2

PubMed Central

Kachaniuk, Hanna; Szadowska-Szlachetka, Zdzisława; Charzyńska-Gula, Marianna; Kocka, Katarzyna; Bartoszek, Agnieszka; Celej-Szuster, Jolanta

2013-01-01

Generally, ostomy is a purposeful connection of the lumen of the intestine with abdominal integuments by surgery. The study presents practical solutions related to care for the colostomy patient, i.e. an ostomy on the large intestine. The following issues will be discussed: regulating the defecation cycle, risk connected with improper selection of ostomy equipment, instruction on colostomy irrigation with practical advice and irrigation equipment supply. The knowledge of these rules and mastering them in practice is to provide ostomy patients not only with highest-standard care and help but also to prepare them for dealing with problems independently, i.e. for self-care. PMID:24596509

Pharmacist consultations in general practice clinics: the Pharmacists in Practice Study (PIPS).

PubMed

Tan, Edwin C K; Stewart, Kay; Elliott, Rohan A; George, Johnson

2014-01-01

Medication-related problems (MRPs) are a concern in primary care settings. Pharmacists based in the community or community pharmacies are able to identify, resolve and prevent MRPs; however, the lack of a formal partnership with physicians and poor access to patients' medical records are limitations. In Australia, delivery of pharmacist services within general practice clinics is rare. To evaluate the effectiveness of consultations by pharmacists based within primary care medical practices. A prospective, before-after intervention study was conducted at two primary health care (general practice) clinics in Melbourne, Australia. Participants were clinic patients who had risk-factors for MRPs (e.g. polypharmacy). Patients received a consultation with the pharmacist in a private consulting room at the clinic or in their home. The pharmacist reviewed the patient's medication regimen and adherence, with full access to their medical record, provided patient education, and produced a report for the general practitioner. The primary outcome was the number of MRPs identified by the pharmacist, and the number that remained unresolved 6 months after the pharmacist consultation. Secondary outcomes included medication adherence, health service use, and patient satisfaction. Eighty-two patients were recruited and 62 (75.6%) completed the study. The median number of MRPs per patient identified by the practice pharmacist was 2 (interquartile range [IQR] 1, 4). Six months after review, this fell to 0 (IQR 0, 1), P < 0.001. The proportion of patients who were adherent to their medications improved significantly, according to both the Morisky (44.1% versus 62.7%, P = 0.023) and the Tool for Adherence Behaviour Screening (TABS) (35.6% versus 57.6%, P = 0.019) scales. There was no significant effect on health service use. Patients were highly satisfied with the pharmacist consultations. Consultations undertaken by pharmacists located within primary health care clinics were effective in identifying and resolving MRPs. The consultations were well received by patients and were associated with improvements in medication adherence. Copyright © 2014 Elsevier Inc. All rights reserved.

Third sector primary health care in New Zealand.

PubMed

Crampton, P; Dowell, A C; Bowers, S

2000-03-24

To describe key organisational characteristics of selected third sector (non-profit and non-government) primary health care organisations. Data were collected, in 1997 and 1998, from 15 third sector primary care organisations that were members of a network of third sector primary care providers, Health Care Aotearoa (HCA). Data were collected by face-to-face interviews of managers and key informants using a semi-structured interview schedule, and from practice computer information systems. Overall the populations served were young: only 4% of patients were aged 65 years or older, and the ethnicity profile was highly atypical, with 21.8% European, 36% Maori, 22.7% Pacific Island, 12% other, and 7.5% not stated. Community services card holding rates were higher than recorded in other studies, and registered patients tended to live in highly deprived areas. HCA organisations had high patient to doctor ratios, in general over 2000:1, and there were significant differences in management structures between HCA practices and more traditional general practice. Third sector organisations provide services for populations that are disadvantaged in many respects. It is likely that New Zealand will continue to develop a diverse range of primary care organisational arrangements. Effort is now required to measure quality and effectiveness of services provided by different primary care organisations serving comparable populations.

The relationship between individualized care and the practice environment: an international study.

PubMed

Papastavrou, Evridiki; Acaroglu, Rengin; Sendir, Merdiye; Berg, Agneta; Efstathiou, Georgios; Idvall, Ewa; Kalafati, Maria; Katajisto, Jouko; Leino-Kilpi, Helena; Lemonidou, Chryssoula; da Luz, Maria Deolinda Antunes; Suhonen, Riitta

2015-01-01

Previous research studies have found that the better the quality of practice environments in hospitals, the better the outcomes for nurses and patients. Practice environment may influence nurses' ability to individualize care but the detailed relationship between individualized care and the professional practice environment has not been investigated widely. Some evidence exists about the association of practice environments with the level of individualization of nursing care, but this evidence is based on single national studies. The aim of this study was to determine whether nurses' views of their professional practice environment associate with their views of the level of care individualization in seven countries. This study had an international, multisite, prospective, cross-sectional, exploratory survey design. The study involved acute orthopedic and trauma surgical inpatient wards (n=91) in acute care hospitals (n=34) in seven countries, Cyprus, Finland, Greece, the State of Kansas, USA, Portugal, Sweden, and Turkey. Nurses (n=1163), registered or licensed practical, working in direct patient care, in orthopedic and trauma inpatient units in acute care hospitals in seven countries participated in the study. Self-administered questionnaires, including two instruments, the Revised Professional Practice Environment and the Individualized Care Scale-Nurse (Individualized Care Scale-Nurse A and B) were used for data collection. Data were analyzed statistically using descriptive statistics, simultaneous multiple regression analysis, and generalized linear model. Two regression models were applied to assess the predictive validity of the Revised Professional Practice Environment on the Individualized Care Scale-Nurse-A and B. The results showed that elements of the professional practice environment were associated with care individualization. Internal work motivation, cultural sensitivity, control over practice, teamwork, and staff relationship with physicians were predictors of support (Individualized Care Scale-A) for and the delivery (Individualized Care Scale-B) of individualized care. The results of this study provide evidence that environment aspect could explain variations in care individualization. These findings support the assertion that individualized care needs to be understood in a broader context than the immediate nurse-patient relationship and that careful development of the care environment may be an effective way to improve care quality and outcomes. Copyright © 2014 Elsevier Ltd. All rights reserved.

Administrative encounters in general practice: low value or hidden value care?

PubMed

Trevena, Lyndal J; Harrison, Christopher; Britt, Helena C

2018-02-19

To determine the frequency of general practice administrative encounters, and to determine whether they represent low value care. Secondary analysis of data from the Bettering Evaluation and Care of Health (BEACH) dataset. 1 568 100 GP-patient encounters in Australia, 2000-01 to 2015-16. An annual nationally representative random sample of about 1000 GPs, who each recorded the details of 100 consecutive encounters with patients. Proportions of general practice encounters that were potentially low value care encounters (among the patient's reasons for the encounter was at least one administrative, medication, or referral request) and potentially low value care only encounters (such reasons were the sole reason for the encounter). For 2015-16, we also examined other health care provided by GPs at these encounters. During 2015-16, 18.5% (95% CI, 17.7-19.3%) of 97 398 GP-patient encounters were potentially low value care request encounters; 7.4% (95% CI, 7.0-7.9%) were potentially low value care only encounters. Administrative work was requested at 3.8% (95% CI, 3.5-4.0%) of GP visits, 35.4% of which were for care planning and coordination, 33.5% for certification, and 31.2% for other reasons. Medication requests were made at 13.1% (95% CI, 12.4-13.7%) of encounters; other health care was provided at 57.9% of medication request encounters, counselling, advice or education at 23.4%, and pathology testing was ordered at 16.7%. Referrals were requested at 2.8% (95% CI, 1.7-3.0%) of visits, at 69.4% of which additional health care was provided. The problems managed most frequently at potentially low value care only encounters were chronic diseases. Most patients requested certificates, medications and referrals in the context of seeking help for other health needs. Additional health care, particularly for chronic diseases, was provided at most GP administrative encounters. The MBS Review should consider the hidden value of these encounters.

Measuring disease prevalence: a comparison of musculoskeletal disease using four general practice consultation databases

PubMed Central

Jordan, Kelvin; Clarke, Alexandra M; Symmons, Deborah PM; Fleming, Douglas; Porcheret, Mark; Kadam, Umesh T; Croft, Peter

2007-01-01

Background Primary care consultation data are an important source of information on morbidity prevalence. It is not known how reliable such figures are. Aim To compare annual consultation prevalence estimates for musculoskeletal conditions derived from four general practice consultation databases. Design of study Retrospective study of general practice consultation records. Setting Three national general practice consultation databases: i) Fourth Morbidity Statistics from General Practice (MSGP4, 1991/92), ii) Royal College of General Practitioners Weekly Returns Service (RCGP WRS, 2001), and iii) General Practice Research Database (GPRD, 1991 and 2001); and one regional database (Consultations in Primary Care Archive, 2001). Method Age-sex standardised persons consulting annual prevalence rates for musculoskeletal conditions overall, rheumatoid arthritis, osteoarthritis and arthralgia were derived for patients aged 15 years and over. Results GPRD prevalence of any musculoskeletal condition, rheumatoid arthritis and osteoarthritis was lower than that of the other databases. This is likely to be due to GPs not needing to record every consultation made for a chronic condition. MSGP4 gave the highest prevalence for osteoarthritis but low prevalence of arthralgia which reflects encouragement for GPs to use diagnostic rather than symptom codes. Conclusion Considerable variation exists in consultation prevalence estimates for musculoskeletal conditions. Researchers and health service planners should be aware that estimates of disease occurrence based on consultation will be influenced by choice of database. This is likely to be true for other chronic diseases and where alternative symptom labels exist for a disease. RCGP WRS may give the most reliable prevalence figures for musculoskeletal and other chronic diseases. PMID:17244418

Using Patient Flow Information to Determine Risk of Hospital Presentation: Protocol for a Proof-of-Concept Study.

PubMed

Pearce, Christopher M; McLeod, Adam; Patrick, Jon; Boyle, Douglas; Shearer, Marianne; Eustace, Paula; Pearce, Mary Catherine

2016-12-20

Every day, patients are admitted to the hospital with conditions that could have been effectively managed in the primary care sector. These admissions are expensive and in many cases are possible to avoid if early intervention occurs. General practitioners are in the best position to identify those at risk of imminent hospital presentation and admission; however, it is not always possible for all the factors to be considered. A lack of shared information contributes significantly to the challenge of understanding a patient's full medical history. Some health care systems around the world use algorithms to analyze patient data in order to predict events such as emergency presentation; however, those responsible for the design and use of such systems readily admit that the algorithms can only be used to assess the populations used to design the algorithm in the first place. The United Kingdom health care system has contributed data toward algorithm development, which is possible through the unified health care system in place there. The lack of unified patient records in Australia has made building an algorithm for local use a significant challenge. Our objective is to use linked patient records to track patient flow through primary and secondary health care in order to develop a tool that can be applied in real time at the general practice level. This algorithm will allow the generation of reports for general practitioners that indicate the relative risk of patients presenting to an emergency department. A previously designed tool was used to deidentify the general practice and hospital records of approximately 100,000 patients. Records were pooled for patients who had attended emergency departments within the Eastern Health Network of hospitals and general practices within the Eastern Health Network catchment. The next phase will involve development of a model using a predictive analytic machine learning algorithm. The model will be developed iteratively, testing the combination of variables that will provide the best predictive model. Records of approximately 97,000 patients who have attended both a general practice and an emergency department have been identified within the database. These records are currently being used to develop the predictive model. Records from general practice and emergency department visits have been identified and pooled for development of the algorithm. The next phase in the project will see validation and live testing of the algorithm in a practice setting. The algorithm will underpin a clinical decision support tool for general practitioners which will be tested for face validity in this initial study into its efficacy. ©Christopher M Pearce, Adam McLeod, Jon Patrick, Douglas Boyle, Marianne Shearer, Paula Eustace, Mary Catherine Pearce. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 20.12.2016.

Analytical performance, agreement and user-friendliness of six point-of-care testing urine analysers for urinary tract infection in general practice.

PubMed

Schot, Marjolein J C; van Delft, Sanne; Kooijman-Buiting, Antoinette M J; de Wit, Niek J; Hopstaken, Rogier M

2015-05-18

Various point-of-care testing (POCT) urine analysers are commercially available for routine urine analysis in general practice. The present study compares analytical performance, agreement and user-friendliness of six different POCT urine analysers for diagnosing urinary tract infection in general practice. All testing procedures were performed at a diagnostic centre for primary care in the Netherlands. Urine samples were collected at four general practices. Analytical performance and agreement of the POCT analysers regarding nitrite, leucocytes and erythrocytes, with the laboratory reference standard, was the primary outcome measure, and analysed by calculating sensitivity, specificity, positive and negative predictive value, and Cohen's κ coefficient for agreement. Secondary outcome measures were the user-friendliness of the POCT analysers, in addition to other characteristics of the analysers. The following six POCT analysers were evaluated: Uryxxon Relax (Macherey Nagel), Urisys 1100 (Roche), Clinitek Status (Siemens), Aution 11 (Menarini), Aution Micro (Menarini) and Urilyzer (Analyticon). Analytical performance was good for all analysers. Compared with laboratory reference standards, overall agreement was good, but differed per parameter and per analyser. Concerning the nitrite test, the most important test for clinical practice, all but one showed perfect agreement with the laboratory standard. For leucocytes and erythrocytes specificity was high, but sensitivity was considerably lower. Agreement for leucocytes varied between good to very good, and for the erythrocyte test between fair and good. First-time users indicated that the analysers were easy to use. They expected higher productivity and accuracy when using these analysers in daily practice. The overall performance and user-friendliness of all six commercially available POCT urine analysers was sufficient to justify routine use in suspected urinary tract infections in general practice. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

The contribution of demographic and morbidity factors to self-reported visit frequency of patients: a cross-sectional study of general practice patients in Australia

PubMed Central

Knox, Stephanie A; Britt, Helena

2004-01-01

Background Understanding the factors that affect patients' utilisation of health services is important for health service provision and effective patient management. This study aimed to investigate the specific morbidity and demographic factors related to the frequency with which general practice patients visit a general practitioner/family physician (GP) in Australia. Methods A sub-study was undertaken as part of an ongoing national study of general practice activity in Australia. A cluster sample of 10,755 general practice patients were surveyed through a random sample of 379 general practitioners. The patient reported the number of times he/she had visited a general practitioner in the previous twelve months. The GP recorded all the patient's major health problems, including those managed at the current consultation. Results Patients reported an average of 8.8 visits to a general practitioner per year. After adjusting for other patient demographics and number of health problems, concession health care card holders made on average 2.6 more visits per year to a general practitioner than did non-card holders (p < .001). After adjustment, patients from remote/very remote locations made 2.3 fewer visits per year than patients from locations where services were highly accessible (p < .001). After adjustment for patient demographics, patients with diagnosed anxiety made on average 2.7 more visits per year (p = 0.003), those with diagnosed depression 2.2 more visits than average (p < .0001), and those with back problems 2.4 more visits (p = 0.009) than patients without the respective disorders. Conclusions Anxiety, back pain and depression are associated with greater patient demand for general practice services than other health problems. The effect of sociodemographic factors on patient utilisation of general practice services is complex. Equity of access to general practice services remains an issue for patients from remote areas, while concession health care card holders are attending general practice more frequently than other patients relative to their number of health problems. PMID:15318948

Acute care nurses' perceptions of spirituality and spiritual care: an exploratory study in Singapore.

PubMed

Chew, Brendan Wk; Tiew, Lay Hwa; Creedy, Debra K

2016-09-01

To investigate acute care nurses' perceptions of spirituality and spiritual care and relationships with nurses' personal and professional characteristics. Spirituality and spiritual care are often neglected or absent in daily nursing practice. Nurses' perceptions of spirituality can be influenced by personal, professional and social factors and affect the provision of spiritual care. A cross-sectional, exploratory, nonexperimental design was used. All nursing staff (n = 1008) from a large acute care hospital in Singapore were invited to participate. Participants completed a demographic form and the Spiritual Care-Giving Scale. Completed surveys were received from 767 staff yielding a response rate of 76%. Descriptive statistics and General Linear Modelling were used to analyse data. Acute care nurses reported positive perceptions of spirituality and spiritual care. Religion, area of clinical practice and view of self as spiritual were associated with nurses' reported perspectives of spirituality and spiritual care. Nurses working in this acute care hospital in Singapore reported positive perceptions of spirituality and spiritual care. Respondents tended to equate religion with spirituality and were often unclear about what constituted spiritual care. They reported a sense of readiness to apply an interprofessional approach to spiritual care. However, positive perceptions of spirituality may not necessarily translate into practice. Spiritual care can improve health outcomes. Nurses' understanding of spirituality is essential for best practice. Interprofessional collaboration with clinicians, administrators, educators, chaplains, clergy and spiritual leaders can contribute to the development of practice guidelines and foster spiritual care by nurses. Further research is needed on the practical applications of spiritual care in nursing. © 2016 John Wiley & Sons Ltd.

Quality assurance of laboratory work and clinical use of laboratory tests in general practice in norway: a survey.

PubMed

Thue, Geir; Jevnaker, Marianne; Gulstad, Guri Andersen; Sandberg, Sverre

2011-09-01

Virtually all the general practices in Norway participate in the Norwegian Quality Improvement of Laboratory Services in Primary Care, NOKLUS. In order to assess and develop NOKLUS's services, it was decided to carry out an investigation in the largest participating group, general practices. In autumn 2008 a questionnaire was sent to all Norwegian general practices asking for feedback on different aspects of NOKLUS's main services: contact with medical laboratory technologists, sending of control materials, use and maintenance of practice-specific laboratory binders, courses, and testing of laboratory equipment. In addition, attitudes were elicited towards possible new services directed at assessing other technical equipment and clinical use of tests. Responses were received from 1290 of 1552 practices (83%). The great majority thought that the frequency of sending out control material should continue as at present, and they were pleased with the feedback reports and follow-up by the laboratory technologists in the counties. Even after many years of practical experience, there is still a need to update laboratory knowledge through visits to practices, courses, and written information. Practices also wanted quality assurance of blood pressure meters and spirometers, and many doctors wanted feedback on their use of laboratory tests. Services regarding quality assurance of point-of-care tests, guidance, and courses should be continued. Quality assurance of other technical equipment and of the doctor's clinical use of laboratory tests should be established as part of comprehensive quality assurance.

Survey of Irish general practitioners' preferences for continuing professional development.

PubMed

Maher, B; O'Neill, R; Faruqui, A; Bergin, C; Horgan, M; Bennett, D; O'Tuathaigh, C M P

2018-01-01

Doctors' continuing professional development (CPD) training needs are known to be strongly influenced by national and local contextual characteristics. Given the changing national demographic profile and government-mandated changes to primary care health care provision, this study aimed to investigate Irish General Practitioners' (GPs) perceptions of, and preferences for, current and future CPD programmes. A cross-sectional questionnaire, using closed- and open-ended questions, was administered to Irish GPs, focusing on training needs analysis; CPD course content; preferred format and the learning environment. The response rate was 719/1000 (71.9%). GPs identified doctor-patient communication as the most important and best-performed GP skill. Discrepancies between perceived importance (high) and current performance (low) emerged for time/workload management, practice finance and business skills. GPs identified clinically-relevant primary care topics and non-clinical topics (stress management, business skills, practice management) as preferences for future CPD. Flexible methods for CPD delivery were important. Gender and practice location (urban or rural) significantly influenced CPD participation and future course preference. The increasing diversity of services offered in the Irish primary care setting, in both clinical and non-clinical areas, should be tailored based to include GP practice location and structure.

Portuguese version of the EUROPEP questionnaire: contributions to the psychometric validation

PubMed Central

Roque, Hugo; Veloso, Ana; Ferreira, Pedro L

2016-01-01

ABSTRACT OBJECTIVE To assess the construct validity and reliability of the Portuguese version of the European Task Force on Patient Evaluation of General Practice Care questionnaire. METHODS We applied the Portuguese version of the European Task Force on Patient Evaluation of General Practice Care to 392 users of 20 Family Health Units from the North of Portugal. The validity of the construct was evaluated by exploratory factor analysis, with the Principal Axis Factoring method, by orthogonal rotation (varimax procedure), by the Kaiser normalization criteria (eigenvalue ≥ 1). The factorability of the data matrix was verified by the Kaiser-Meyer-Olkin and Bartlett’s sphericity test. We estimated the reliability by the indicator of internal consistency Cronbach’s alpha. To analyze the correlations between satisfaction and loyalty, we used the Pearson correlations. The predictor effect of satisfaction on loyalty was analyzed by simple linear regression. RESULTS Satisfaction presented five robust and well individualized dimensions – medical care, nursing care, clinical secretariat services, accessibility, and organization of services – with alpha values between 0.86 and 0.97, good levels of internal consistency. The loyalty showed alpha value of 0.72, considered a reasonable internal consistency. The satisfaction was predictive of loyalty. CONCLUSIONS The Portuguese European Task Force on Patient Evaluation of General Practice Care questionnaire is a robust and reliable instrument to measure the satisfaction and loyalty of users of the Family Health Units. PMID:27706374

Promoting Mental Health and Preventing Mental Illness in General Practice

PubMed Central

Thomas, Steve; Jenkins, Rachel; Burch, Tony; Calamos Nasir, Laura; Fisher, Brian; Giotaki, Gina; Gnani, Shamini; Hertel, Lise; Marks, Marina; Mathers, Nigel; Millington-Sanders, Catherine; Morris, David; Ruprah-Shah, Baljeet; Stange, Kurt; Thomas, Paul; White, Robert; Wright, Fiona

2016-01-01

Abstract This paper calls for the routine integration of mental health promotion and prevention into UK General Practice in order to reduce the burden of mental and physical disorders and the ensuing pressure on General Practice. The proposals & the resulting document (https://ethicscharity.files.wordpress.com/2015/09/rcgp_keymsg_150925_v5.pdf) arise from an expert ‘Think Tank’ convened by the London Journal of Primary Care, Educational Trust for Health Improvement through Cognitive Strategies (ETHICS Foundation) and the Royal College of General Practitioners. It makes 12 recommendations for General Practice: (1) Mental health promotion and prevention are too important to wait. (2) Work with your community to map risk factors, resources and assets. (3) Good health care, medicine and best practice are biopsychosocial rather than purely physical. (4) Integrate mental health promotion and prevention into your daily work. (5) Boost resilience in your community through approaches such as community development. (6) Identify people at increased risk of mental disorder for support and screening. (7) Support early intervention for people of all ages with signs of illness. (8) Maintain your biopsychosocial skills. (9) Ensure good communication, interdisciplinary team working and inter-sectoral working with other staff, teams and agencies. (10) Lead by example, taking action to promote the resilience of the general practice workforce. (11) Ensure mental health is appropriately included in the strategic agenda for your ‘cluster’ of General Practices, at the Clinical Commissioning Groups, and the Health and Wellbeing Board. (12) Be aware of national mental health strategies and localise them, including action to destigmatise mental illness within the context of community development. PMID:28250821

Digital technologies and chronic disease management.

PubMed

Georgeff, Michael

2014-12-01

Digital technologies will become a major part of our healthcare system, with particular impact in primary care. However, many healthcare professionals are not sufficiently informed of the digital technologies available today and how they and their patients can gain substantial benefit from adoption of these technologies. To raise awareness of the potential benefits of using digital technologies for improving practice efficiencies and patient health outcomes. Implementing best practice care for patients with chronic and complex conditions is one of the greatest challenges facing general practice and other primary care providers. It has been suggested that digital technologies could assist by decreasing the administrative burden of care delivery, improving quality of care, increasing practice efficiencies and better supporting patient self-management. In this paper, we consider some areas in the management of chronic and long-term conditions where digital and mobile health solutions can make a difference today.

The impact of funding changes on the implementation of primary health care policy.

PubMed

Finlayson, Mary P; Sheridan, Nicolette F; Cumming, Jacqueline M; Fowler, Sandra

2012-04-01

To ascertain how new funding arrangements, introduced in New Zealand's 2001 Primary Health Care (PHC) Strategy, have impacted on the expansion of nurses' role in general practice. Nurses are central to the new policy that was designed to improve the health status of New Zealanders and reduce inequalities in health. Nurses were to be a crucial part of the PHC team, expanding their current roles to provide increased access to appropriate services. This paper investigates how the new funding arrangements, introduced as part of the policy, have impacted on the expansion of nurses' roles and consequently the realisation of the policy goals. Semi-structured interviews were undertaken with 128 key stakeholders five years after the introduction of the PHC Strategy, and surveys were completed by practice nurses, general practitioners and practice managers in purposively selected practices within the 20 participating Primary Health Organisations. There has been substantial growth in the development of nursing roles for some nurses in general practice; however, this expansion has not been universal and one of the main reasons for this is the way funding devolves at the practice level. One of the consequences of the policymakers not taking into account the business model of the majority of general practices, is the resulting overarching goal of the strategy not being realised, and inequalities in health status remaining.

A person based formula for allocating commissioning funds to general practices in England: development of a statistical model.

PubMed

Dixon, Jennifer; Smith, Peter; Gravelle, Hugh; Martin, Steve; Bardsley, Martin; Rice, Nigel; Georghiou, Theo; Dusheiko, Mark; Billings, John; Lorenzo, Michael De; Sanderson, Colin

2011-11-22

To develop a formula for allocating resources for commissioning hospital care to all general practices in England based on the health needs of the people registered in each practice Multivariate prospective statistical models were developed in which routinely collected electronic information from 2005-6 and 2006-7 on individuals and the areas in which they lived was used to predict their costs of hospital care in the next year, 2007-8. Data on individuals included all diagnoses recorded at any inpatient admission. Models were developed on a random sample of 5 million people and validated on a second random sample of 5 million people and a third sample of 5 million people drawn from a random sample of practices. All general practices in England as of 1 April 2007. All NHS inpatient admissions and outpatient attendances for individuals registered with a general practice on that date. All individuals registered with a general practice in England at 1 April 2007. Power of the statistical models to predict the costs of the individual patient or each practice's registered population for 2007-8 tested with a range of metrics (R(2) reported here). Comparisons of predicted costs in 2007-8 with actual costs incurred in the same year were calculated by individual and by practice. Models including person level information (age, sex, and ICD-10 codes diagnostic recorded) and a range of area level information (such as socioeconomic deprivation and supply of health facilities) were most predictive of costs. After accounting for person level variables, area level variables added little explanatory power. The best models for resource allocation could predict upwards of 77% of the variation in costs at practice level, and about 12% at the person level. With these models, the predicted costs of about a third of practices would exceed or undershoot the actual costs by 10% or more. Smaller practices were more likely to be in these groups. A model was developed that performed well by international standards, and could be used for allocations to practices for commissioning. The best formulas, however, could predict only about 12% of the variation in next year's costs of most inpatient and outpatient NHS care for each individual. Person-based diagnostic data significantly added to the predictive power of the models.

Practices used in Israel by nurses who care during hospitalization for older patients with dementia or who are bedridden.

PubMed

Iecovich, Esther; Rabin, Barbara

2014-03-01

The study's purpose was to examine (a) bedside nurses' care practices when providing care to patients with dementia or those who are physically disabled and (b) the extent to which these actions vary by type of hospital, type of ward, and nurse's characteristics. The sample included 265 nurses in internal medicine and geriatric wards in 2 general hospitals in Israel. The results showed that the most prevalent practices were giving greater attention to these patients, locating them in a room near the nurses' station and asking family members to stay with the patient or to hire paid carers. Use of restraints was more prevalent in patients with dementia than those who were physically disabled. Use of specific practices significantly varied by type of ward and hospital, suggesting that nurses' care practices are more connected with organizational characteristics than other factors.

The variety of primary healthcare organisations in Australia: a taxonomy.

PubMed

Rodwell, John; Gulyas, Andre

2013-04-08

Healthcare policy appears to treat healthcare organisations as being homogenous, despite evidence that they vary considerably. This study develops a taxonomy of primary health care practices using characteristics associated with the job satisfaction of general medical practitioners (GPs) and the practices. The study used data from 3,662 survey respondents who were GPs in the 2009 wave of the MABEL survey. Cluster analyses were used to determine natural groups of medical practices based on multidimensional characteristics. Seven configurations of primary health care practices emerged from multivariate cluster analyses: optimised team, independent craft, reactive, winding down, classic, practitioner flexible, and scale efficiency. This taxonomy of configurations moves beyond simplistic categorisations such as geographic location and highlights the complexity of primary health care organisations in Australia. Health policy, workforce and procedure interventions informed by taxonomies can engage the diversity of primary health care practices.

Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence.

PubMed

Phillips, Christine B; Pearce, Christopher M; Hall, Sally; Travaglia, Joanne; de Lusignan, Simon; Love, Tom; Kljakovic, Marjan

2010-11-15

To review the literature on different models of clinical governance and to explore their relevance to Australian primary health care, and their potential contributions on quality and safety. 25 electronic databases, scanning reference lists of articles and consultation with experts in the field. We searched publications in English after 1999, but a search of the German language literature for a specific model type was also undertaken. The grey literature was explored through a hand search of the medical trade press and websites of relevant national and international clearing houses and professional or industry bodies. 11 software packages commonly used in Australian general practice were reviewed for any potential contribution to clinical governance. 19 high-quality studies that assessed outcomes were included. All abstracts were screened by one researcher, and 10% were screened by a second researcher to crosscheck screening quality. Studies were reviewed and coded by four reviewers, with all studies being rated using standard critical appraisal tools such as the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Two researchers reviewed the Australian general practice software. Interviews were conducted with 16 informants representing service, regional primary health care, national and international perspectives. Most evidence supports governance models which use targeted, peer-led feedback on the clinician's own practice. Strategies most used in clinical governance models were audit, performance against indicators, and peer-led reflection on evidence or performance. The evidence base for clinical governance is fragmented, and focuses mainly on process rather than outcomes. Few publications address models that enhance safety, efficiency, sustainability and the economics of primary health care. Locally relevant clinical indicators, the use of computerised medical record systems, regional primary health care organisations that have the capacity to support the uptake of clinical governance at the practice level, and learning from the Aboriginal community-controlled sector will help integrate clinical governance into primary care.

Understanding quit decisions in primary care: a qualitative study of older GPs.

PubMed

Sansom, Anna; Calitri, Raff; Carter, Mary; Campbell, John

2016-02-19

To investigate the reasons behind intentions to quit direct patient care among experienced general practitioners (GPs) aged 50-60 years. Qualitative study based on semistructured interviews with GPs in the South West region of England. Transcribed interviews were analysed thematically. 23 GPs aged 50-60 years: 3 who had retired from direct patient care before age 60, and 20 who intended to quit direct patient care within the next 5 years. The analysis identified four key themes: early retirement is a viable option for many GPs; GPs have employment options other than undertaking direct patient care; GPs report feeling they are doing an (almost) undoable job; and GPs may have other aspirations that pull them away from practice. Findings from this study confirmed those from earlier research, with high workload, ageing and health, family and domestic life, and organisational change all influencing GPs' decisions about when to retire/quit direct patient care. However, in addition, GPs expressed feelings of insecurity and uncertainty regarding the future of general practice, low morale, and issues regarding accountability (appraisal and revalidation) and governance. Suggestions about how to help retain GPs within the active clinical workforce were offered, covering individual, practice and organisational levels. This research highlights aspects of the current professional climate for GPs that are having an impact on retirement decisions. Any future changes to policy or practice to help retain experienced GPs will benefit from this informed understanding of GPs' views. Key factors to take into account include: making the GP workload more manageable; managing change sympathetically; paying attention to GPs' own health; improving confidence in the future of general practice; and improving GP morale. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

70,489 primary care encounters: retrospective analysis of morbidity at a primary care centre in Ireland.

PubMed

Molony, D; Beame, C; Behan, W; Crowley, J; Dennehy, T; Quinlan, M; Cullen, W

2016-11-01

While considerable changes are happening in primary care in Ireland and considerable potential exists in intelligence derived from practice-based data to inform these changes, relatively few large-scale general morbidity surveys have been published. To examine the most common reasons why people attend primary care, specifically 'reasons for encounter' (RFEs) among the general practice population and among specific demographic groups (i.e., young children and older adults). We retrospectively examined clinical encounters (which had a diagnostic code) over a 4-year time period. Descriptive analyses were conducted on anonymised data. 70,489 RFEs consultations were recorded (mean 13.53 recorded RFEs per person per annum) and consultations involving multiple RFEs were common. RFE categories for which codes were most commonly recorded were: 'general/unspecified' (31.6 %), 'respiratory' (15.4 %) and 'musculoskeletal' (12.6 %). Most commonly recorded codes were: 'medication renewal' (6.8 %), 'cough' (6.6 %), and 'health maintenance/prevention' (5.8 %). There was considerable variation in the number of RFEs recorded per age group. 6239 RFEs (8.9 %) were recorded by children under 6 years and 15,295 RFEs (21.7 %) were recorded by adults aged over 70. RFEs recorded per calendar month increased consistently through the study period and there was a marked seasonal and temporal variation in the number of RFEs recorded. Practice databases can generate intelligence on morbidity and health service utilisation in the community. Future research to optimise diagnostic coding at a practice level and to promote this activity in a more representative sample of practices is a priority.

Drivers for change in primary care of diabetes following a protected learning time educational event: interview study of practitioners.

PubMed

Siriwardena, Aloysius Niroshan; Middlemass, Jo B; Ward, Kate; Wilkinson, Carol

2008-01-19

A number of protected learning time schemes have been set up in primary care across the United Kingdom but there has been little published evidence of their impact on processes of care. We undertook a qualitative study to investigate the perceptions of practitioners involved in a specific educational intervention in diabetes as part of a protected learning time scheme for primary health care teams, relating to changing processes of diabetes care in general practice. We undertook semistructured interviews of key informants from a sample of practices stratified according to the extent they had changed behaviour in prescribing of ramipril and diabetes care more generally, following a specific educational intervention in Lincolnshire, United Kingdom. Interviews sought information on facilitators and barriers to change in organisational behaviour for the care of diabetes. An interprofessional protected learning time scheme event was perceived by some but not all participants as bringing about changes in processes for diabetes care. Participants cited examples of change introduced partly as a result of the educational session. This included using ACE inhibitors as first line for patients with diabetes who developed hypertension, increased use of aspirin, switching patients to glitazones, and conversion to insulin either directly or by referral to secondary care. Other reported factors for change, unrelated to the educational intervention, included financially driven performance targets, research evidence and national guidance. Facilitators for change linked to the educational session were peer support and teamworking supported by audit and comparative feedback. This study has shown how a protected learning time scheme, using interprofessional learning, local opinion leaders and early implementers as change agents may have influenced changes in systems of diabetes care in selected practices but also how other confounding factors played an important part in changes that occurred in practice.

The characteristics and impact of a hospitalist-staffed post-discharge clinic.

PubMed

Doctoroff, Lauren; Nijhawan, Ank; McNally, Diane; Vanka, Anita; Yu, Roger; Mukamal, Kenneth J

2013-11-01

Limited primary care access and care discontinuities hamper care for patients following hospital discharge. As the proportion of inpatient care delivered by hospitalists continues to increase, hybrid models that incorporate hospitalists in post-discharge care may ameliorate this problem. We established a post-discharge clinic staffed by hospitalists in a large academic urban primary care practice in October 2009. We compared visits of recently hospitalized patients seen in the post-discharge clinic with post-discharge visits elsewhere in the practice, including patient demographics, health care utilization, and duration from discharge, using generalized estimating equations to account for repeated hospitalizations. Patients seen in the post-discharge clinic and elsewhere in the practice were generally similar, although patients seen in the post-discharge clinic were particularly likely to be black and receive primary care from residents. Relative to other patients seen following discharge, patients in the post-discharge clinic were seen 8.45 ± 0.43 days earlier (P <.001). Among all 10,845 discharges of Healthcare Associates patients between 2009 and 2011, patients were 40% more likely to be seen within a week of discharge when the post-discharge clinic was open than when it was closed (adjusted odds ratio 1.41; 95% confidence interval, 1.25-1.57). In this primary care practice, a hospitalist-staffed post-discharge clinic was associated with substantially shorter time to first post-hospitalization visit and with improvement in the overall likelihood of an early visit among all hospitalized patients. It was particularly used by black patients and those seen by residents, in whom access tends to be most fragmented, and may represent a novel approach to the problem of post-discharge care. Copyright © 2013 Elsevier Inc. All rights reserved.

Reproducibility of clinical research in critical care: a scoping review.

PubMed

Niven, Daniel J; McCormick, T Jared; Straus, Sharon E; Hemmelgarn, Brenda R; Jeffs, Lianne; Barnes, Tavish R M; Stelfox, Henry T

2018-02-21

The ability to reproduce experiments is a defining principle of science. Reproducibility of clinical research has received relatively little scientific attention. However, it is important as it may inform clinical practice, research agendas, and the design of future studies. We used scoping review methods to examine reproducibility within a cohort of randomized trials examining clinical critical care research and published in the top general medical and critical care journals. To identify relevant clinical practices, we searched the New England Journal of Medicine, The Lancet, and JAMA for randomized trials published up to April 2016. To identify a comprehensive set of studies for these practices, included articles informed secondary searches within other high-impact medical and specialty journals. We included late-phase randomized controlled trials examining therapeutic clinical practices in adults admitted to general medical-surgical or specialty intensive care units (ICUs). Included articles were classified using a reproducibility framework. An original study was the first to evaluate a clinical practice. A reproduction attempt re-evaluated that practice in a new set of participants. Overall, 158 practices were examined in 275 included articles. A reproduction attempt was identified for 66 practices (42%, 95% CI 33-50%). Original studies reported larger effects than reproduction attempts (primary endpoint, risk difference 16.0%, 95% CI 11.6-20.5% vs. 8.4%, 95% CI 6.0-10.8%, P = 0.003). More than half of clinical practices with a reproduction attempt demonstrated effects that were inconsistent with the original study (56%, 95% CI 42-68%), among which a large number were reported to be efficacious in the original study and to lack efficacy in the reproduction attempt (34%, 95% CI 19-52%). Two practices reported to be efficacious in the original study were found to be harmful in the reproduction attempt. A minority of critical care practices with research published in high-profile journals were evaluated for reproducibility; less than half had reproducible effects.

The short-term effects of an integrated care model for the frail elderly on health, quality of life, health care use and satisfaction with care.

PubMed

Looman, Wilhelmina Mijntje; Fabbricotti, Isabelle Natalina; Huijsman, Robbert

2014-10-01

This study explores the short-term value of integrated care for the frail elderly by evaluating the effects of the Walcheren Integrated Care Model on health, quality of life, health care use and satisfaction with care after three months. Frailty was preventively detected in elderly living at home with the Groningen Frailty Indicator. Geriatric nurse practitioners and secondary care geriatric nursing specialists were assigned as case managers and co-ordinated the care agreed upon in a multidisciplinary meeting. The general practitioner practice functions as a single entry point and supervises the co-ordination of care. The intervention encompasses task reassignment between nurses and doctors and consultations between primary, secondary and tertiary care providers. The entire process was supported by multidisciplinary protocols and web-based patient files. The design of this study was quasi-experimental. In this study, 205 frail elderly patients of three general practitioner practices that implemented the integrated care model were compared with 212 frail elderly patients of five general practitioner practices that provided usual care. The outcomes were assessed using questionnaires. Baseline measures were compared with a three-month follow-up by chi-square tests, t-tests and regression analysis. In the short term, the integrated care model had a significant effect on the attachment aspect of quality of life. The frail elderly patients were better able to obtain the love and friendship they desire. The use of care did not differ despite the preventive element and the need for assessments followed up with case management in the integrated care model. In the short term, there were no significant changes in health. As frailty is a progressive state, it is assumed that three months are too short to influence changes in health with integrated care models. A more longitudinal approach is required to study the value of integrated care on changes in health and the preservation of the positive effects on quality of life and health care use.

The short-term effects of an integrated care model for the frail elderly on health, quality of life, health care use and satisfaction with care

PubMed Central

Looman, Wilhelmina Mijntje; Fabbricotti, Isabelle Natalina; Huijsman, Robbert

2014-01-01

Purpose This study explores the short-term value of integrated care for the frail elderly by evaluating the effects of the Walcheren Integrated Care Model on health, quality of life, health care use and satisfaction with care after three months. Intervention Frailty was preventively detected in elderly living at home with the Groningen Frailty Indicator. Geriatric nurse practitioners and secondary care geriatric nursing specialists were assigned as case managers and co-ordinated the care agreed upon in a multidisciplinary meeting. The general practitioner practice functions as a single entry point and supervises the co-ordination of care. The intervention encompasses task reassignment between nurses and doctors and consultations between primary, secondary and tertiary care providers. The entire process was supported by multidisciplinary protocols and web-based patient files. Methods The design of this study was quasi-experimental. In this study, 205 frail elderly patients of three general practitioner practices that implemented the integrated care model were compared with 212 frail elderly patients of five general practitioner practices that provided usual care. The outcomes were assessed using questionnaires. Baseline measures were compared with a three-month follow-up by chi-square tests, t-tests and regression analysis. Results and conclusion In the short term, the integrated care model had a significant effect on the attachment aspect of quality of life. The frail elderly patients were better able to obtain the love and friendship they desire. The use of care did not differ despite the preventive element and the need for assessments followed up with case management in the integrated care model. In the short term, there were no significant changes in health. As frailty is a progressive state, it is assumed that three months are too short to influence changes in health with integrated care models. A more longitudinal approach is required to study the value of integrated care on changes in health and the preservation of the positive effects on quality of life and health care use. PMID:25489294

Family-centred care delivery

PubMed Central

Mayo-Bruinsma, Liesha; Hogg, William; Taljaard, Monica; Dahrouge, Simone

2013-01-01

Abstract Objective To determine whether models of primary care service delivery differ in their provision of family-centred care (FCC) and to identify practice characteristics associated with FCC. Design Cross-sectional study. Setting Primary care practices in Ontario (ie, 35 salaried community health centres, 35 fee-for-service practices, 32 capitation-based health service organizations, and 35 blended remuneration family health networks) that belong to 4 models of primary care service delivery. Participants A total of 137 practices, 363 providers, and 5144 patients. Main outcome measures Measures of FCC in patient and provider surveys were based on the Primary Care Assessment Tool. Statistical analyses were conducted using linear mixed regression models and generalized estimating equations. Results Patient-reported FCC scores were high and did not vary significantly by primary care model. Larger panel size in a practice was associated with lower odds of patients reporting FCC. Provider-reported FCC scores were significantly higher in community health centres than in family health networks (P = .035). A larger number of nurse practitioners and clinical services on-site were both associated with higher FCC scores, while scores decreased as the number of family physicians in a practice increased and if practices were more rural. Conclusion Based on provider and patient reports, primary care reform strategies that encourage larger practices and more patients per family physician might compromise the provision of FCC, while strategies that encourage multidisciplinary practices and a range of services might increase FCC. PMID:24235195

The GP's perception of poverty: a qualitative study.

PubMed

Willems, Sara J; Swinnen, Wilfried; De Maeseneer, Jan M

2005-04-01

Health differences between people from lower and higher social classes increase. The accessibility of the health care system is one of the multiple and complex causes. The Physician's perceptions, beliefs and attitudes towards the patient are in this context important determinants. To explore the general practitioners' definition of poverty and their perception of the deprived patients' attitude towards health and health care, to get insight into the ways general practitioners deal with the problem of poverty and to present the proposals general practitioners make to improve health care for the deprived. The study involved qualitative methodology using 21 semi-structured interviews. The interviews were recorded and transcribed verbatim. The transcripts were coded using Framework Analysis techniques. Interviews were undertaken with general practitioners in primary care, working in a deprived area in the city of Ghent. In the definition of poverty, three concepts can be identified: socioeconomic aspects, psychological and individual characteristics, and socio-cultural concepts. General practitioners adopt different types of approaches to deal with deprived patients in practice: adaptation of the doctor-patient communication, lowering of the financial threshold, referral to specialists and other health care professionals. Including the issue of poverty and poverty in the curriculum of the medical students and in the in-service training for practicing doctors could have a positive impact on their attitude towards this patient group. Further research is needed into the barriers in the accessibility of the health care system for the deprived, exploring qualitatively and quantitatively the experiences and the living conditions of deprived patients and the perceptions of health care providers.

Reconfiguring diagnostic work in Danish general practice; regulation, triage and the secretaries as diagnostician.

PubMed

Andersen, Rikke Sand; Aarhus, Rikke

2017-07-31

Health care systems as well as bodies of medical knowledge are dynamic and change as the result of political and social transformations. In recent decades, health care systems have been subjected to a whole assemblage of regulatory practices. The local changes undertaken in Denmark that are being explored here are indicative of a long-term shift that has occurred in many welfare states intended to make public services in the Global North more efficient and transparent. Departing in prolonged field work in Danish general practice and the anthropological literature on audit culture, this paper suggests that the introduction of regulatory practices has enhanced the need for triage as a key organising principle. The term triage literally means separating out and refers to the process of sorting and placing patients in time and space. The paper suggests that an increasing introduction of triage feeds into a reconfiguration of diagnostic work, where the clinical setting is gradually becoming more intertwined with the governing domains of policy, and the work of the secretary is gradually becoming more intertwined with that of the doctor. Finally, the paper argues that an increasing regulation of general practice poses an ethically charged challenge to existing welfare politics of responsibility between the state and the public, as it makes it increasingly difficult to negotiate access to care.

Understanding the primary care paradigm: an experiential learning focus of the early veterinary graduate.

PubMed

Dixon, William H R; Kinnison, Tierney; May, Stephen A

2017-11-01

At a time where high levels of stress are reported in the veterinary profession, this study explores the challenges that veterinary graduates encounter when they enter general (first opinion) practice. Participants had written reflective accounts of their 'Most Puzzling Cases' for the postgraduate Professional Key Skills module of the Certificate in Advanced Veterinary Practice, offered by the Royal Veterinary College. Reasons that a case was puzzling, or became challenging, were thematically analysed. Fifteen summaries were analysed. Three core themes were identified: 'clinical reasoning', centred on the limitations of pattern recognition and the methods used to overcome this; the 'veterinary healthcare system', focusing on the need for continuity of care, time pressure and support in the transition to practice; and the 'owner', looking at the broader clinical skills needed to succeed in general practice. Clinical reasoning was raised as an issue; discussion of when pattern recognition is not appropriate and what to do in these cases was common. A lack of experience in general practice case types, and how to best operate in the resource-constrained environment in which they present, is the likely cause of this, suggesting that a greater focus on the primary care paradigm is needed within veterinary education. © British Veterinary Association (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Implementation of evidence-based knowledge in general practice.

PubMed

Le, Jette Videbæk

2017-12-01

Background Keeping up with the evidence and implementing it into the daily care for patients are fundamental prerequisites for delivering a high quality of care in general practice. However, despite many years of research into dissemination and implementation of evidence-based recommendations, significant challenges remain. In recent years, organisational factors have become widely acknowledged as vitally important for ensuring successful implementation. Further knowledge is needed to understand more about which factors affect the seeking and implementation of evidence-based knowledge in general practice. Aim The overall aim was to investigate how evidence-based knowledge is sought and implemented in general practice and to analyse associations with GP characteristics and quality of care. Three separate studies, each covering a specific part of the overall aim, were undertaken: I. To examine how GPs implement clinical practice guidelines in everyday clinical practice, and how implementation approaches differ between practices. II. To assess GPs’ information seeking behaviour with regard to the use and perceived importance of scientific medical information sources and to investigate associations with GP characteristics. III. To investigate if there are associations between specific formalised implementation activities within general practice and quality of care – exemplified by the use of spirometry testing among first-time users of medication against obstructive lung diseases. Methods The study was designed as a mixed methods study combining qualitative interviews, questionnaire and register data. Study I was a qualitative interview study that involved purposefully selected GPs representing seven different practices. The interviews were analysed using systematic text condensation, and results were used to qualify the development of a national survey of general practitioners regarding their seeking and implementation of evidence-based knowledge. This survey was distributed on December 4th to all GPs in Denmark who at the time had an email address registered at the Danish Organisation of GPs (N = 3,440). Study II was a cross-sectional study based on the survey data. In study III, while also applying a cross-sectional design, data on quality of care from national registers were linked to data from the survey. Spirometry testing among patients redeeming a first-time prescription for medication targeted obstructive lung diseases (R03 medication) was used as an example of an evidence-based recommendation, and thereby as a proxy for quality of care. Results Study I: The analysis of the semi-structured individual interviews revealed that approaches to implementation of clinical guidelines differed substantially between practices. Overall, three different approaches were identified, depending on the degree to which implementation was collectively and formally organised. In some practices, the GPs prioritised time and resources for collective implementation activities and organized their everyday practice to support these activities. In other practices, GPs discussed guidelines collectively, but left the application up to the individual GP whilst others saw no need for discussion or collective activities depending entirely on the individual GP’s decision on whether and how to manage implementation. The GPs’ attitudes to consistency in patient care appeared to be closely related to their approach to implementation. Study II: A total of 1,580 (46.4%) GPs responded to the questionnaire. Results showed that GPs’ information-seeking behaviour is associated with gender, age and practice form. Single-handed GPs use their colleagues as an information source significantly less than GPs working in partnership practices, and they do not use other sources more frequently. Compared with their younger colleagues, GPs aged over 44 years are less likely to seek information from colleagues, guidelines and websites, but more likely to seek information from medical journals. Male and female GPs seek information equally frequently. However, whereas male GPs are more likely than female GPs to find that pharmaceutical sales representative and non-refundable CME meetings are important sources in keeping medically updated, they are less likely to find that colleagues, refundable CME meetings, guidelines and drug information websites are important. Study III: GPs from 1,114 practices (58%) responded to the questionnaire, and 33,788 patients were linked to a responding practice. In partnership practices, compared with less frequent or no meetings, weekly interdisciplinary and weekly GP meetings were significantly associated with higher quality of care measured by patients’ OR of having spirometry performed. Furthermore, the development of practice protocols and standard recordings in the EMR in a range of disease areas, compared with only a few areas or none at all, were significantly associated with quality of care. The effect of formalised implementation activities was not as evident in single-handed practices as in partnerships. Conclusion The results show how GP characteristics could be taken into consideration when disseminating scientific medical information to better ensure that patients are provided with medically updated, high-quality care. Further, the study demonstrates the variation in approaches to implementation of evidence-based knowledge in general practices. This variation should be taken into consideration when developing quality improvement initiatives or interventions. Thus, knowledge of which approaches are used in specific practice settings could prove essential when deciding where to put the focus and support. Finally, the study indicates that important factors to be considered in that respect are the presence of formalised implementation activities in the practices as some degree of formalisation appears to contribute to sustaining a high quality of care by supporting implementation of evidence-based recommendations. Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

The evolution of nursing in Australian general practice: a comparative analysis of workforce surveys ten years on

PubMed Central

2014-01-01

Background Nursing in Australian general practice has grown rapidly over the last decade in response to government initiatives to strengthen primary care. There are limited data about how this expansion has impacted on the nursing role, scope of practice and workforce characteristics. This study aimed to describe the current demographic and employment characteristics of Australian nurses working in general practice and explore trends in their role over time. Methods In the nascence of the expansion of the role of nurses in Australian general practice (2003–2004) a national survey was undertaken to describe nurse demographics, clinical roles and competencies. This survey was repeated in 2009–2010 and comparative analysis of the datasets undertaken to explore workforce changes over time. Results Two hundred eighty four nurses employed in general practice completed the first survey (2003/04) and 235 completed the second survey (2009/10). Significantly more participants in Study 2 were undertaking follow-up of pathology results, physical assessment and disease specific health education. There was also a statistically significant increase in the participants who felt that further education/training would augment their confidence in all clinical tasks (p < 0.001). Whilst the impact of legal implications as a barrier to the nurses’ role in general practice decreased between the two time points, more participants perceived lack of space, job descriptions, confidence to negotiate with general practitioners and personal desire to enhance their role as barriers. Access to education and training as a facilitator to nursing role expansion increased between the two studies. The level of optimism of participants for the future of the nurses’ role in general practice was slightly decreased over time. Conclusions This study has identified that some of the structural barriers to nursing in Australian general practice have been addressed over time. However, it also identifies continuing barriers that impact practice nurse role development. Understanding and addressing these issues is vital to optimise the effectiveness of the primary care nursing workforce. PMID:24666420

Implementation of a health data-sharing infrastructure across diverse primary care organizations.

PubMed

Cole, Allison M; Stephens, Kari A; Keppel, Gina A; Lin, Ching-Ping; Baldwin, Laura-Mae

2014-01-01

Practice-based research networks bring together academic researchers and primary care clinicians to conduct research that improves health outcomes in real-world settings. The Washington, Wyoming, Alaska, Montana, and Idaho region Practice and Research Network implemented a health data-sharing infrastructure across 9 clinics in 3 primary care organizations. Following implementation, we identified challenges and solutions. Challenges included working with diverse primary care organizations, adoption of health information data-sharing technology in a rapidly changing local and national landscape, and limited resources for implementation. Overarching solutions included working with a multidisciplinary academic implementation team, maintaining flexibility, and starting with an established network for primary care organizations. Approaches outlined may generalize to similar initiatives and facilitate adoption of health data sharing in other practice-based research networks.

Implementation of a Health Data-Sharing Infrastructure Across Diverse Primary Care Organizations

PubMed Central

Cole, Allison M.; Stephens, Kari A.; Keppel, Gina A.; Lin, Ching-Ping; Baldwin, Laura-Mae

2014-01-01

Practice-based research networks bring together academic researchers and primary care clinicians to conduct research that improves health outcomes in real-world settings. The Washington, Wyoming, Alaska, Montana, and Idaho region Practice and Research Network implemented a health data-sharing infrastructure across 9 clinics in 3 primary care organizations. Following implementation, we identified challenges and solutions. Challenges included working with diverse primary care organizations, adoption of health information data-sharing technology in a rapidly changing local and national landscape, and limited resources for implementation. Overarching solutions included working with a multidisciplinary academic implementation team, maintaining flexibility, and starting with an established network for primary care organizations. Approaches outlined may generalize to similar initiatives and facilitate adoption of health data sharing in other practice-based research networks. PMID:24594564

The development and optimisation of a primary care-based whole system complex intervention (CARE Plus) for patients with multimorbidity living in areas of high socioeconomic deprivation

PubMed Central

O'Brien, Rosaleen; Fitzpatrick, Bridie; Higgins, Maria; Guthrie, Bruce; Watt, Graham; Wyke, Sally

2016-01-01

Objectives To develop and optimise a primary care-based complex intervention (CARE Plus) to enhance the quality of life of patients with multimorbidity in the deprived areas. Methods Six co-design discussion groups involving 32 participants were held separately with multimorbid patients from the deprived areas, voluntary organisations, general practitioners and practice nurses working in the deprived areas. This was followed by piloting in two practices and further optimisation based on interviews with 11 general practitioners, 2 practice nurses and 6 participating multimorbid patients. Results Participants endorsed the need for longer consultations, relational continuity and a holistic approach. All felt that training and support of the health care staff was important. Most participants welcomed the idea of additional self-management support, though some practitioners were dubious about whether patients would use it. The pilot study led to changes including a revised care plan, the inclusion of mindfulness-based stress reduction techniques in the support of practitioners and patients, and the stream-lining of the written self-management support material for patients. Discussion We have co-designed and optimised an augmented primary care intervention involving a whole-system approach to enhance quality of life in multimorbid patients living in the deprived areas. CARE Plus will next be tested in a phase 2 cluster randomised controlled trial. PMID:27068113

'Who's actually gonna read this?' An evaluation of staff experiences of the value of information contained in written care plans in supporting care in three different dementia care settings.

PubMed

Drummond, C; Simpson, A

2017-08-01

WHAT IS KNOWN ON THE SUBJECT?: A written plan is designed to improve communication and co-ordinate care between mental health inpatient wards and community settings. Reports of care plan quality issues and staff and service user dissatisfaction with healthcare bureaucracy have focused on working age mental health or general hospital settings. Little is known about mental health staff perspectives on the value of written care plans in supporting dementia care. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Competing demands on staff time and resources to meet administrative standards for care plans caused a tension with their own professional priorities for supporting care. Mental health staff face difficulties using electronic records alongside other systems of information sharing. Further exploration is needed of the gap between frontline staff values and those of the local organization and managers when supporting good dementia care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Frontline staff should be involved in designing new information systems including care plans. Care plan documentation needs to be refocused to ensure it is effective in enabling staff to communicate amongst themselves and with others to support people with dementia. Practice-based mentors could be deployed to strengthen good practice in effective information sharing. Background Reports of increased healthcare bureaucracy and concerns over care plan quality have emerged from research and surveys into staff and service user experiences. Little is known of mental health staff perspectives on the value of written care plans in supporting dementia care. Aim To investigate the experiences and views of staff in relation to care planning in dementia services in one National Health Service (NHS) provider Trust in England. Method Grounded Theory methodology was used. A purposive sample of 11 multidisciplinary staff were interviewed across three sites in one NHS Trust. Interviews were transcribed, coded and analysed using the constant comparative method. Findings Five themes were identified and are explored in detail below: (1) Repetition; (2) the impact of electronic records on practice; (3) ambivalence about the value of paperwork; (4) time conflicts; and (5) alternative sources of information to plan care. Discussion Participants perceived that written care plans did not help staff with good practice in planning care or to support dementia care generally. Staff were frustrated by repetitive documentation, inflexible electronic records and conflicting demands on their time. Implications for practice Frontline staff should be involved in designing new information systems including care plans. © 2017 John Wiley & Sons Ltd.

Proactive cancer care in primary care: a mixed-methods study.

PubMed

Kendall, Marilyn; Mason, Bruce; Momen, Natalie; Barclay, Stephen; Munday, Dan; Lovick, Roberta; Macpherson, Stella; Paterson, Euan; Baughan, Paul; Cormie, Paul; Kiehlmann, Peter; Free, Amanda; Murray, Scott A

2013-06-01

Current models of post-treatment cancer care are based on traditional practices and clinician preference rather than evidence of benefit. To assess the feasibility of using a structured template to provide holistic follow-up of patients in primary care from cancer diagnosis onwards. A two-phase mixed methods action research project. An electronic cancer ongoing review document (CORD) was first developed with patients and general practitioners, and used with patients with a new diagnosis of cancer. This was evaluated through documentary analysis of the CORDs, qualitative interviews with patients, family carers and health professionals and record reviews. The records of 107 patients from 13 primary care teams were examined and 45 interviews conducted. The document was started in 54% of people with newly diagnosed cancer, and prompted clear documentation of multidimension needs and understanding. General practitioners found using the document helped to structure consultations and cover psychosocial areas, but they reported it needed to be better integrated in their medical records with computerized prompts in place. Few clinicians discussed the review openly with patients, and the template was often completed afterwards. Anticipatory cancer care from diagnosis to cure or death, 'in primary care', is feasible in the U.K. and acceptable to patients, although there are barriers. The process promoted continuity of care and holism. A reliable system for proactive cancer care in general practice supported by hospital specialists may allow more survivorship care to be delivered in primary care, as in other long-term conditions.

Evidence from household surveys for measuring coverage of newborn care practices

PubMed Central

Sitrin, Deborah; Perin, Jamie; Vaz, Lara ME; Carvajal–Aguirre, Liliana; Khan, Shane M; Fishel, Joy; Amouzou, Agbessi

2017-01-01

Background Aside from breastfeeding, there are little data on use of essential newborn care practices, such as thermal protection and hygienic cord care, in high mortality countries. These practices have not typically been measured in national household surveys, often the main source for coverage data in these settings. The Every Newborn Action Plan proposed early breastfeeding as a tracer for essential newborn care due to data availability and evidence for the benefits of breastfeeding. In the past decade, a few national surveys have added questions on other practices, presenting an opportunity to assess the performance of early breastfeeding initiation as a tracer indicator. Methods We identified twelve national surveys between 2005–2014 that included at least one indicator for immediate newborn care in addition to breastfeeding. Because question wording and reference populations varied, we standardized data to the extent possible to estimate coverage of newborn care practices, accounting for strata and multistage survey design. We assessed early breastfeeding as a tracer by: 1) examining associations with other indicators using Pearson correlations; and 2) stratifying by early breastfeeding to determine differences in coverage of other practices for initiators vs non–initiators in each survey, then pooling across surveys for a meta–analysis, using the inverse standard error as the weight for each observation. Findings Associations between pairs of coverage indicators are generally weak, including those with breastfeeding. The exception is drying and wrapping, which have the strongest association of any two interventions in all five surveys where measured; estimated correlations for this range from 0.47 in Bangladesh’s 2007 DHS to 0.83 in Nepal’s 2006 DHS. The contrast in coverage for other practices by early breastfeeding is generally small; the greatest absolute difference was 6.7%, between coverage of immediate drying for newborns breastfed early compared to those who were not. Conclusions Early initiation of breastfeeding is not a high performing tracer indicator for essential newborn care practices measured in previous national surveys. To have informative data on whether newborns are getting life–saving services, standardized questions about specific practices, in addition to breastfeeding initiation, need to be added to surveys. PMID:29423180

[Need for clinical guidelines for chronic periodontitis in general and specialized Belgian practice].

PubMed

Cosyn, Jan; Thevissen, Eric; Reners, Michèle; Rompen, Eric; Klinge, Björn; De Bruyn, Hugo

2008-01-01

As the prevalence of periodontitis is more than 40 % in the adult Belgian population, periodontists are clearly understaffed to treat this disease in all patients. Therefore, it seems logic that mild forms of chronic periodontitis are treated by the general practitioner especially because Belgium lacks dental hygienists. Important prerequisites for organizing periodontal care as such relate to the general practitioner who should use the same techniques, have comparable communicative skills to motivate patients and create a similar amount of time for periodontal treatment as the specialist. After all, the patient has the right to qualitative treatment regardless of the level of education of the care provider. In order to guarantee this in general practice as much as possible, there is a need for clinical guidelines developed by specialists. These guidelines should not only support the general practitioner in treating disease; above all, they should assist the dentist in periodontal diagnosis. Hitherto, periodontal screening by general dentists seems to be infrequently performed even though reimbursement of the Dutch Periodontal Screening Index is implemented in the Belgian healthcare security system. In this manuscript possible explanations for this phenomenon are discussed. Apart from the need for guidelines in general practice, guidelines for surgical treatment seem compulsory to uniform treatment protocols in specialized practice. Extreme variation in the recommendation of surgery among Belgian specialists calls for consensus statements.

Improving the identification and management of chronic kidney disease in primary care: lessons from a staged improvement collaborative.

PubMed

Harvey, Gill; Oliver, Kathryn; Humphreys, John; Rothwell, Katy; Hegarty, Janet

2015-02-01

Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD. Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ∼ 30% were estimated to have suboptimal management according to Public Health Observatory analyses. An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices. A two-phase collaborative was implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do-Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement. Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as a marker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ∼ 2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved. An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention. © The Author 2014. Published by Oxford University Press in association with the International Society for Quality in Health Care.

Emergency general surgery: definition and estimated burden of disease.

PubMed

Shafi, Shahid; Aboutanos, Michel B; Agarwal, Suresh; Brown, Carlos V R; Crandall, Marie; Feliciano, David V; Guillamondegui, Oscar; Haider, Adil; Inaba, Kenji; Osler, Turner M; Ross, Steven; Rozycki, Grace S; Tominaga, Gail T

2013-04-01

Acute care surgery encompasses trauma, surgical critical care, and emergency general surgery (EGS). While the first two components are well defined, the scope of EGS practice remains unclear. This article describes the work of the American Association for the Surgery of Trauma to define EGS. A total of 621 unique International Classification of Diseases-9th Rev. (ICD-9) diagnosis codes were identified using billing data (calendar year 2011) from seven large academic medical centers that practice EGS. A modified Delphi methodology was used by the American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes to review these codes and achieve consensus on the definition of primary EGS diagnosis codes. National Inpatient Sample data from 2009 were used to develop a national estimate of EGS burden of disease. Several unique ICD-9 codes were identified as primary EGS diagnoses. These encompass a wide spectrum of general surgery practice, including upper and lower gastrointestinal tract, hepatobiliary and pancreatic disease, soft tissue infections, and hernias. National Inpatient Sample estimates revealed over 4 million inpatient encounters nationally in 2009 for EGS diseases. This article provides the first list of ICD-9 diagnoses codes that define the scope of EGS based on current clinical practices. These findings have wide implications for EGS workforce training, access to care, and research.

Contribution by primary health nurses and general practitioners to the Diabetes Annual Review (Get Checked) programme in Auckland, New Zealand.

PubMed

Daly, Barbara; Kenealy, Timothy; Arroll, Bruce; Sheridan, Nicolette; Scragg, Robert

2013-08-16

To describe primary health care (practice and specialist) nurses involvement in the government-funded annual diabetes review 'Get Checked' programme and the division of care between nurses and general practitioners in Auckland, New Zealand. Of the total 911 practice and specialist nurses identified and working in the greater Auckland region, 276 (30%) were randomly selected and invited to undertake a self-administered questionnaire and telephone interview in 2006-8. An 86% response rate was achieved. Over 60% of practice nurses and over half of specialist nurses participate in 'Get Checked' reviews. Of those nurses, 40% of practice and 70% specialist nurses, reported completing over half of the total number of 'Get Checked' reviews at their practice. Of the nurses sampled who work in general practice (n=198), 38% reported that 'nurses mostly complete' the reviews, 45% stated that 'nurses and doctors equally complete' them and 17% reported that only 'doctors' did so. For the nurses who reported that 'nurses and doctors equally complete' the reviews (n=89), most nurses undertake blood pressure measurements (90%), weigh patients (88%), give lifestyle advice (87%), examine patient's feet (73%), and 44% carried out the complete review of the patients they consult. These findings show the 'Get Checked' programme was successful in engaging practice and community-based specialist nurses in the community management of diabetes and has revealed positive relationships between nurses and doctors, extended roles for nurses and the importance of engaging nurses in the design of health care programmes.

Quantity, topics, methods and findings of randomised controlled trials published by German university departments of general practice - systematic review.

PubMed

Heinmüller, Stefan; Schneider, Antonius; Linde, Klaus

2016-04-23

Academic infrastructures and networks for clinical research in primary care receive little funding in Germany. We aimed to provide an overview of the quantity, topics, methods and findings of randomised controlled trials published by German university departments of general practice. We searched Scopus (last search done in April 2015), publication lists of institutes and references of included articles. We included randomised trials published between January 2000 and December 2014 with a first or last author affiliated with a German university department of general practice or family medicine. Risk of bias was assessed with the Cochrane tool, and study findings were quantified using standardised mean differences (SMDs). Thirty-three trials met the inclusion criteria. Seventeen were cluster-randomised trials, with a majority investigating interventions aimed at improving processes compared with usual care. Sample sizes varied between 6 and 606 clusters and 168 and 7807 participants. The most frequent methodological problem was risk of selection bias due to recruitment of individuals after randomisation of clusters. Effects of interventions over usual care were mostly small (SMD <0.3). Sixteen trials randomising individual participants addressed a variety of treatment and educational interventions. Sample sizes varied between 20 and 1620 participants. The methodological quality of the trials was highly variable. Again, effects of experimental interventions over controls were mostly small. Despite limited funding, German university institutes of general practice or family medicine are increasingly performing randomised trials. Cluster-randomised trials on practice improvement are a focus, but problems with allocation concealment are frequent.

Anaesthetic management of obese parturients: what is the evidence supporting practice guidelines?

PubMed

Eley, V A; van Zundert, A A J; Lipman, J; Callaway, L K

2016-09-01

Increasing rates of obesity in western populations present management difficulties for clinicians caring for obese pregnant women. Various governing bodies have published clinical guidelines for the care of obese parturients. These guidelines refer to two components of anaesthetic care: anaesthetic consultation in the antenatal period for women with a body mass index (BMI) ≥ 40 kg/m 2 and the provision of early epidural analgesia in labour. These recommendations are based on the increased incidence of obstetric complications and the predicted risks and difficulties in providing anaesthetic care. The concept behind early epidural analgesia is logical-site the epidural early, use it for surgical anaesthesia and avoid general anaesthesia if surgery is required. Experts support this recommendation, but there is weak supporting evidence. It is known that the management of labour epidurals in obese women is complicated and that women with extreme obesity require higher rates of general anaesthesia. Anecdotally, anaesthetists view and apply the early epidural recommendation inconsistently and the acceptability of early epidural analgesia to pregnant women is variable. In this topic review, we critically appraise these two practice recommendations. The elements required for effective implementation in multidisciplinary maternity care are considered. We identify gaps in the current literature and suggest areas for future research. While prospective cohort studies addressing epidural extension ('top-up') in obese parturients would help inform practice, audit of local practice may better answer the question "is early epidural analgesia beneficial to obese women in my practice?".

Experiences with online consultation systems in primary care: case study of one early adopter site

PubMed Central

Casey, Michael; Shaw, Sara; Swinglehurst, Deborah

2017-01-01

Background There is a strong policy drive towards implementing alternatives to face-to-face consultations in general practice to improve access, efficiency, and cost-effectiveness. These alternatives embrace novel technologies that are assumed to offer potential to improve care. Aim To explore the introduction of one online consultation system (Tele-Doc) and how it shapes working practices. Design and setting Mixed methods case study in an inner-city general practice. Method The study was conducted through interviews with IT developers, clinicians, and administrative staff, and scrutiny of documents, websites, and demonstrator versions of Tele-Doc, followed by thematic analysis and discourse analysis. Results Three interrelated themes were identified: online consultation systems as innovation, managing the ‘messiness’ of general practice consultations, and redistribution of the work of general practice. These themes raise timely questions about what it means to consult in contemporary general practice. Uptake of Tele-Doc by patients was low. Much of the work of the consultation was redistributed to patients and administrators, sometimes causing misunderstandings. The ‘messiness’ of consultations was hard to eliminate. In-house training focused on the technical application rather than associated transformations to practice work that were not anticipated. GPs welcomed varied modes of consulting, but the aspiration of improved efficiency was not realised in practice. Conclusion Tele-Doc offers a new kind of consultation that is still being worked out in practice. It may offer convenience for patients with discrete, single problems, and a welcome variation to GPs’ workload. Tele-Doc’s potential for addressing more complex problems and achieving efficiency is less clear, and its adoption may involve unforeseeable consequences. PMID:28993306

Do patient and practice characteristics confound age-group differences in preferences for general practice care? A quantitative study

PubMed Central

2013-01-01

Background Previous research showed inconsistent results regarding the relationship between the age of patients and preference statements regarding GP care. This study investigates whether elderly patients have different preference scores and ranking orders concerning 58 preference statements for GP care than younger patients. Moreover, this study examines whether patient characteristics and practice location may confound the relationship between age and the categorisation of a preference score as very important. Methods Data of the Consumer Quality Index GP Care were used, which were collected in 32 general practices in the Netherlands. The rank order and preference score were calculated for 58 preference statements for four age groups (0–30, 31–50, 51–74, 75 years and older). Using chi-square tests and logistic regression analyses, it was investigated whether a significant relationship between age and preference score was confounded by patient characteristics and practice location. Results Elderly patients did not have a significant different ranking order for the preference statements than the other three age groups (r = 0.0193; p = 0.41). However, in 53% of the statements significant differences were found in preference score between the four age groups. Elderly patients categorized significantly less preference statements as ‘very important’. In most cases, the significant relationships were not confounded by gender, education, perceived health, the number of GP contacts and location of the GP practice. Conclusion The preferences of elderly patients for GP care concern the same items as younger patients. However, their preferences are less strong, which cannot be ascribed to gender, education, perceived health, the number of GP contacts and practice location. PMID:23800156

Relationship between quality of care and choice of clinical computing system: retrospective analysis of family practice performance under the UK's quality and outcomes framework

PubMed Central

Kontopantelis, Evangelos; Buchan, Iain; Reeves, David; Checkland, Kath; Doran, Tim

2013-01-01

Objectives To investigate the relationship between performance on the UK Quality and Outcomes Framework pay-for-performance scheme and choice of clinical computer system. Design Retrospective longitudinal study. Setting Data for 2007–2008 to 2010–2011, extracted from the clinical computer systems of general practices in England. Participants All English practices participating in the pay-for-performance scheme: average 8257 each year, covering over 99% of the English population registered with a general practice. Main outcome measures Levels of achievement on 62 quality-of-care indicators, measured as: reported achievement (levels of care after excluding inappropriate patients); population achievement (levels of care for all patients with the relevant condition) and percentage of available quality points attained. Multilevel mixed effects multiple linear regression models were used to identify population, practice and clinical computing system predictors of achievement. Results Seven clinical computer systems were consistently active in the study period, collectively holding approximately 99% of the market share. Of all population and practice characteristics assessed, choice of clinical computing system was the strongest predictor of performance across all three outcome measures. Differences between systems were greatest for intermediate outcomes indicators (eg, control of cholesterol levels). Conclusions Under the UK's pay-for-performance scheme, differences in practice performance were associated with the choice of clinical computing system. This raises the question of whether particular system characteristics facilitate higher quality of care, better data recording or both. Inconsistencies across systems need to be understood and addressed, and researchers need to be cautious when generalising findings from samples of providers using a single computing system. PMID:23913774

The PULSAR primary care protocol: a stepped-wedge cluster randomized controlled trial to test a training intervention for general practitioners in recovery-oriented practice to optimize personal recovery in adult patients.

PubMed

Enticott, Joanne C; Shawyer, Frances; Brophy, Lisa; Russell, Grant; Fossey, Ellie; Inder, Brett; Mazza, Danielle; Vasi, Shiva; Weller, Penelope June; Wilson-Evered, Elisabeth; Edan, Vrinda; Meadows, Graham

2016-12-20

General practitioners (GPs) in Australia play a central role in the delivery of mental health care. This article describes the PULSAR (Principles Unite Local Services Assisting Recovery) Primary Care protocol, a novel mixed methods evaluation of a training intervention for GPs in recovery-oriented practice. The aim of the intervention is to optimize personal recovery in patients consulting study GPs for mental health issues. The intervention mixed methods design involves a stepped-wedge cluster randomized controlled trial testing the outcomes of training in recovery-oriented practice, together with an embedded qualitative study to identify the contextual enablers and challenges to implementing recovery-oriented practice. The project is conducted in Victoria, Australia between 2013 and 2017. Eighteen general practices and community health centers are randomly allocated to one of two steps (nine months apart) to start an intervention comprising GP training in the delivery of recovery-oriented practice. Data collection consists of cross-sectional surveys collected from patients of participating GPs at baseline, and again at the end of Steps 1 and 2. The primary outcome is improvement in personal recovery using responses to the Questionnaire about the Process of Recovery. Secondary outcomes are improvements in patient-rated measures of personal recovery and wellbeing, and of the recovery-oriented practice they have received, using the INSPIRE questionnaire, the Warwick-Edinburgh Mental Well-being Scale, and the Kessler Psychological Distress Scale. Participant data will be analyzed in the group that the cluster was assigned to at each study time point. Another per-protocol dataset will contain all data time-stamped according to the date of intervention received at each cluster site. Qualitative interviews with GPs and patients at three and nine months post-training will investigate experiences and challenges related to implementing recovery-oriented practice in primary care. Recovery-oriented practice is gaining increasing prominence in mental health service delivery and the outcomes of such an approach within the primary care sector for the first time will be evaluated in this project. If findings are positive, the intervention has the potential to extend recovery-oriented practice to GPs throughout the community. Australian and New Zealand Clinical Trial Registry ( ACTRN12614001312639 ). Registered: 8 August 2014.

An Exploratory Study of GP Perceptions of the Impact of a Primary Care Counselling Service on Their Practice

ERIC Educational Resources Information Center

Schafer, Tim; Amoateng, Geoffrey; Wrycraft, Nick

2009-01-01

This paper presents the results of research into GP perceptions of the impact of on-site counselling on general practice. The research is part of a larger evaluation of a local enhanced primary care mental service. The initial survey and in-depth interviews with GPs reported here focused on the pre-existing counselling service. The results suggest…

Readiness of Primary Care Practices for Medical Home Certification

PubMed Central

Clark, Sarah J.; Sakshaug, Joseph W.; Chen, Lena M.; Hollingsworth, John M.

2013-01-01

OBJECTIVES: To assess the prevalence of medical home infrastructure among primary care practices for children and identify practice characteristics associated with medical home infrastructure. METHODS: Cross-sectional analysis of restricted data files from 2007 and 2008 of the National Ambulatory Medical Care Survey. We mapped survey items to the 2011 National Committee on Quality Assurance’s Patient-Centered Medical home standards. Points were awarded for each “passed” element based on National Committee for Quality Assurance scoring, and we then calculated the percentage of the total possible points met for each practice. We used multivariate linear regression to assess associations between practice characteristics and the percentage of medical home infrastructure points attained. RESULTS: On average, pediatric practices attained 38% (95% confidence interval 34%–41%) of medical home infrastructure points, and family/general practices attained 36% (95% confidence interval 33%–38%). Practices scored higher on medical home elements related to direct patient care (eg, providing comprehensive health assessments) and lower in areas highly dependent on health information technology (eg, computerized prescriptions, test ordering, laboratory result viewing, or quality of care measurement and reporting). In multivariate analyses, smaller practice size was significantly associated with lower infrastructure scores. Practice ownership, urban versus rural location, and proportion of visits covered by public insurers were not consistently associated with a practice’s infrastructure score. CONCLUSIONS: Medical home programs need effective approaches to support practice transformation in the small practices that provide the vast majority of the primary care for children in the United States. PMID:23382438

Implementing evidence-based medicine in general practice: a focus group based study

PubMed Central

Hannes, Karin; Leys, Marcus; Vermeire, Etienne; Aertgeerts, Bert; Buntinx, Frank; Depoorter, Anne-Marie

2005-01-01

Background Over the past years concerns are rising about the use of Evidence-Based Medicine (EBM) in health care. The calls for an increase in the practice of EBM, seem to be obstructed by many barriers preventing the implementation of evidence-based thinking and acting in general practice. This study aims to explore the barriers of Flemish GPs (General Practitioners) to the implementation of EBM in routine clinical work and to identify possible strategies for integrating EBM in daily work. Methods We used a qualitative research strategy to gather and analyse data. We organised focus groups between September 2002 and April 2003. The focus group data were analysed using a combined strategy of 'between-case' analysis and 'grounded theory approach'. Thirty-one general practitioners participated in four focus groups. Purposeful sampling was used to recruit participants. Results A basic classification model documents the influencing factors and actors on a micro-, meso- as well as macro-level. Patients, colleagues, competences, logistics and time were identified on the micro-level (the GPs' individual practice), commercial and consumer organisations on the meso-level (institutions, organisations) and health care policy, media and specific characteristics of evidence on the macro-level (policy level and international scientific community). Existing barriers and possible strategies to overcome these barriers were described. Conclusion In order to implement EBM in routine general practice, an integrated approach on different levels needs to be developed. PMID:16153300

Predicting the scope of practice of family physicians.

PubMed

Wong, Eric; Stewart, Moira

2010-06-01

To identify factors that are associated with the scope of practice of FPs and GPs who have office-based practices. Secondary univariable and multivariable analyses of cross-sectional data from the 2001 National Family Physician Workforce Survey conducted by the College of Family Physicians of Canada. Canada. General community of FPs and GPs who spent most of their clinical time in office settings. Demographic characteristics and scope of practice score (SPS), which was the number of 12 selected medical services provided by office-based FPs and GPs. The multivariable model explained 35.1% of the variation in the SPS among participants. Geographic factors of provincial division and whether or not the population served was rural explained 30.5% of the variation in the SPS. Male physician sex, younger physician age, being in group practice, greater access to hospital beds, less access to specialists, main practice setting of an academic teaching unit, mixed method physician payment, additional structured postresidency training, and greater number of different types of allied health professionals in the main practice setting were also associated with higher SPSs. Geographic factors were the strongest determinants of scope of practice; physician-related factors, availability of health care resources to the main practice setting, and practice organization factors were weaker determinants. It is important to understand how and why geographic factors influence scope of practice, and whether a broad scope of practice independent of population needs benefits the population. This study supports primary care renewal efforts that use mixed payment systems, incorporate allied health care professionals into family and general practices, and foster group practices.

Management of venous leg ulcers in general practice - a practical guideline.

PubMed

Sinha, Sankar; Sreedharan, Sadhishaan

2014-09-01

Chronic venous leg ulcers are the most common wounds seen in general practice. Their management can be both challenging and time-consuming. To produce a short practical guideline incorporating the TIME concept and A2BC2D approach to help general practitioners and their practice nurses in delivering evidence-based initial care to patients with chronic venous leg ulcers. Most chronic venous leg ulcers can be managed effectively in the general practice setting by following the simple, evidence-based approach described in this article. Figure 1 provides a flow chart to aid in this process. Figure 2 illustrates the principles of management in general practice. Effective management of chronic ulcers involves the assessment of both the ulcer and the patient. The essential requirements of management are to debride the ulcer with appropriate precautions, choose dressings that maintain adequate moisture balance, apply graduated compression bandage after evaluation of the arterial circulation and address the patient's concerns, such as pain and offensive wound discharge.

Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England.

PubMed

Sansom, Anna; Terry, Rohini; Fletcher, Emily; Salisbury, Chris; Long, Linda; Richards, Suzanne H; Aylward, Alex; Welsman, Jo; Sims, Laura; Campbell, John L; Dean, Sarah G

2018-01-10

To identify factors influencing general practitioners' (GPs') decisions about whether or not to remain in direct patient care in general practice and what might help to retain them in that role. Qualitative, in-depth, individual interviews exploring factors related to GPs leaving, remaining in and returning to direct patient care. South West England, UK. 41 GPs: 7 retired; 8 intending to take early retirement; 11 who were on or intending to take a career break; 9 aged under 50 years who had left or were intending to leave direct patient care and 6 who were not intending to leave or to take a career break. Plus 19 stakeholders from a range of primary care-related professional organisations and roles. Reasons for leaving direct patient care were complex and based on a range of job-related and individual factors. Three key themes underpinned the interviewed GPs' thinking and rationale: issues relating to their personal and professional identity and the perceived value of general practice-based care within the healthcare system; concerns regarding fear and risk, for example, in respect of medical litigation and managing administrative challenges within the context of increasingly complex care pathways and environments; and issues around choice and volition in respect of personal social, financial, domestic and professional considerations. These themes provide increased understanding of the lived experiences of working in today's National Health Service for this group of GPs. Future policies and strategies aimed at retaining GPs in direct patient care should clarify the role and expectations of general practice and align with GPs' perception of their own roles and identity; demonstrate to GPs that they are valued and listened to in planning delivery of the UK healthcare; target GPs' concerns regarding fear and risk, seeking to reduce these to manageable levels and give GPs viable options to support them to remain in direct patient care. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice.

PubMed

MacKichan, Fiona; Brangan, Emer; Wye, Lesley; Checkland, Kath; Lasserson, Daniel; Huntley, Alyson; Morris, Richard; Tammes, Peter; Salisbury, Chris; Purdy, Sarah

2017-05-04

To describe how processes of primary care access influence decisions to seek help at the emergency department (ED). Ethnographic case study combining non-participant observation, informal and formal interviewing. Six general practitioner (GP) practices located in three commissioning organisations in England. Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29). Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like 'urgent' and 'emergency' was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use. This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around 'inappropriate' patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Mental health and health-care use of detainees in police custody.

PubMed

Dorn, Tina; Ceelen, Manon; Buster, Marcel; Stirbu, Irina; Donker, Gé; Das, Kees

2014-08-01

In many countries, forensic physicians function as primary care providers for detainees in police custody. Their task is comparable to the tasks of general practitioners. Nevertheless, problems presented by both patient populations may differ. We therefore aimed to systematically compare presented problems and medication use in a population of police detainees to those of regular patients in general practice. Health problems and prescription medications of 3232 detainees seen by the Amsterdam Forensic Medical Service were compared to those of general practice patients (n = 78,975) adjusted for age and gender during a 12-month period. Among those obtaining medical attention (28% of all detainees), almost 50% were diagnosed with mental health problems, with substance abuse as the leading reason for consultation. Forty-two percent received at least one prescription affecting the nervous system. In general practice, 17% (P < 0.001) of patients consulting their GP were diagnosed with mental health problems and 22% (P < 0.001) were prescribed medications affecting the nervous system. The magnitude of mental health problems among police detainees has significant implications for the qualifications of police health staff and those who provide health care in the police setting especially concerning substance abuse. Copyright © 2014 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

A regional programme to improve skin cancer management.

PubMed

McGeoch, Graham R; Sycamore, Mark J; Shand, Brett I; Simcock, Jeremy W

2015-12-01

In 2008, public specialist and general practice services in Canterbury were unable to manage demand for skin cancer treatment. Local clinicians decided the solution was to develop a see-and-treat skin excision clinic staffed by plastic surgeons and general practitioners (GPs), and the introduction of subsidised excisions in general practice. This paper describes the collaboration between clinicians, managers and funders and the results and quality management measures of these initiatives. There is an increasing incidence of skin cancer. GPs in Canterbury were unable to meet increasing demand for skin cancer treatment because some lacked confidence and competence in skin cancer management. There was no public funding for primary care management of skin cancer, driving patients to fully funded secondary care services. Secondary care services were at capacity, with no coordinated programme across primary and secondary care. The programme has resulted in a greater number of skin cancers being treated by the public health system, a reduction in waiting times for treatment, and fewer minor skin lesions being referred to secondary care. Quality measures have been achieved and are improving steadily. Development of the programme has improved working relationships between primary and secondary care clinicians. The strategy was to facilitate the working relationship between primary and secondary care and increase the capacity for skin lesion excisions in both sectors. Skin cancer management can be improved by a coordinated approach between primary and secondary care.

Treatment of hip/knee osteoarthritis in Dutch general practice and physical therapy practice: an observational study.

PubMed

Barten, Di-Janne J A; Swinkels, Llse C S; Dorsman, Sara A; Dekker, Joost; Veenhof, Cindy; de Bakker, Dinny H

2015-06-27

A multidisciplinary, guideline-based Stepped-Care-Strategy (SCS), has recently been developed to improve the management of hip and knee osteoarthritis (OA). To date, it is unknown to what extent current Dutch OA care is consistent with the SCS, both with respect to the content of care as well as the sequence of care. Furthermore, there is a lack of clarity regarding the role of different health care providers in the performance of OA care according to the SCS. Therefore, the main purpose of this study is to describe the content of primary care in patients with hip/knee OA, including the compliance to the SCS and taking into account the introduction of patient self-referral to physical therapy. Data were used from NIVEL Primary Care Database. In total, 12.118 patients with hip/knee OA who visited their GP or physical therapist were selected. Descriptive statistics were used to compare the content of care in GP-referred and self-referred patients to physical therapy. Content of care performed by GPs mostly concerned consultations, followed by NSAID prescriptions and referrals to secondary care. Both prescriptions of acetaminophen and referrals to physical therapy respectively dietary therapy were rarely mentioned. Nevertheless, still 65% of the patients in physical therapy practice were referred by their GP. Compared to GP-referred patients, self-referred patients more often presented recurrent complaints and were treated less often by activity-related exercise therapy. Education was rarely registered as singular intervention, neither in GP-referred nor in self-referred patients. In accordance with the SCS, less advanced interventions are more often applied than more advanced interventions. To optimize the adherence to the SCS, GPs could reconsider the frequent use of NSAIDs instead of analgesics and the low referral rate to allied health care. Self-referral to physical therapy partially distorts both the low referral rate in general practice and the low application rate of education as singular intervention in physical therapy practice. Further research is recommended to evaluate the effects of task-shifting in OA care, taking into account the content of the SCS.

A randomised controlled trial of a lengthened and multi-disciplinary consultation model in a socially deprived community: a study protocol.

PubMed

Whitford, David L; Chan, Wai-Sun

2007-06-28

There has been little development of the general practice consultation over the years, and many aspects of the present consultation do not serve communities with multiple health and social problems well. Many of the problems presenting to general practitioners in socio-economically disadvantaged areas are not amenable to a purely medical solution, and would particularly benefit from a multidisciplinary approach. Socio-economic deprivation is also associated with those very factors (more psychosocial problems, greater need for health promotion, more chronic diseases, more need for patient enablement) that longer consultations have been shown to address. This paper describes our study protocol, which aims to evaluate whether a lengthened multidisciplinary primary care team consultation with families in a socially deprived area can improve the psychological health of mothers in the families. In a randomised controlled trial, families with a history of social problems, substance misuse or depression are randomly allocated to an intervention or control group. The study is based in three general practices in a highly deprived area of North Dublin. Primary health care teams will be trained in conducting a multidisciplinary lengthened consultation. Families in the intervention group will participate in the new style multidisciplinary consultation. Outcomes of families receiving the intervention will be compared to the control group who will receive only usual general practitioner care. The primary outcome is the psychological health of mothers of the families and secondary outcomes include general health status, quality of life measures and health service usage. The main aim of this study is to evaluate the effectiveness of a lengthened multidisciplinary team consultation in primary care. The embedded nature of this study in general practices in a highly deprived area ensures generalisability to other deprived communities, but more particularly it promises relevance to primary care. Current Controlled Trials ISRCTN70578736.

Proactive cancer care in primary care: a mixed-methods study

PubMed Central

Murray, Scott A

2013-01-01

Background. Current models of post-treatment cancer care are based on traditional practices and clinician preference rather than evidence of benefit. Objectives. To assess the feasibility of using a structured template to provide holistic follow-up of patients in primary care from cancer diagnosis onwards. Methods. A two-phase mixed methods action research project. An electronic Cancer Ongoing Review Document (CORD) was first developed with patients and general practitioners, and used with patients with a new diagnosis of cancer. This was evaluated through documentary analysis of the CORDs, qualitative interviews with patients, family carers and health professionals and record reviews. Results. The records of 107 patients from 13 primary care teams were examined and 45 interviews conducted. The document was started in 54% of people with newly diagnosed cancer, and prompted clear documentation of multidimension needs and understanding. General practitioners found using the document helped to structure consultations and cover psychosocial areas, but they reported it needed to be better integrated in their medical records with computerized prompts in place. Few clinicians discussed the review openly with patients, and the template was often completed afterwards. Conclusions. Anticipatory cancer care from diagnosis to cure or death, ‘in primary care’, is feasible in the UK and acceptable to patients, although there are barriers. The process promoted continuity of care and holism. A reliable system for proactive cancer care in general practice supported by hospital specialists may allow more survivorship care to be delivered in primary care, as in other long-term conditions. PMID:23382502

Overcoming barriers in care for the dying: Theoretical analysis of an innovative program model.

PubMed

Wallace, Cara L

2016-08-01

This article explores barriers to end-of-life (EOL) care (including development of a death denying culture, ongoing perceptions about EOL care, poor communication, delayed access, and benefit restrictions) through the theoretical lens of symbolic interactionism (SI), and applies general systems theory (GST) to a promising practice model appropriate for addressing these barriers. The Compassionate Care program is a practice model designed to bridge gaps in care for the dying and is one example of a program offering concurrent care, a recent focus of evaluation though the Affordable Care Act. Concurrent care involves offering curative care alongside palliative or hospice care. Additionally, the program offers comprehensive case management and online resources to enrollees in a national health plan (Spettell et al., 2009).SI and GST are compatible and interrelated theories that provide a relevant picture of barriers to end-of-life care and a practice model that might evoke change among multiple levels of systems. These theories promote insight into current challenges in EOL care, as well as point to areas of needed research and interventions to address them. The article concludes with implications for policy and practice, and discusses the important role of social work in impacting change within EOL care.

Fostering clinical engagement and medical leadership and aligning cultural values: an evaluation of a general practice specialty trainee integrated training placement in a primary care trust.

PubMed

Ruston, Annmarie; Tavabie, Abdol

2010-01-01

To report on the extent to which a general practice specialty trainee integrated training placement (ITP) developed the leadership skills and knowledge of general practice specialty trainees (GPSTRs) and on the potential of the ITP to improve clinical engagement. A case study method was used in a Kent primary care trust (PCT). Sources of data included face-to-face and telephone interviews (three GPSTRs, three PCT clinical supervisors, three general practitioner (GP) clinical supervisors and three Deanery/PCT managers), reflective diaries, documentary sources and observation. Interview data were transcribed and analysed using the constant comparative method. All respondents were positive about the value and success of the ITP in developing the leadership skills of the GPSTRs covering three dimensions: leadership of self, leadership of teams and leadership of organisations within systems. The ITP had enabled GP trainees to understand the context for change, to develop skills to set the direction for change and to collect and apply evidence to decision making. The ITP was described as an effective means of breaking down cultural barriers between general practice and the PCT and as having the potential for improving clinical engagement. The ITP provided a model to enable the effective exchange of knowledge and understanding of differing cultures between GPSTRs, general practice and the PCT. It provided a sound basis for effective, dispersed clinical engagement and leadership.

What’s in a dental practice-based research network?

PubMed Central

Cunha-Cruz, Joana; Hilton, Thomas J.; Ferracane, Jack; Berg, Joel; Zhou, Lingmei; Rothen, Marilynn

2011-01-01

Objectives The authors conducted a study to describe the general dentists, practices, patients and patient care patterns of the dental practice-based research network (PBRN) Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry (PRECEDENT). Methods Northwest PRECEDENT is a dental PBRN of general and pediatric dentists and orthodontists from five U.S. states in the Northwest: Idaho, Montana, Oregon, Utah and Washington. The authors collected data from general dentists in Northwest PRECEDENT (n = 101) regarding the diagnosis and treatment of oral diseases in a survey with a systematic random sample of patients (N = 1,943) visiting their practices. They also obtained demographic data from the general dentists and their patients. Results The authors found that 50 percent of the general dentists were 51 to 60 years of age, 14 percent were female and 76 percent were non-Hispanic white. More than one-half (55 percent) of the dentists had practiced dentistry for more than 20 years, 83 percent had private solo practices and 32 percent practiced in rural community settings. The majority (71 percent) of patients visiting the dental practices was in the age range of 18 to 64 years, 55 percent were female and 84 percent were non-Hispanic white. In terms of reasons for seeking dental care, 52 percent of patients overall visited the dentist for oral examinations, checkups, prophylaxis or caries-preventive treatment. In the preceding year, 85 percent of the patients had received prophylaxis, 49 percent restorative treatments, 34 percent caries-preventive treatments and 10 percent endodontic treatments. Conclusions Northwest PRECEDENT general dentists are dispersed geographically and are racially and ethnically diverse, owing in part to efforts by network administrators and coordinators to enroll minority dentists and those who practice in rural areas. Estimates of characteristics of dentists and patients in Northwest PRECEDENT will be valuable in planning future studies of oral diseases and treatments. PMID:20592411

What's in a dental practice-based research network? Characteristics of Northwest PRECEDENT dentists, their patients and office visits.

PubMed

DeRouen, Timothy A; Cunha-Cruz, Joana; Hilton, Thomas J; Ferracane, Jack; Berg, Joel; Zhou, Lingmei; Rothen, Marilynn

2010-07-01

The authors conducted a study to describe the general dentists, practices, patients and patient care patterns of the dental practice-based research network (PBRN) Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry (PRECEDENT). Northwest PRECEDENT is a dental PBRN of general and pediatric dentists and orthodontists from five U.S. states in the Northwest: Idaho, Montana, Oregon, Utah and Washington. The authors collected data from general dentists in Northwest PRECEDENT (n = 101) regarding the diagnosis and treatment of oral diseases in a survey with a systematic random sample of patients (N = 1,943) visiting their practices. They also obtained demographic data from the general dentists and their patients. The authors found that 50 percent of the general dentists were 51 to 60 years of age, 14 percent were female and 76 percent were non-Hispanic white. More than one-half (55 percent) of the dentists had practiced dentistry for more than 20 years, 83 percent had private solo practices and 32 percent practiced in rural community settings. The majority (71 percent) of patients visiting the dental practices was in the age range of 18 to 64 years, 55 percent were female and 84 percent were non-Hispanic white. In terms of reasons for seeking dental care, 52 percent of patients overall visited the dentist for oral examinations, checkups, prophylaxis or caries-preventive treatment. In the preceding year, 85 percent of the patients had received prophylaxis, 49 percent restorative treatments, 34 percent caries-preventive treatments and 10 percent endodontic treatments. Northwest PRECEDENT general dentists are dispersed geographically and are racially and ethnically diverse, owing in part to efforts by network administrators and coordinators to enroll minority dentists and those who practice in rural areas. Estimates of characteristics of dentists and patients in Northwest PRECEDENT will be valuable in planning future studies of oral diseases and treatments.

Interest and applicability of acute care surgery among surgeons in Quebec: a provincial survey.

PubMed

Joos, Émilie; Trottier, Vincent; Thauvette, Daniel

2013-08-01

Acute care surgery (ACS) comprises trauma and emergency surgery. The purpose of this new specialty is to involve trauma and nontrauma surgeons in the care of acutely ill patients with a surgical pathology. In Quebec, few acute care surgery services (ACSS) exist, and the concept is still poorly understood by most general surgeons. This survey was meant to determine the opinions and interest of Quebec general surgeons in this new model. We created a bilingual electronic survey using a Web interface and sent it by email to all surgeons registered with the Association québécoise de chirurgie. A reminder was sent 2 weeks later to boost response rates. The response rate was 36.9%. Most respondents had academic practices, and 16% worked in level 1 trauma centres. Most respondents had a high operative case load, and 66% performed at least 10 urgent general surgical cases per month. Although most (88%) thought that ACS was an interesting field, only 45% were interested in participating in an ACSS. Respondents who deemed this concept least applicable to their practices were more likely to be working in nonacademic centres. Despite a strong interest in emergency general surgery, few surgeons were interested in participating in an ACSS. This finding may be explained by lack of comprehension of this new model and by comfort with traditional practice. We aim to change this paradigm by demonstrating the feasibility and benefits of the new ACSS at our centre in a follow-up study.

Applying clinical guidelines in general practice: a qualitative study of potential complications.

PubMed

Austad, Bjarne; Hetlevik, Irene; Mjølstad, Bente Prytz; Helvik, Anne-Sofie

2016-07-22

Clinical guidelines for single diseases often pose problems in general practice work with multimorbid patients. However, little research focuses on how general practice is affected by the demand to follow multiple guidelines. This study explored Norwegian general practitioners' (GPs') experiences with and reflections upon the consequences for general practice of applying multiple guidelines. Qualitative focus group study carried out in Mid-Norway. The study involved a purposeful sample of 25 Norwegian GPs from four pre-existing groups. Interviews were audio-recorded, transcribed and analyzed using systematic text condensation, i.e. applying a phenomenological approach. The GPs' responses clustered around two major topics: 1) Complications for the GPs of applying multiple guidelines; and, 2) Complications for their patients when GPs apply multiple guidelines. For the GPs, applying multiple guidelines created a highly problematic situation as they felt obliged to implement guidelines that were not suited to their patients: too often, the map and the terrain did not match. They also experienced greater insecurity regarding their own practice which, they admitted, resulted in an increased tendency to practice 'defensive medicine'. For their patients, the GPs experienced that applying multiple guidelines increased the risk of polypharmacy, excessive non-pharmacological recommendations, a tendency toward medicalization and, for some, a reduction in quality of life. The GPs experienced negative consequences when obliged to apply a variety of single disease guidelines to multimorbid patients, including increased risk of polypharmacy and overtreatment. We believe patient-centered care and the GPs' courage to non-comply when necessary may aid in reducing these risks. Health care authorities and guideline developers need to be aware of the potential negative effects of applying a single disease focus in general practice, where multimorbidity is highly prevalent.

Sharing resources to create a district drug formulary: a countywide controlled trial.

PubMed Central

Hill-Smith, I

1996-01-01

BACKGROUND: Creating a drug formulary takes considerable time, but merely adopting one lacks local perspective and ownership. Sharing resources between several practices treads a middle path between these extremes, but is it effective? AIM: The aim of the study was to audit the influence of a district primary care drug formulary on prescribing by general practitioners. METHOD: A controlled trial was carried out to compare prescribing by 50 general practitioners from 11 urban and semirural practices in south Bedfordshire that participated in creating a district drug formulary with prescribing by all other general practitioners in the county. RESULTS: The proportion of prescription items that were for drugs listed in the formulary rose significantly in three therapeutics groups: cardiovascular (by 7-12% above control practice values); musculoskeletal (by 1-11% above control practice values); and obstetrics and gynaecology (by 6-9% above control practice values). The number of items prescribed per prescribing unit fell significantly in three therapeutic groups: musculoskeletal (by 1-7% below control practice values); nervous (by 7-12% below control practice values); and nutrition and blood (by 15-21% below control practice values). The estimated saving resulting from the creation of the formulary was 150,000 pounds (3000 pounds per doctor) per year. CONCLUSIONS: Sharing resources between practices to create a district-wide primary care drug formulary can lead to changes in prescribing and reduce costs sustained over 3 years. PMID:8762741

Provision of medical student teaching in UK general practices: a cross-sectional questionnaire study

PubMed Central

Harding, Alex; Rosenthal, Joe; Al-Seaidy, Marwa; Gray, Denis Pereira; McKinley, Robert K

2015-01-01

Background Health care is increasingly provided in general practice. To meet this demand, the English Department of Health recommends that 50% of all medical students should train for general practice after qualification. Currently 19% of medical students express general practice as their first career choice. Undergraduate exposure to general practice positively influences future career choice. Appropriate undergraduate exposure to general practice is therefore highly relevant to workforce planning Aim This study seeks to quantify current exposure of medical students to general practice and compare it with past provision and also with postgraduate provision. Design and setting A cross-sectional questionnaire in the UK. Method A questionnaire regarding provision of undergraduate teaching was sent to the general practice teaching leads in all UK medical schools. Information was gathered on the amount of undergraduate teaching, how this was supported financially, and whether there was an integrated department of general practice. The data were then compared with results from previous studies of teaching provision. The provision of postgraduate teaching in general practice was also examined. Results General practice teaching for medical students increased from <1.0% of clinical teaching in 1968 to 13.0% by 2008; since then, the percentage has plateaued. The total amount of general practice teaching per student has fallen by 2 weeks since 2002. Medical schools providing financial data delivered 14.6% of the clinical curriculum and received 7.1% of clinical teaching funding. The number of departments of general practice has halved since 2002. Provision of postgraduate teaching has tripled since 2000. Conclusion Current levels of undergraduate teaching in general practice are too low to fulfil future workforce requirements and may be falling. Financial support for current teaching is disproportionately low and the mechanism counterproductive. Central intervention may be required to solve this. PMID:26009536

Room for improvement? Leadership, innovation culture and uptake of quality improvement methods in general practice.

PubMed

Apekey, Tanefa A; McSorley, Gerry; Tilling, Michelle; Siriwardena, A Niroshan

2011-04-01

Leadership and innovation are currently seen as essential elements for the development and maintenance of high-quality care. Little is known about the relationship between leadership and culture of innovation and the extent to which quality improvement methods are used in general practice. This study aimed to assess the relationship between leadership behaviour, culture of innovation and adoption of quality improvement methods in general practice. Self-administered postal questionnaires were sent to general practitioner quality improvement leads in one county in the UK between June and December 2007. The questionnaire consisted of background information, a 12-item scale to assess leadership behaviour, a seven-dimension self-rating scale for culture of innovation and questions on current use of quality improvement tools and techniques. Sixty-three completed questionnaires (62%) were returned. Leadership behaviours were not commonly reported. Most practices reported a positive culture of innovation, featuring relationship most strongly, followed by targets and information but rated lower on other dimensions of rewards, risk and resources. There was a significant positive correlation between leadership behaviour and the culture of innovation (r = 0.57; P < 0.001). Apart from clinical audit and significant event analysis, quality improvement methods were not adopted by most participating practices. Leadership behaviours were infrequently reported and this was associated with a limited culture of innovation in participating general practices. There was little use of quality improvement methods beyond clinical and significant event audit. Practices need support to enhance leadership skills, encourage innovation and develop quality improvement skills if improvements in health care are to accelerate. © 2010 Blackwell Publishing Ltd.

Maldistribution or scarcity of nurses? The devil is in the detail.

PubMed

Both-Nwabuwe, Jitske M C; Dijkstra, Maria T M; Klink, Ab; Beersma, Bianca

2018-03-01

The goal of this paper was to improve our understanding of nursing shortages across the variety of health care sectors and how this may affect the agenda for addressing nursing shortages. A health care sector comprises a number of health care services for one particular type of patient care, for example, the hospital care sector. Most Western countries are shifting health care services from hospital care towards community and home care, thus increasing nursing workforce challenges in home and community care. In order to implement appropriate policy responses to nursing workforce challenges, we need to know if these challenges are caused by maldistribution of nurses and/or the scarcity of nurses in general. Focusing on the Netherlands, we reviewed articles based on data of a labour market research programme and/or data from the Dutch Employed Persons' Insurance Administration Agency. The data were analysed using a data synthesis approach. Nursing shortages are unevenly distributed across the various health care sectors. Shortages of practical nurses are caused by maldistribution, with a long-term projected surplus of practical nurses in hospitals and projected shortages in nursing/convalescent homes and home care. Shortages of first-level registered nurses are caused by general scarcity in the long term, mainly in hospitals and home care. Nursing workforce challenges are caused by a maldistribution of nurses and the scarcity of nurses in general. To implement appropriate policy responses to nursing workforce challenges, integrated health care workforce planning is necessary. Integrated workforce planning models could forecast the impact of health care transformation plans and guide national policy decisions on transitioning programmes. Effective transitioning programmes are required to address nursing shortages and to diminish maldistribution. In addition, increased recruitment and retention as well as new models of care are required to address the scarcity of nurses in general. © 2017 John Wiley & Sons Ltd.

Encourages and guides, or diagnoses and monitors: Woman centred-ness in the discourse of professional midwifery bodies.

PubMed

O'Malley-Keighran, M P; Lohan, G

2016-12-01

the purpose of this study was to conduct a preliminary exploration of the language used by midwifery professional bodies to define the scope of practice of midwives in relation to woman-centred care. this is a qualitative study in which Critical Discourse Analysis and Transitivity Analysis from the Systemic Functional Linguistics tradition were used. Data were sampled from nine international midwifery professional bodies. three general types of definitions of scope of practice were identified; a formal type which focused on midwifery practice in which the midwife and woman were largely absent as agents, a second, less formal type which focused on the midwife as agent, from which the woman was largely absent as an active participant and one exception to the pattern which featured the woman as agent. The main type of verb used in the definitions was Doing Processes such as monitor, diagnose. Saying (advise), Sensing (identify), and Being (be able to) processes were much less frequent in the data. The definitions of scope of practice explored in this study (with one exception) revealed a general lack of woman-centeredness and more of a focus on an orientation to birth as a medically managed event. definitions of scope of practice statements by professional bodies are systematically developed through much conscious thought and discussion by the writers on behalf of a community of practice and are formulated specifically for the purpose of being available to the general public as well as midwives. It can be assumed that the choices of wording and content are carefully constructed with public dissemination in mind. These ideologies communicated via the professional body texts emanate from a socio-cultural context that varies from country to country and professional bodies construct the definitions by drawing on the available, circulating discourses. Although woman-centred care is a key focus in contemporary maternity care, many definitions of scope of practice reveal a continuing orientation to a medical model of pregnancy and birth and a synonymisation of midwife-led care with woman centred care. by analysing statements of scope of practice by professional bodies and the contexts in which they are produced, we can continue to reveal the underlying social, political, and historical forces that influence midwifery practice. This paper examines some key examples of the professional discourse of midwifery in relation to the definition of the midwife and scope of practice in order to reflect on what these examples may tell us about the professional culture of midwifery and the implications for woman-centred care. Copyright © 2016 Elsevier Ltd. All rights reserved.

Quality of tuberculosis care in India: a systematic review

PubMed Central

Satyanarayana, S.; Subbaraman, R.; Shete, P.; Gore, G.; Das, J.; Cattamanchi, A.; Mayer, K.; Menzies, D.; Harries, A. D.; Hopewell, P.; Pai, M.

2015-01-01

SUMMARY BACKGROUND While Indian studies have assessed care providers’ knowledge and practices, there is no systematic review on the quality of tuberculosis (TB) care. METHODS We searched multiple sources to identify studies (2000–2014) on providers’ knowledge and practices. We used the International Standards for TB Care to benchmark quality of care. RESULTS Of the 47 studies included, 35 were questionnaire surveys and 12 used chart abstraction. None assessed actual practice using standardised patients. Heterogeneity in the findings precluded meta-analysis. Of 22 studies evaluating provider knowledge about using sputum smears for diagnosis, 10 found that less than half of providers had correct knowledge; 3 of 4 studies assessing self-reported practices by providers found that less than a quarter reported ordering smears for patients with chest symptoms. In 11 of 14 studies that assessed treatment, less than one third of providers knew the standard regimen for drug-susceptible TB. Adherence to standards in practice was generally lower than correct knowledge of those standards. Eleven studies with both public and private providers found higher levels of appropriate knowledge/practice in the public sector. CONCLUSIONS Available evidence suggests suboptimal quality of TB care, particularly in the private sector. Improvement of quality of care should be a priority for India. PMID:26056098

Using Practice-Based Evidence to Improve Supportive Care Practices to Reduce Central Line-Associated Bloodstream Infections in a Pediatric Oncology Unit [Formula: see text].

PubMed

Linder, Lauri A; Gerdy, Cheryl; Abouzelof, Rouett; Wilson, Andrew

Children with cancer are a subset of patients with central lines with distinct risk factors for infection including periods of prolonged neutropenia and compromised mucous membrane integrity. This article relates the implementation of principles of practice-based evidence to identify interventions in addition to best practice maintenance care bundles to reduce central line-associated bloodstream infections involving viridans group streptococci and coagulase-negative staphylococci on an inpatient pediatric oncology unit. Review of individual events combined with review of current clinical practice guided the development of structured protocols emphasizing routine oral care and general supportive cares. Key principles of the protocols emphasized a 1-2-3 mnemonic and included daily bathing, twice daily oral care, and out-of-bed activity 3 times daily. Poisson regression identified a significant main effect for time period for central line-associated bloodstream infection rates involving both viridans group streptococci and coagulase-negative staphylococci. Significant differences were present between the preintervention baseline and implementation of the supportive care protocols. Project outcomes demonstrate the added value of using principles of practice-based evidence to guide the development of interventions to improve clinical care when evidence-based sources are limited.

Primary care clinicians' recognition and management of depression: a model of depression care in real-world primary care practice.

PubMed

Baik, Seong-Yi; Crabtree, Benjamin F; Gonzales, Junius J

2013-11-01

Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered. This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions. Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n = 24, 2 h each), two surveys per clinician, and investigators' field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data. Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners. A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians' interactions with patients, practice, and the local community. A clinician's interactional familiarity ("familiarity capital") was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression. The clinician's ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.

A letter on the state of general practice in England.

PubMed

Majeed, Azeem

2015-01-01

The last few years have been a time of considerable change for general practitioners in England. In 2004, general practitioners negotiated a new contract with the United Kingdom's National Health Service. In came a new pay for performance scheme, along with the option of opting out of after-hours primary care. General practitioners' pay increased and job satisfaction improved. However, rather than then entering a period of stability, general practitioners subsequently found themselves facing even more changes in their working practices. Workload has increased, new responsibilities for commissioning health services have been given to general practitioners, and their income has fallen.

Depressive disorder in the last phase of life in patients with cardiovascular disease, cancer, and COPD: data from a 20-year follow-up period in general practice.

PubMed

Warmenhoven, Franca; Bor, Hans; Lucassen, Peter; Vissers, Kris; van Weel, Chris; Prins, Judith; Schers, Henk

2013-05-01

Depression is assumed to be common in chronically ill patients during their last phase of life and is associated with poorer outcomes. The prevalence of depression is widely varying in previous studies due to the use of different terminology, classification, and assessment methods. To explore the reported incidence of depressive disorder, as registered in the last phase of life of patients who died from cardiovascular disease, cancer or COPD, in a sample of primary care patients. A historic cohort study, using a 20-year period registration database of medical records in four Dutch general practices (a dynamic population based on the Continuous Morbidity Registration database). Medical history of the sample cohort was analysed for the diagnosis of a new episode of depressive disorder and descriptive statistics were used. In total 982 patients were included, and 19 patients (1.9%) were diagnosed with a new depressive disorder in the last year of their life. The lifetime prevalence of depressive disorder in this sample was 8.2%. The incidence of depressive disorder in the last phase of life is remarkably low in this study. These data were derived from actual patient care in general practice. Psychiatric diagnoses were made by GPs in the context of both patient needs and delivered care. A broader concept of depression in general practice is recommended to improve the diagnosis and treatment of mood disorders in patients in the last phase of life.

Comparison of range of commercial or primary care led weight reduction programmes with minimal intervention control for weight loss in obesity: lighten Up randomised controlled trial.

PubMed

Jolly, Kate; Lewis, Amanda; Beach, Jane; Denley, John; Adab, Peymane; Deeks, Jonathan J; Daley, Amanda; Aveyard, Paul

2011-11-03

To assess the effectiveness of a range of weight management programmes in terms of weight loss. Eight arm randomised controlled trial. Primary care trust in Birmingham, England. 740 obese or overweight men and women with a comorbid disorder identified from general practice records. Weight loss programmes of 12 weeks' duration: Weight Watchers; Slimming World; Rosemary Conley; group based, dietetics led programme; general practice one to one counselling; pharmacy led one to one counselling; choice of any of the six programmes. The comparator group was provided with 12 vouchers enabling free entrance to a local leisure (fitness) centre. The primary outcome was weight loss at programme end (12 weeks). Secondary outcomes were weight loss at one year, self reported physical activity, and percentage weight loss at programme end and one year. Follow-up data were available for 658 (88.9%) participants at programme end and 522 (70.5%) at one year. All programmes achieved significant weight loss from baseline to programme end (range 1.37 kg (general practice) to 4.43 kg (Weight Watchers)), and all except general practice and pharmacy provision resulted in significant weight loss at one year. At one year, only the Weight Watchers group had significantly greater weight loss than did the comparator group (2.5 (95% confidence interval 0.8 to 4.2) kg greater loss,). The commercial programmes achieved significantly greater weight loss than did the primary care programmes at programme end (mean difference 2.3 (1.3 to 3.4) kg). The primary care programmes were the most costly to provide. Participants allocated to the choice arm did not have better outcomes than those randomly allocated to a programme. Commercially provided weight management services are more effective and cheaper than primary care based services led by specially trained staff, which are ineffective. Trial registration Current Controlled Trials ISRCTN25072883.

Ward nurses' experiences of the discharge process between intensive care unit and general ward.

PubMed

Kauppi, Wivica; Proos, Matilda; Olausson, Sepideh

2018-05-01

Intensive care unit (ICU) discharges are challenging practices that carry risks for patients. Despite the existing body of knowledge, there are still difficulties in clinical practice concerning unplanned ICU discharges, specifically where there is no step-down unit. The aim of this study was to explore general ward nurses' experiences of caring for patients being discharged from an ICU. Data were collected from focus groups and in-depth interviews with a total of 16 nurses from three different hospitals in Sweden. An inductive qualitative design was chosen. The analysis revealed three themes that reflect the challenges in nursing former ICU patients: a vulnerable patient, nurses' powerlessness and organizational structure. The nurses described the challenge of nursing a fragile patient based on several aspects. They expressed feeling unrealistic demands when caring for a fragile former ICU patient. The demands were related to their own profession and knowledge regarding how to care for this group of patients. The organizational structure had an impact on how the nurses' caring practice could be realized. This evoked ethical concerns that the nurses had to cope with as the organization's care guidelines did not always favour the patients. The structure of the organization and its leadership appear to have a significant impact on the nurses' ability to offer patients the care they need. This study sheds light on the need for extended outreach services and intermediate care in order to meet the needs of patients after the intensive care period. © 2018 British Association of Critical Care Nurses.

Attitudes towards general practice and primary care: a survey of senior house officers in accident and emergency.

PubMed Central

Dale, J; Williams, S

1999-01-01

OBJECTIVES: The attitudes and knowledge of hospital based staff about the capabilities of general practice may be important obstacles to continuity of care and the quality of communication at the primary-secondary care interface. However, little research has sought to investigate such factors or how they change over time. The study aims to assess how senior house officers (SHOs) in accident and emergency (A&E) departments perceive general practice, and to test how attitudes change during their six months' tenure. METHODS: Questionnaires were sent to all A&E SHOs working in the 27 A&E departments in South Thames region. At the end of the first month and at the end of the sixth months SHOs were asked to respond using 100 mm visual analogue scales to statements about the quality of general practitioner (GP) services in their area and their attitudes towards treating primary care patients in A&E. RESULTS: After sending reminders, 135 (79%) SHOs responded to the questionnaire at the end of the first month, and 115 (67%) responded to the questionnaire at the end of the sixth month; 104 (61%) responded to both. Statements relating to GP accessibility within and outside normal working hours, perceptions of patients' satisfaction with GP services, GPs' effectiveness in educating patients about use of services, and the frustrations and lack of reward of treating primary care patients scored most negatively. The overall trend was for attitudes to become more negative during SHOs' period of employment in A&E, particularly for those intent on hospital specialist careers or those working within London hospitals. CONCLUSIONS: The findings indicate the extent to which attitudes become more entrenched over time. This may lead to care that is more hospital focused. These issues need to be addressed if quality improvement is to occur across the A&E-primary care interface. PMID:9918286

Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec

PubMed Central

2012-01-01

Background In the context of the high prevalence and impact of mental disorders worldwide, and less than optimal utilisation of services and adequacy of care, strengthening primary mental healthcare should be a leading priority. This article assesses the state of collaboration among general practitioners (GPs), psychiatrists and psychosocial mental healthcare professionals, factors that enable and hinder shared care, and GPs’ perceptions of best practices in the management of mental disorders. A collaboration model is also developed. Methods The study employs a mixed-method approach, with emphasis on qualitative investigation. Drawing from a previous survey representative of the Quebec GP population, 60 GPs were selected for further investigation. Results Globally, GPs managed mental healthcare patients in solo practice in parallel or sequential follow-up with mental healthcare professionals. GPs cited psychologists and psychiatrists as their main partners. Numerous hindering factors associated with shared care were found: lack of resources (either professionals or services); long waiting times; lack of training, time and incentives for collaboration; and inappropriate GP payment modes. The ideal practice model includes GPs working in multidisciplinary group practice in their own settings. GPs recommended expanding psychosocial services and shared care to increase overall access and quality of care for these patients. Conclusion As increasing attention is devoted worldwide to the development of optimal integrated primary care, this article contributes to the discussion on mental healthcare service planning. A culture of collaboration has to be encouraged as comprehensive services and continuity of care are key recovery factors of patients with mental disorders. PMID:23730332

Hospital adoption of automated surveillance technology and the implementation of infection prevention and control programs.

PubMed

Halpin, Helen; Shortell, Stephen M; Milstein, Arnold; Vanneman, Megan

2011-05-01

This research analyzes the relationship between hospital use of automated surveillance technology (AST) for identification and control of hospital-acquired infections (HAI) and implementation of evidence-based infection control practices. Our hypothesis is that hospitals that use AST have made more progress implementing infection control practices than hospitals that rely on manual surveillance. A survey of all acute general care hospitals in California was conducted from October 2008 through January 2009. A structured computer-assisted telephone interview was conducted with the quality director of each hospital. The final sample includes 241 general acute care hospitals (response rate, 83%). Approximately one third (32.4%) of California's hospitals use AST for monitoring HAI. Adoption of AST is statistically significant and positively associated with the depth of implementation of evidence-based practices for methicillin-resistant Staphylococcus aureus and ventilator-associated pneumonia and adoption of contact precautions and surgical care infection practices. Use of AST is also statistically significantly associated with the breadth of hospital implementation of evidence-based practices across all 5 targeted HAI. Our findings suggest that hospitals using AST can achieve greater depth and breadth in implementing evidenced-based infection control practices. Copyright © 2011 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007-14.

PubMed

Hobbs, F D Richard; Bankhead, Clare; Mukhtar, Toqir; Stevens, Sarah; Perera-Salazar, Rafael; Holt, Tim; Salisbury, Chris

2016-06-04

Primary care is the main source of health care in many health systems, including the UK National Health Service (NHS), but few objective data exist for the volume and nature of primary care activity. With rising concerns that NHS primary care workload has increased substantially, we aimed to assess the direct clinical workload of general practitioners (GPs) and practice nurses in primary care in the UK. We did a retrospective analysis of GP and nurse consultations of non-temporary patients registered at 398 English general practices between April, 2007, and March, 2014. We used data from electronic health records routinely entered in the Clinical Practice Research Datalink, and linked CPRD data to national datasets. Trends in age-standardised and sex-standardised consultation rates were modelled with joinpoint regression analysis. The dataset comprised 101,818,352 consultations and 20,626,297 person-years of observation. The crude annual consultation rate per person increased by 10·51%, from 4·67 in 2007-08, to 5·16 in 2013-14. Consultation rates were highest in infants (age 0-4 years) and elderly people (≥85 years), and were higher for female patients than for male patients of all ages. The greatest increases in age-standardised and sex-standardised rates were in GPs, with a rise of 12·36% per 10,000 person-years, compared with 0·9% for practice nurses. GP telephone consultation rates doubled, compared with a 5·20% rise in surgery consultations, which accounted for 90% of all consultations. The mean duration of GP surgery consultations increased by 6·7%, from 8·65 min (95% CI 8·64-8·65) to 9·22 min (9·22-9·23), and overall workload increased by 16%. Our findings show a substantial increase in practice consultation rates, average consultation duration, and total patient-facing clinical workload in English general practice. These results suggest that English primary care as currently delivered could be reaching saturation point. Notably, our data only explore direct clinical workload and not indirect activities and professional duties, which have probably also increased. This and additional research questions, including the outcomes of workload changes on other sectors of health care, need urgent answers for primary care provision internationally. Department of Health Policy Research Programme. Copyright © 2016 Hobbs et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.

The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial).

PubMed

Campbell, John L; Fletcher, Emily; Britten, Nicky; Green, Colin; Holt, Tim; Lattimer, Valerie; Richards, David A; Richards, Suzanne H; Salisbury, Chris; Taylor, Rod S; Calitri, Raff; Bowyer, Vicky; Chaplin, Katherine; Kandiyali, Rebecca; Murdoch, Jamie; Price, Linnie; Roscoe, Julia; Varley, Anna; Warren, Fiona C

2015-02-01

Telephone triage is proposed as a method of managing increasing demand for primary care. Previous studies have involved small samples in limited settings, and focused on nurse roles. Evidence is limited regarding the impact on primary care workload, costs, and patient safety and experience when triage is used to manage patients requesting same-day consultations in general practice. In comparison with usual care (UC), to assess the impact of GP-led telephone triage (GPT) and nurse-led computer-supported telephone triage (NT) on primary care workload and cost, patient experience of care, and patient safety and health status for patients requesting same-day consultations in general practice. Pragmatic cluster randomised controlled trial, incorporating economic evaluation and qualitative process evaluation. General practices (n = 42) in four regions of England, UK (Devon, Bristol/Somerset, Warwickshire/Coventry, Norfolk/Suffolk). Patients requesting same-day consultations. Practices were randomised to GPT, NT or UC. Data collection was not blinded; however, analysis was conducted by a statistician blinded to practice allocation. Primary - primary care contacts [general practice, out-of-hours primary care, accident and emergency (A&E) and walk-in centre attendances] in the 28 days following the index consultation request. Secondary - resource use and costs, patient safety (deaths and emergency hospital admissions within 7 days of index request, and A&E attendance within 28 days), health status and experience of care. Of 20,990 eligible randomised patients (UC n = 7283; GPT n = 6695; NT n = 7012), primary outcome data were analysed for 16,211 patients (UC n = 5572; GPT n = 5171; NT n = 5468). Compared with UC, GPT and NT increased primary outcome contacts (over 28-day follow-up) by 33% [rate ratio (RR) 1.33, 95% confidence interval (CI) 1.30 to 1.36] and 48% (RR 1.48, 95% CI 1.44 to 1.52), respectively. Compared with GPT, NT was associated with a marginal increase in primary outcome contacts by 4% (RR 1.04, 95% CI 1.01 to 1.08). Triage was associated with a redistribution of primary care contacts. Although GPT, compared with UC, increased the rate of overall GP contacts (face to face and telephone) over the 28 days by 38% (RR 1.38, 95% CI 1.28 to 1.50), GP face-to-face contacts were reduced by 39% (RR 0.61, 95% CI 0.54 to 0.69). NT reduced the rate of overall GP contacts by 16% (RR 0.84, 95% CI 0.78 to 0.91) and GP face-to-face contacts by 20% (RR 0.80, 95% CI 0.71 to 0.90), whereas nurse contacts increased. The increased rate of primary care contacts in triage arms is largely attributable to increased telephone contacts. Estimated overall patient-clinician contact time on the index day increased in triage (GPT = 10.3 minutes; NT = 14.8 minutes; UC = 9.6 minutes), although patterns of clinician use varied between arms. Taking account of both the pattern and duration of primary outcome contacts, overall costs over the 28-day follow-up were similar in all three arms (approximately £75 per patient). Triage appeared safe, and no differences in patient health status were observed. NT was somewhat less acceptable to patients than GPT or UC. The process evaluation identified the complexity associated with introducing triage but found no consistency across practices about what works and what does not work when implementing it. Introducing GPT or NT was associated with a redistribution of primary care workload for patients requesting same-day consultations, and at similar cost to UC. Although triage seemed to be safe, investigation of the circumstances of a larger number of deaths or admissions after triage might be warranted, and monitoring of these events is necessary as triage is implemented. Current Controlled Trials ISRCTN20687662. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 13. See the NIHR Journals Library website for further project information.

Use of the consultation satisfaction questionnaire to examine patients' satisfaction with general practitioners and community nurses: reliability, replicability and discriminant validity.

PubMed Central

Poulton, B C

1996-01-01

BACKGROUND: Primary health care services are the most frequently used in the health care system. Consumer feedback on these services is important. Research in this area relates mainly to doctor-patient relationships which fails to reflect the multidisciplinary nature of primary health care. AIM: A pilot study aimed to examine the feasibility of using a patient satisfaction questionnaire designed for use with general practitioner consultations as an instrument for measuring patient satisfaction with community nurses. METHOD: The questionnaire measuring patient satisfaction with general practitioner consultations was adapted for measuring satisfaction with contacts with a nurse practitioner, district nurses, practice nurses and health visitors. A total of 1575 patients in three practices consulting general practitioners or community nurses were invited to complete a questionnaire. Data were subjected to principal components analysis and the dimensions identified were tested for internal reliability and replicability. To establish discriminant validity, patients' mean satisfaction scores for consultations with general practitioners, the nurse practitioner, health visitors and nurses (district and practice nurses) were compared. RESULTS: Questionnaires were returned relating to 400 general practitioner, 54 nurse practitioner, 191 district/practice nurse and 83 health visitor consultations (overall response rate 46%). Principal components analysis demonstrated a factor structure similar to that found in an earlier study of the consultation satisfaction questionnaire. Three dimensions of patient satisfaction were identified: professional care, depth of relationship and perceived time spent with the health professional. The dimensions were found to have acceptable levels of reliability. Factor structures obtained from data relating to general practitioner and community nurse consultations were found to correlate significantly. Comparison between health professionals showed that patients rated satisfaction with professional care significantly more highly for nurses than for general practitioners and health visitors. Patients' rating of satisfaction with the depth of relationships with health visitors was significantly lower than their ratings of this relationship with the other groups of health professionals. There were so significant differences between health professional groups regarding patients' ratings of satisfaction with the perceived amount of time spent with health professionals. CONCLUSION: The pilot study showed that it is possible to use the consultation satisfaction questionnaire for both general practitioners and community nurses. Comparison between health professional groups should be undertaken with caution as data were available for only a small number of consultations with some of the groups of health professionals studied. PMID:8745848

Training informal caregivers to care for older people after stroke: a quasi-experimental study.

PubMed

Araújo, Odete; Lage, Isabel; Cabrita, José; Teixeira, Laetitia

2018-05-12

The present study aimed at evaluating whether training on practical skills involved in providing care reduces the burden experienced by informal caregivers and improves their general health condition. A substantial number of informal caregivers lack skills to deliver post-stroke assistance to older people after hospital discharge, which leads to burden situations as well as mental and physical health deterioration of the former. A quasi-experimental design. This study involved 174 informal caregivers of older people who overcame a stroke. The control group (N= 89) received the usual type of care delivered in healthcare units. The experimental group (N=85) adopted the InCARE programme for 1 week (T0), 1 month (T1) and 3 (T2) months and received telephone support by counselling caregivers on the subsequent 3rd, 6th, 8th and 10th weeks to hospital discharge. It aimed at facilitating the caregiver's adjustment to the demands of a post- stroke stage and at increasing knowledge and practical skills to support the decision making. Data collection occurred between February - December 2014 at the Community Home Care Services in northern Portugal. The experimental group obtained significantly better results regarding practical skills as well as lower burden levels and a better general mental health condition when compared with the control group 1 (T1) and 3 (T2) months after intervention. Findings suggest that our programme improved practical skills, helped reduce burden levels with better scores and improvement regarding general mental health condition of informal caregivers. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

The Diabetes Care Project: an Australian multicentre, cluster randomised controlled trial [study protocol].

PubMed

Leach, Matthew J; Segal, Leonie; Esterman, Adrian; Armour, Caroline; McDermott, Robyn; Fountaine, Tim

2013-12-20

Diabetes mellitus is an increasingly prevalent metabolic disorder that is associated with substantial disease burden. Australia has an opportunity to improve ways of caring for the growing number of people with diabetes, but this may require changes to the way care is funded, organised and delivered. To inform how best to care for people with diabetes, and to identify the extent of change that is required to achieve this, the Diabetes Care Project (DCP) will evaluate the impact of two different, evidence-based models of care (compared to usual care) on clinical quality, patient and provider experience, and cost. The DCP uses a pragmatic, cluster randomised controlled trial design. Accredited general practices that are situated within any of the seven Australian Medicare Locals/Divisions of General Practice that have agreed to take part in the study were invited to participate. Consenting practices will be randomly assigned to one of three treatment groups for approximately 18 to 22 months: (a) control group (usual care); (b) Intervention 1 (which tests improvements that could be made within the current funding model, facilitated through the use of an online chronic disease management network); or (c) Intervention 2 (which includes the same components as Intervention 1, as well as altered funding to support voluntary patient registration with their practice, incentive payments and a care facilitator). Adult patients who attend the enrolled practices and have established (≥12 month's duration) type 1 diabetes mellitus or newly diagnosed or established type 2 diabetes mellitus are invited to participate. Multiple outcomes will be studied, including changes in glycosylated haemoglobin (primary outcome), changes in other biochemical and clinical metrics, incidence of diabetes-related complications, quality of life, clinical depression, success of tailored care, patient and practitioner satisfaction, and budget sustainability. This project responds to a need for robust evidence of the clinical and economic effectiveness of coordinated care for the management of diabetes in the Australian primary care setting. The outcomes of the study will have implications not only for diabetes management, but also for the management of other chronic diseases, both in Australia and overseas. Australian New Zealand Clinical Trials Registry (ACTRN12612000363886); World Health Organisation (U1111-1128-0481).

Association of practice size and pay-for-performance incentives with the quality of diabetes management in primary care.

PubMed

Vamos, Eszter P; Pape, Utz J; Bottle, Alex; Hamilton, Fiona Louise; Curcin, Vasa; Ng, Anthea; Molokhia, Mariam; Car, Josip; Majeed, Azeem; Millett, Christopher

2011-09-06

Not enough is known about the association between practice size and clinical outcomes in primary care. We examined this association between 1997 and 2005, in addition to the impact of the Quality and Outcomes Framework, a pay-for-performance incentive scheme introduced in the United Kingdom in 2004, on diabetes management. We conducted a retrospective open-cohort study using data from the General Practice Research Database. We enrolled 422 general practices providing care for 154,945 patients with diabetes. Our primary outcome measures were the achievement of national treatment targets for blood pressure, glycated hemoglobin (HbA(1c)) levels and total cholesterol. We saw improvements in the recording of process of care measures, prescribing and achieving intermediate outcomes in all practice sizes during the study period. We saw improvement in reaching national targets after the introduction of the Quality and Outcomes Framework. These improvements significantly exceeded the underlying trends in all practice sizes for achieving targets for cholesterol level and blood pressure, but not for HbA(1c) level. In 1997 and 2005, there were no significant differences between the smallest and largest practices in achieving targets for blood pressure (1997 odds ratio [OR] 0.98, 95% confidence interval [CI] 0.82 to 1.16; 2005 OR 0.92, 95% CI 0.80 to 1.06 in 2005), cholesterol level (1997 OR 0.94, 95% CI 0.76 to 1.16; 2005 OR 1.1, 95% CI 0.97 to 1.40) and glycated hemoglobin level (1997 OR 0.79, 95% CI 0.55 to 1.14; 2005 OR 1.05, 95% CI 0.93 to 1.19). We found no evidence that size of practice is associated with the quality of diabetes management in primary care. Pay-for-performance programs appear to benefit both large and small practices to a similar extent.

Coalition of attitude and practice behaviors among dental practitioners regarding pregnant patient's oral health and pregnant patient's perception toward oral health in and around Pondicherry.

PubMed

Jeelani, S; Khader, K Abdul; Rangdhol, R Vishwanath; Dany, A; Paulose, Swetha

2015-08-01

This study aims to evaluate the knowledge, attitude, practice behaviors among general dental practitioners and assess the perception toward oral health by pregnant patients in and around Puducherry. A self-designed and structured questionnaire was used to obtain information from the dental practitioner and the pregnant patients. The majority of the dental practitioners had a lack of knowledge, attitude, practice behaviors regarding pregnant patient's oral health and similarly majority of pregnant patient's perception toward oral health was poor. Drowning and dilemmatic attitude and practice behavior of dentists to be streamlined to render right care to the pregnant women at the right time. Perplexing perception toward oral health care by pregnant women to be overcome to orient them to understand the impact of oral health on their general systemic health.

Cannabis in End-of-Life Care: Examining Attitudes and Practices of Palliative Care Providers.

PubMed

Luba, Rachel; Earleywine, Mitch; Farmer, Stacey; Slavin, Melissa

2018-05-01

Medical cannabis research has become quite extensive, with indications ranging from glaucoma to chemotherapy-induced nausea. Despite increased interest in cannabis' potential medical uses, research barriers, cannabis legislation, stigma, and lack of dissemination of data contribute to low adoption for some medical populations. Of interest, cannabis use appears low in palliative care settings, with few guidelines available to palliative care providers. The present study sought to examine the attitudes, beliefs, and practices of palliative care providers regarding the use of cannabis for terminally ill patients. Palliative care providers (N = 426) completed a one-time online survey assessing these attitudes, beliefs, and practices. Results demonstrated that palliative care providers endorse cannabis for a wide range of palliative care symptoms, end-of-life care generally, and as an adjuvant medication. Nevertheless, the gap between these beliefs and actual recommendation or prescription appears vast. Many who support the use of cannabis in palliative care do not recommend it as a treatment. These data suggest recommendations for healthcare providers and palliative care organizations.

Effectiveness and cost-effectiveness of an educational intervention for practice teams to deliver problem focused therapy for insomnia: rationale and design of a pilot cluster randomised trial

PubMed Central

Siriwardena, A Niroshan; Apekey, Tanefa; Tilling, Michelle; Harrison, Andrew; Dyas, Jane V; Middleton, Hugh C; Ørner, Roderick; Sach, Tracey; Dewey, Michael; Qureshi, Zubair M

2009-01-01

Background Sleep problems are common, affecting over a third of adults in the United Kingdom and leading to reduced productivity and impaired health-related quality of life. Many of those whose lives are affected seek medical help from primary care. Drug treatment is ineffective long term. Psychological methods for managing sleep problems, including cognitive behavioural therapy for insomnia (CBTi) have been shown to be effective and cost effective but have not been widely implemented or evaluated in a general practice setting where they are most likely to be needed and most appropriately delivered. This paper outlines the protocol for a pilot study designed to evaluate the effectiveness and cost-effectiveness of an educational intervention for general practitioners, primary care nurses and other members of the primary care team to deliver problem focused therapy to adult patients presenting with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety. Methods and design This will be a pilot cluster randomised controlled trial of a complex intervention. General practices will be randomised to an educational intervention for problem focused therapy which includes a consultation approach comprising careful assessment (using assessment of secondary causes, sleep diaries and severity) and use of modified CBTi for insomnia in the consultation compared with usual care (general advice on sleep hygiene and pharmacotherapy with hypnotic drugs). Clinicians randomised to the intervention will receive an educational intervention (2 × 2 hours) to implement a complex intervention of problem focused therapy. Clinicians randomised to the control group will receive reinforcement of usual care with sleep hygiene advice. Outcomes will be assessed via self-completion questionnaires and telephone interviews of patients and staff as well as clinical records for interventions and prescribing. Discussion Previous studies in adults have shown that psychological treatments for insomnia administered by specialist nurses to groups of patients can be effective within a primary care setting. This will be a pilot study to determine whether an educational intervention aimed at primary care teams to deliver problem focused therapy for insomnia can improve sleep management and outcomes for individual adult patients presenting to general practice. The study will also test procedures and collect information in preparation for a larger definitive cluster-randomised trial. The study is funded by The Health Foundation. Trial Registration ClinicalTrials.gov ID ISRCTN55001433 – PMID:19171070

Web-based consultation between general practitioners and nephrologists: a cluster randomized controlled trial.

PubMed

van Gelder, Vincent A; Scherpbier-de Haan, Nynke D; van Berkel, Saskia; Akkermans, Reinier P; de Grauw, Inge S; Adang, Eddy M; Assendelft, Pim J; de Grauw, Wim J C; Biermans, Marion C J; Wetzels, Jack F M

2017-08-01

Consultation of a nephrologist is important in aligning care for patients with chronic kidney disease (CKD) at the primary-secondary care interface. However, current consultation methods come with practical difficulties that can lead to postponed consultation or patient referral instead. This study aimed to investigate whether a web-based consultation platform, telenephrology, led to a lower referral rate of indicated patients. Furthermore, we assessed consultation rate, quality of care, costs and general practitioner (GPs') experiences with telenephrology. Cluster randomized controlled trial with 47 general practices in the Netherlands was randomized to access to telenephrology or to enhanced usual care. A total of 3004 CKD patients aged 18 years or older who were under primary care were included (intervention group n = 1277, control group n = 1727) and 2693 completed the trial. All practices participated in a CKD management course and were given an overview of their CKD patients. The referral rates amounted to 2.3% (n = 29) in the intervention group and 3.0% (n = 52) in the control group, which was a non-significant difference, OR 0.61; 95% CI 0.31 to 1.23. The intervention group's consultation rate was 6.3% (n = 81) against 5.0% (n = 87) (OR 2.00; 95% CI 0.75-5.33). We found no difference in quality of care or costs. The majority of GPs had a positive opinion about telenephrology. The data in our study do not allow for conclusions on the effect of telenephrology on the rate of patient referrals and provider-to-provider consultations, compared to conventional methods. It was positively evaluated by GPs and was non-inferior in terms of quality of care and costs. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Does capitation affect the delivery of oral healthcare and access to services? Evidence from a pilot contact in Northern Ireland.

PubMed

Hill, Harry; Birch, Stephen; Tickle, Martin; McDonald, Ruth; Donaldson, Michael; O'Carolan, Donncha; Brocklehurst, Paul

2017-03-06

In May 2009, the Northern Ireland government introduced General Dental Services (GDS) contracts based on capitation in dental practices newly set up by a corporate dental provider to promote access to dental care in populations that had previously struggled to secure service provision. Dental service provision forms an important component of general health services for the population, but the implications of health system financing on care delivered and the financial cost of services has received relatively little attention in the research literature. The aim of this study is to evaluate the policy effect capitation payment in recently started corporate practices had on the delivery of primary oral healthcare in Northern Ireland and access to services. We analysed the policy initiative in Northern Ireland as a natural experiment to find the impact on healthcare delivery of the newly set up corporate practices that use a prospective capitation system to remunerate primary care dentists. Data was collected from GDS claim forms submitted to the Business Services Organisation (BSO) between April 2011 and October 2014. Health and Social Care Board (HSCB) practices operating within a capitation system were matched to a control group, who were remunerated using a retrospective fee-for-service system. No evidence of patient selection was found in the HSCB practices set up by a corporate provider and operated under capitation. However, patients were less likely to visit the dentist and received less treatment when they did attend, compared to those belonging to the control group (P < 0.05). The extent of preventive activity offered and the patient payment charge revenue did not differ between the two practice groups. Although remunerating NHS primary care dentists in newly set up corporate practices using a prospective capitation system managed costs within healthcare, there is evidence that this policy may have reduced access to care of registered patients.

Flexible but boring: medical students' perceptions of a career in general practice.

PubMed

Koehler, Nicole; McMenamin, Christine

2016-07-01

Australia will continue to face a general practitioner (GP) shortage unless a significant number of medical students make general practice their chosen career. Perceptions regarding general practice may influence career choices. Thus this study investigated what Australian medical students perceived to be the advantages and disadvantages of pursuing a career in general practice via an anonymous online survey. Fifty-one students indicated general practice to be their first ranked career preference, 200 indicated a career other than general practice, and 106 were undecided. Two-hundred and two students reported having been on a GP placement, whereas 88 students had not. Flexibility, continuity of patient care and work-life balance were the three most common stated advantages to pursuing a career in general practice whereas general practice being boring, poorly paid, and of low prestige were the three most common disadvantages stated. Some disadvantages stated by those with a non-GP preference were not stated by those with a GP preference (e.g. lack of procedural skills, lack of career advancement opportunities). Students with more than 80 h of GP placement experience were more likely to list the advantages of work-life balance and a diversity of problems/illnesses/patients than those with no placement experience but were also more likely to list the disadvantage of low prestige. Negative stereotypes regarding general practice continue to exist which may influence students' career choices.

Primary care practice characteristics associated with the quality of care received by patients with depression and comorbid chronic conditions.

PubMed

Menear, Matthew; Duhoux, Arnaud; Roberge, Pasquale; Fournier, Louise

2014-01-01

This study aimed to identify primary care practice characteristics associated with the quality of depression care in patients with comorbid chronic medical and/or psychiatric conditions. Using data from cross-sectional organizational and patient surveys conducted within 61 primary care clinics in Quebec, Canada, the relationships between primary care practice characteristics, comorbidity profile, and the recognition and minimally adequate treatment of depression were assessed using multilevel logistic regression analysis with 824 adults with past-year depression and comorbid chronic conditions. Likelihood of depression recognition was higher in clinics where accessibility of mental health professionals was not viewed to be a major barrier to depression care [odds ratio (OR)=1.61; 95% confidence interval (CI) 1.13-2.30]. Four practice characteristics were associated with minimal treatment adequacy: greater use of treatment algorithms for depression (OR=1.77; 95% CI=1.18-2.65), high value given to teamwork (OR=2.48; 95% CI=1.40-4.38), having at least one general practitioner at the clinic devote significant time in practice to mental health (OR=1.54; 95% CI=1.07-2.21) and low perceived barriers to depression care due to inadequate payment models (OR=2.12; 95% CI=1.30-3.46). Several primary care practice characteristics significantly influence the quality of care provided to patients with depression and comorbid chronic conditions and should be targeted in quality improvement efforts. Copyright © 2014 Elsevier Inc. All rights reserved.

Self-Care Practices among Diabetes Patients in Addis Ababa: A Qualitative Study

PubMed Central

Tewahido, Dagmawit; Berhane, Yemane

2017-01-01

Background Self-care practices that include self-monitoring of blood sugar level, diet management, physical exercise, adherence to medications, and foot care are the cornerstones of diabetes management. However, very little is known about self-care in developing countries where the prevalence of diabetes is increasing. Objective The objective of this study was to describe self-care practices among individuals with type II diabetes in Addis Ababa, Ethiopia. Methods A qualitative method was used to gather data from type II diabetes patients. Patients were recruited from the outpatient diabetes clinics of two public hospitals in Addis Ababa. Data were collected using a semi structured interview guide. A thematic analysis approach was used to process the data. Results Overall self-care practices were not adequate. Most patients reported irregular self-monitoring of blood sugar. Dietary and physical exercise recommendations were inadequately practiced by most of the participants. Most patients better adhered to medication prescriptions. Patients generally lack proper information/knowledge regarding the importance of self-care and how it should be implemented. Based on reported behavior we identified three main categories of patients; which are those ‘endeavor to be compliant’, ‘confused’ and ‘negligent’. Conclusion Diabetes patients largely depend on prescribed medications to control their blood sugar level. The importance of proper self-care practices for effective management of diabetes is not adequately emphasized in diabetes care centers and patients lack sufficient knowledge for proper self-care. PMID:28045992

The new era of postgraduate certified general practice training in Japan.

PubMed

Takamura, Akiteru

2016-09-01

This paper describes the background to, and the recent evolution of general practice as a recognised medical specialism in Japan (2015), and the evolution of a system of training to support this development. We, the general practitioners (GPs) in Japan have not been recognised as one body of medical specialists and have been training in our own way. A new certified training system will commence in 2018, authorised by a new third organisation, the Japanese Medical Specialty Board. An effective educational system has been developed for medical graduates that have a career intention in general practice that is distinct from other basic medical fields, but collaborates with them. A challenge exists to provide clarity to the Japanese population about what the specialty of general practice is, and what professionals in general practice can do for them. Japan currently has approximately 500 certified GPs and it is unclear at present what numbers will eventually be required. This paper reviews some of the challenges facing the development of general practice from the perspective of the Japan Primary Care Association.

[Medical confidentiality for minors].

PubMed

Peyrebrune, Cécile; Génot-Pok, Isabelle

2009-12-20

The new statutory provisions on the care of minors have given a legal framework for primary healthcare professionals. They clarify the rights of minors and their general application to improve the quality of the healthcare system. They are valuable and relevant tools for general practitioners in their day to day practice, and they help improve the medical care of minors, currently considered as a real public health problem.

Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data.

PubMed

Cowling, Thomas E; Harris, Matthew; Watt, Hilary; Soljak, Michael; Richards, Emma; Gunning, Elinor; Bottle, Alex; Macinko, James; Majeed, Azeem

2016-06-01

The UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes. To determine whether primary care access is associated with the route of emergency admission-via a GP versus via an A and E department. Retrospective analysis of national administrative data from English hospitals for 2011-2012. Adults admitted in an emergency (unscheduled) for ≥1 night via a GP or an A and E department formed the study population. The measure of primary care access-the percentage of patients able to get a general practice appointment on their last attempt-was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics. The analysis included 2 322 112 emergency admissions (81.9% via an A and E department). With a 5 unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ≥95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139 673 fewer GP admissions (456 232 vs 316 559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England. Among hospital inpatients admitted as an emergency, patients registered to more accessible general practices were more likely to have been admitted via a GP (vs an A and E department). This furthers evidence suggesting that access to general practice is related to use of emergency hospital services in England. The relative merits of the two admission routes remain unclear. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Practical Considerations in Pediatric Surgery

PubMed Central

Louis, Matthew R.; Meaike, Jesse D.; Chamata, Edward; Hollier, Larry H.

2016-01-01

The care of pediatric patients requires special considerations that are often not addressed in the literature. Relatively straightforward tasks such as clinical evaluation, antibiotic use, splinting, wound closure, and care of simple burns become complicated in the pediatric population for several reasons. The authors seek to demystify some of these topics using the senior author's years of clinical experience treating pediatric patients by giving practical advice and general considerations when treating children. PMID:27895539

Oral and dental health in pregnant women: attitudes among dentists in southeastern Spain.

PubMed

López-Jornet, Pia; Camacho-Alonso, Fabio; Sanchez-Siles, Mariano; Molina-Miñano, Francisco

2014-01-01

A study was undertaken to determine the general level of knowledge, attitudes and practices in clinical dental care of pregnant women. This was a transversal descriptive study in the form of a structured and anonymous survey completed by dentists in Murcia (southeast Spain). The questionnaire was sent by e-mail and investigated dentists' knowledge of and attitudes toward different dental procedures applying to pregnant women. The response rate to the questionnaire was 60%. The vast majority of dentists (81.3%) agreed that oral care should be part of general healthcare for pregnant women. However, discrepancies were found in knowledge and attitudes to practice.

Lessons from bad general practice *

PubMed Central

Wilkes, Eric

1975-01-01

The paucity of resources for general practice correlates well with high losses through emigration and questions the expensive over-production of doctors now being undertaken. The variable quality of community care and the absence of a structure yet providing real planning or capital, leads to the uneconomic abuse of hospital facilities and to an excessive emphasis on institutionalisation. Medicine is becoming depersonalised because unrealistic expectations lead to an overloading of the service. Simultaneously we allocate a low priority to education in the use of the service, have little training in the sociological aspects of medical care, and even less in how best to use the skills of our non-medical professional colleagues. PMID:1177214

Management of Periprocedural Anticoagulation: A Survey of Contemporary Practice.

PubMed

Flaker, Greg C; Theriot, Paul; Binder, Lea G; Dobesh, Paul P; Cuker, Adam; Doherty, John U

2016-07-12

Interruption of oral anticoagulation (AC) for surgery or an invasive procedure is a complicated process. Practice guidelines provide only general recommendations, and care of such patients occurs across multiple specialties. The availability of direct oral anticoagulants further complicates decision making and guidance here is limited. To evaluate current practice patterns in the United States for bridging AC, a survey was developed by the American College of Cardiology Anticoagulation Work Group. The goal of the survey was to assess how general and subspecialty cardiologists, internists, gastroenterologists, and orthopedic surgeons currently manage patients who receive AC and undergo surgery or an invasive procedure. The survey was completed by 945 physicians involved in the periprocedural management of AC. The results provide a template for educational and research projects geared toward the development of clinical pathways and point-of-care tools to improve this area of health care. Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Supporting Mentoring Relationships of Youth in Foster Care: Do Program Practices Predict Match Length?

PubMed

Stelter, Rebecca L; Kupersmidt, Janis B; Stump, Kathryn N

2018-04-15

Implementation of research- and safety-based program practices enhance the longevity of mentoring relationships, in general; however, little is known about how mentoring programs might support the relationships of mentees in foster care. Benchmark program practices and Standards in the Elements of Effective Practice for Mentoring, 3rd Edition (MENTOR, 2009) were assessed in the current study as predictors of match longevity. Secondary data analyses were conducted on a national agency information management database from 216 Big Brothers Big Sisters agencies serving 641 youth in foster care and 70,067 youth not in care from across the United States (Mean = 11.59 years old at the beginning of their matches) in one-to-one, community-based (55.06%) and school- or site-based (44.94%) matches. Mentees in foster care had shorter matches and matches that were more likely to close prematurely than mentees who were not in foster care. Agency leaders from 32 programs completed a web-based survey describing their policies and practices. The sum total numbers of Benchmark program practices and Standards were associated with match length for 208 mentees in foster care; however, neither predicted premature match closure. Results are discussed in terms of how mentoring programs and their staff can support the mentoring relationships of high-risk youth in foster care. © Society for Community Research and Action 2018.

Cost-effectiveness of i-Sleep, a guided online CBT intervention, for patients with insomnia in general practice: protocol of a pragmatic randomized controlled trial.

PubMed

van der Zweerde, Tanja; Lancee, Jaap; Slottje, Pauline; Bosmans, Judith; Van Someren, Eus; Reynolds, Charles; Cuijpers, Pim; van Straten, Annemieke

2016-04-02

Insomnia is a highly prevalent disorder causing clinically significant distress and impairment. Furthermore, insomnia is associated with high societal and individual costs. Although cognitive behavioural treatment for insomnia (CBT-I) is the preferred treatment, it is not used often. Offering CBT-I in an online format may increase access. Many studies have shown that online CBT for insomnia is effective. However, these studies have all been performed in general population samples recruited through media. This protocol article presents the design of a study aimed at establishing feasibility, effectiveness and cost-effectiveness of a guided online intervention (i-Sleep) for patients suffering from insomnia that seek help from their general practitioner as compared to care-as-usual. In a pragmatic randomized controlled trial, adult patients with insomnia disorder recruited through general practices are randomized to a 5-session guided online treatment, which is called "i-Sleep", or to care-as-usual. Patients in the care-as-usual condition will be offered i-Sleep 6 months after inclusion. An ancillary clinician, known as the psychological well-being practitioner who works in the GP practice (PWP; in Dutch: POH-GGZ), will offer online support after every session. Our aim is to recruit one hundred and sixty patients. Questionnaires, a sleep diary and wrist actigraphy will be administered at baseline, post intervention (at 8 weeks), and at 6 months and 12 months follow-up. Effectiveness will be established using insomnia severity as the main outcome. Cost-effectiveness and cost-utility (using costs per quality adjusted life year (QALY) as outcome) will be conducted from a societal perspective. Secondary measures are: sleep diary, daytime consequences, fatigue, work and social adjustment, anxiety, alcohol use, depression and quality of life. The results of this trial will help establish whether online CBT-I is (cost-) effective and feasible in general practice as compared to care-as-usual. If it is, then quality of care might be increased because implementation of i-Sleep makes it easier to adhere to insomnia guidelines. Strengths and limitations are discussed. Netherlands Trial register NTR 5202 (registered April 17(st) 2015).

Barriers and enablers to good communication and information-sharing practices in care planning for chronic condition management.

PubMed

Lawn, Sharon; Delany, Toni; Sweet, Linda; Battersby, Malcolm; Skinner, Timothy

2015-01-01

Our aim was to document current communication and information-sharing practices and to identify the barriers and enablers to good practices within the context of care planning for chronic condition management. Further aims were to make recommendations about how changes to policy and practice can improve communication and information sharing in primary health care. A mixed-method approach was applied to seek the perspectives of patients and primary health-care workers across Australia. Data was collected via interviews, focus groups, non-participant observations and a national survey. Data analysis was performed using a mix of thematic, discourse and statistical approaches. Central barriers to effective communication and information sharing included fragmented communication, uncertainty around client and interagency consent, and the unacknowledged existence of overlapping care plans. To be most effective, communication and information sharing should be open, two-way and inclusive of all members of health-care teams. It must also only be undertaken with the appropriate participant consent, otherwise this has the potential to cause patients harm. Improvements in care planning as a communication and information-sharing tool may be achieved through practice initiatives that reflect the rhetoric of collaborative person-centred care, which is already supported through existing policy in Australia. General practitioners and other primary care providers should operationalise care planning, and the expectation of collaborative and effective communication of care that underpins it, within their practice with patients and all members of the care team. To assist in meeting these aims, we make several recommendations.

'Most young men think you have to be naked in front of the GP': a qualitative study of male university students' views on barriers to sexual health.

PubMed

Ewert, Cameron; Collyer, Archibald; Temple-Smith, Meredith

2016-04-01

Background In Australia, 15- to 29-year-olds account for 75% of all sexually transmissible infection (STI) diagnoses. STI rates among young men are rising, with most diagnosed in general practice. Young men less frequently attend general practice than young women, and rarely present with sexual health issues, making it difficult for general practitioners (GPs) to offer opportunistic STI education and screening. Little is known of the barriers preventing male university students accessing general practice for sexual health care, or what would facilitate this. Semi-structured interviews were conducted with young men aged 18-24 years attending university between 2012 and 2014. Interviews were recorded, transcribed and analysed using content and thematic analysis. Twenty-eight interviews of 26-50min duration found self-imposed views of masculinity, privacy and embarrassment as key barriers to accessing GPs for sexual health care. This was compounded by poor STI knowledge and not knowing when or where to go for care. Participants, except if they were international students, acknowledged school as an important source of sexual health education. The need for sexual health education at university was identified. While the Internet was a popular source, there were mixed views on the benefits of social media and text messaging for sexual health promotion. Current expectations of young male university students to seek sexual health care or acquire sexual health information from medical care may be misplaced. Universities have an excellent opportunity to provide young men with appropriate sexual health information and could offer novel strategies to help young men look after their sexual health.

Management of patients with coronary heart disease in family medicine: correlates of quality of care.

PubMed

Tušek-Bunc, Ksenija; Petek, Davorina

2018-04-10

Family medicine plays an important role in quality of care (QoC) of coronary heart disease (CHD) patients. This study's aim was to determine the quality of secondary cardiovascular disease prevention in the everyday practice of family physicians. This study was observational cross-sectional. About 36 randomly selected family medicine practices stratified by size and location in Slovenia. CHD patients randomly selected from a patient register available in family medicine practices. The instrument for assessment of quality included a form for collecting data from medical records, a general practice assessment questionnaire and a patient questionnaire. QoC was defined by two composite variables, namely risk factor registration and CHD patient process of care, as the two care outcomes. In multivariate analysis, we performed multilevel regression analysis to identify the associations between QoC, the patient and the practice characteristics. The final sample included 423 CHD patients from 36 family medicine practices. Risk factor registration was associated with the practice organisation score (P = 0.004), practice size (P = 0.042), presence of comorbid atherosclerotic diseases (P = 0.043) and a lower age of CHD patients (P = 0.001). CHD patient process of care was associated with the practice organisation score (0.045) and a lower age of CHD patients (P = 0.035). The most important factors affecting the quality of CHD patient care were linked to the organisational characteristics of the family medicine practices.

Strategies to promote practice nurse capacity to deliver evidence-based care: An example from sexual healthcare.

PubMed

Dadich, Ann; Abbott, Penny; Hosseinzadeh, Hassan

2015-01-01

Evidence-based practice is pivotal to effective patient care. However, its translation into practice remains limited. Given the central role of primary care in many healthcare systems, it is important to identify strategies that bolster clinician-capacity to promote evidence-based care. The purpose of this paper is to identify strategies to increase Practice Nurse capacity to promote evidence-based sexual healthcare within general practice. A survey of 217 Practice Nurses in an Australian state and ten respondent-interviews regarding two resources to promote evidence-based sexual healthcare - namely, a clinical aide and online training. The perceived impact of both resources was determined by views on relevance and design - particularly for the clinical aide. Resource-use was influenced by role and responsibilities within the workplace, accessibility, and support from patients and colleagues. This is the first Australian study to reveal strategies to promote evidence-based sexual healthcare among Practice Nurses. The findings provide a platform for future research on knowledge translation processes, particularly among clinicians who might be disengaged from sexual healthcare. Given the benefits of evidence-based practices, it is important that managers recognize their role, and the role of their services, in promoting these. Without explicit support for evidence-based care and recognition of the Practice Nurse role in such care, knowledge translation is likely to be limited. Knowledge translation among Practice Nurses can be facilitated by: resources-deemed informative, relevant, and user-friendly, as well as support from patients, colleagues, and their workplace.

Receptionists' role in new approaches to consultations in primary care: a focused ethnographic study.

PubMed

Brant, Heather Dawn; Atherton, Helen; Bikker, Annemieke; Porqueddu, Tania; Salisbury, Chris; McKinstry, Brian; Campbell, John; Gibson, Andy; Ziebland, Sue

2018-06-04

The receptionist is pivotal to the smooth running of general practice in the UK, communicating with patients and booking appointments. The authors aimed to explore the role of the receptionist in the implementation of new approaches to consultations in primary care. The authors conducted a team-based focused ethnography. Three researchers observed eight general practices across England and Scotland between June 2015 and May 2016. Interviews were conducted with 39 patients and 45 staff in the practices, all of which had adopted one or more methods (telephone, email, e-consultation, or internet video) for providing an alternative to face-to-face consultation. Receptionists have a key role in facilitating patient awareness regarding new approaches to consultations in primary care, while at the same time ensuring that patients receive a consultation appropriate to their needs. In this study, receptionists' involvement in implementation and planning for the introduction of alternative approaches to face-to-face consultations was minimal, despite the expectation that they would be involved in delivery. A shared understanding within practices of the potential difficulties and extra work that might ensue for reception staff was lacking. This might contribute to the low uptake by patients of potentially important innovations in service delivery. Involvement of the wider practice team in planning and piloting changes, supporting team members through service reconfiguration, and providing an opportunity to discuss and contribute to modifications of any new system would ensure that reception staff are suitably prepared to support the introduction of a new approach to consultations. © British Journal of General Practice 2018.

Improving the identification and management of chronic kidney disease in primary care: lessons from a staged improvement collaborative

PubMed Central

Harvey, Gill; Oliver, Kathryn; Humphreys, John; Rothwell, Katy; Hegarty, Janet

2015-01-01

Quality problem Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD. Initial assessment Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ∼30% were estimated to have suboptimal management according to Public Health Observatory analyses. Choice of solution An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices. Implementation A two-phase collaborative was implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do-Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement. Evaluation Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as a marker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ∼2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved. Lessons learned An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention. PMID:25525148

A randomised controlled trial of clinics in secondary schools for adolescents with asthma.

PubMed Central

Salisbury, Chris; Francis, Caia; Rogers, Chris; Parry, Kate; Thomas, Huw; Chadwick, Stephanie; Turton, Pat

2002-01-01

AIM: To compare a nurse-led clinic in schools versus care in general practice for adolescents with asthma. DESIGN OF STUDY: Randomised controlled trial in four schools; parallel observational study in two schools. SETTING: Six comprehensive schools. METHOD: In the randomised trial, pupils were invited to attend asthma review at a nurse-led clinic either in school, or in general practice. The parallel observational study compared pupils invited to practice care within and outside the randomised trial. Primary outcome measures were attendance for asthma review, symptom control, and quality of life. Secondary outcomes were knowledge, attitudes, inhaler technique, use of steroids, school absence, peak flow rate, preference for future care, health service utilisation, and costs. RESULTS: School clinic pupils were more likely to attend an asthma review than those randomised to practice care (90.8% versus 51.0% overall [P < 0.001, not consistent across schools]). No differences were observed in symptom control (P = 0.42) or quality of life (P = 0.63). Pupils attending school clinics had greater knowledge of asthma (difference = +0.38, 95% CI = 0.19 to 0.56), more positive attitudes (difference = +0.21, 95% CI = 0.05 to 0.36), and better inhaler technique (P < 0.001, not consistent across all schools). No differences were observed in school absence or peak flow rate. A majority (63%) of those who had received care at school preferred this model in future. Median costs of providing care at school and at the practice were 32.10 Pounds and 19.80 Pounds, respectively. No differences were observed between the groups in the observational comparison on any outcome. CONCLUSIONS: The schools asthma clinic increased uptake of asthma reviews. There were improvements in various process measures, but not in clinical outcomes. PMID:12528584

Technical Elements, Demonstration Projects, and Fiscal Models in Medicaid Managed Care for People with Developmental Disabilities.

ERIC Educational Resources Information Center

Kastner, Theodore A.; Walsh, Kevin K.; Criscione, Teri

1997-01-01

Presents a general model of the structure and functioning of managed care and describes elements (provider networks, fiscal elements, risk estimation, case-mix, management information systems, practice parameters, and quality improvement) critical to people with developmental disabilities. Managed care demonstration projects and a hypothetical…

Health Care Reform: Implications of the President's Plan for Nursing Education.

ERIC Educational Resources Information Center

Bednash, Geraldine

This paper discusses factors emerging from the health care reform movement that will shape health care service delivery in general and nursing practice and education in particular. First, cost concerns will increase moves toward managed competition which will, in turn, create changes in service use patterns. These patterns seem overall to tend…

42 CFR 417.801 - Agreements between CMS and health care prepayment plans.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Agreements between CMS and health care prepayment... CMS and health care prepayment plans. (a) General requirement. (1) In order to participate and receive... written agreement with CMS. (2) An existing group practice prepayment plan (GPPP) that continues as an...

Priority setting in health care: trends and models from Scandinavian experiences.

PubMed

Hofmann, Bjørn

2013-08-01

The Scandinavian welfare states have public health care systems which have universal coverage and traditionally low influence of private insurance and private provision. Due to raises in costs, elaborate public control of health care, and a significant technological development in health care, priority setting came on the public agenda comparatively early in the Scandinavian countries. The development of health care priority setting has been partly homogeneous and appears to follow certain phases. This can be of broader interest as it may shed light on alternative models and strategies in health care priority setting. Some general trends have been identified: from principles to procedures, from closed to open processes, and from experts to participation. Five general approaches have been recognized: The moral principles and values based approach, the moral principles and economic assessment approach, the procedural approach, the expert based practice defining approach, and the participatory practice defining approach. There are pros and cons with all of these approaches. For the time being the fifth approach appears attractive, but its lack of true participation and the lack of clear success criteria may pose significant challenges in the future.

Case study of an anxious child with extensive caries treated in general dental practice: financial viability under the terms of the UK National Health Service.

PubMed

Shelley, A; Mackie, I

2001-10-01

This case study describes the management of Callum, an anxious 7-year-old boy with extensive caries. Callum's dental care was carried out in a general dental practice in the North of England under the terms of the National Health Service. A preventive programme was carried out in conjunction with the restorative philosophy according to guidelines published by the Dental Practice Board in 1997.

The brave new world of older patients: preparing general practice training for an ageing population.

PubMed

Bonney, Andrew; Phillipson, Lyn; Jones, Sandra C; Hall, Julie; Sharma, Rashmi

2015-11-01

Develop and pilot test evidence-based resources for general practice training practices to enhance older patients' (65+ years) interactions with General Practice Registrars (GPRs). In Australia, general practice trainees, referred to as GPRs, see fewer older patients and patients with chronic conditions than doctors who have completed their specialist GP training. This reduces learning opportunities for GPRs in the management of these important patient groups. Therefore, developing effective strategies to improve GPR-older patient interaction is critical to primary care training, to meet the current and future needs of an ageing population. Adopting a social marketing approach, GPR practice resources were developed to address knowledge and attitudinal barriers at the practice and patient level to improve older patient comfort, and willingness to engage, with GPR care. Two focus groups with older patients (n=18) and interviews with staff of training practices (n=12) were utilised to pre-test resources. Amended resources were pilot tested and evaluated in a naturalistic GPR training practice setting using a structured patient questionnaire (n=44). Pilot evaluation suggests improved comfort and willingness of older patients to interact with GPRs. In all, 54% of survey participants indicated they would be more likely to make an appointment with a Registrar in the future as a result of exposure to the resources. In all, 40% of patients would feel comfortable having a GPR manage a complex or chronic condition, which compares favourably with 28% of similarly aged patients in previous research. The use of tailored, engaging and informative GPR resources for older patients and practice staff may be an important contributor to addressing the growing problem of ensuring GPRs are adequately engaged in treating older patients. The adoption of a social marketing framework was instrumental in enhancing the acceptance and effectiveness of this intervention.

Child obesity prevention in primary health care: investigating practice nurse roles, attitudes and current practices.

PubMed

Robinson, Alison; Denney-Wilson, Elizabeth; Laws, Rachel; Harris, Mark

2013-04-01

Overweight and obesity affects approximately 20% of Australian pre-schoolers. The general practice nurse (PN) workforce has increased in recent years; however, little is known of PN capacity and potential to provide routine advice for the prevention of child obesity. This mixed methods pilot study aims to explore the current practices, attitudes, confidence and training needs of Australian PNs surrounding child obesity prevention in the general practice setting. PNs from three Divisions of General Practice in New South Wales were invited to complete a questionnaire investigating PN roles, attitudes and practices in preventive care with a focus on child obesity. A total of 59 questionnaires were returned (response rate 22%). Semi-structured qualitative interviews were also conducted with a subsample of PNs (n = 10). Questionnaire respondent demographics were similar to that of national PN data. PNs described preventive work as enjoyable despite some perceived barriers including lack of confidence. Number of years working in general practice did not appear to strongly influence nurses' perceived barriers. Seventy per cent of PNs were interested in being more involved in conducting child health checks in practice, and 85% expressed an interest in taking part in child obesity prevention training. Findings from this pilot study suggest that PNs are interested in prevention of child obesity despite barriers to practice and low confidence levels. More research is needed to determine the effect of training on PN confidence and behaviours in providing routine healthy life-style messages for the prevention of child obesity. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Early psychosocial interventions after disasters, terrorism and other shocking events: is there a gap between norms and practice in Europe?

PubMed Central

Te Brake, Hans

2013-01-01

Background Internationally, several initiatives exist to describe standards for post-disaster psychosocial care. Objective This study explored the level of consensus of experts within Europe on a set of recommendations on early psychosocial intervention after shocking events (Dutch guidelines), and to what degree these standards are implemented into mental health care practice. Methods Two hundred and six (mental) health care professionals filled out a questionnaire to assess the extent to which they consider the guidelines’ scope and recommendations relevant and part of the regular practice in their own country. Forty-five European experts from 24 EU countries discussed the guidelines at an international seminar. Results The data suggest overall agreement on the standards although many of the recommendations appear not (yet) to be embedded in everyday practice. Conclusions Although large consensus exists on standards for early psychosocial care, a chasm between norms and practice appears to exist throughout the EU, stressing the general need for investments in guideline development and implementation. PMID:23393613

Variations in achievement of evidence-based, high-impact quality indicators in general practice: An observational study

PubMed Central

West, Robert; Rushforth, Bruno; Stokes, Tim; Glidewell, Liz; Carder, Paul; Faulkner, Simon; Foy, Robbie

2017-01-01

Background There are widely recognised variations in the delivery and outcomes of healthcare but an incomplete understanding of their causes. There is a growing interest in using routinely collected ‘big data’ in the evaluation of healthcare. We developed a set of evidence-based ‘high impact’ quality indicators (QIs) for primary care and examined variations in achievement of these indicators using routinely collected data in the United Kingdom (UK). Methods Cross-sectional analysis of routinely collected, electronic primary care data from a sample of general practices in West Yorkshire, UK (n = 89). The QIs covered aspects of care (including processes and intermediate clinical outcomes) in relation to diabetes, hypertension, atrial fibrillation, myocardial infarction, chronic kidney disease (CKD) and ‘risky’ prescribing combinations. Regression models explored the impact of practice and patient characteristics. Clustering within practice was accounted for by including a random intercept for practice. Results Median practice achievement of the QIs ranged from 43.2% (diabetes control) to 72.2% (blood pressure control in CKD). Considerable between-practice variation existed for all indicators: the difference between the highest and lowest performing practices was 26.3 percentage points for risky prescribing and 100 percentage points for anticoagulation in atrial fibrillation. Odds ratios associated with the random effects for practices emphasised this; there was a greater than ten-fold difference in the likelihood of achieving the hypertension indicator between the lowest and highest performing practices. Patient characteristics, in particular age, gender and comorbidity, were consistently but modestly associated with indicator achievement. Statistically significant practice characteristics were identified less frequently in adjusted models. Conclusions Despite various policy and improvement initiatives, there are enduring inappropriate variations in the delivery of evidence-based care. Much of this variation is not explained by routinely collected patient or practice variables, and is likely to be attributable to differences in clinical and organisational behaviour. PMID:28704407

Patient satisfaction with ambulatory care in Germany: effects of patient- and medical practice-related factors.

PubMed

Auras, Silke; Ostermann, Thomas; de Cruppé, Werner; Bitzer, Eva-Maria; Diel, Franziska; Geraedts, Max

2016-12-01

The study aimed to illustrate the effect of the patients' sex, age, self-rated health and medical practice specialization on patient satisfaction. Secondary analysis of patient survey data using multilevel analysis (generalized linear mixed model, medical practice as random effect) using a sequential modelling strategy. We examined the effects of the patients' sex, age, self-rated health and medical practice specialization on four patient satisfaction dimensions: medical practice organization, information, interaction, professional competence. The study was performed in 92 German medical practices providing ambulatory care in general medicine, internal medicine or gynaecology. In total, 9888 adult patients participated in a patient survey using the validated 'questionnaire on satisfaction with ambulatory care-quality from the patient perspective [ZAP]'. We calculated four models for each satisfaction dimension, revealing regression coefficients with 95% confidence intervals (CIs) for all independent variables, and using Wald Chi-Square statistic for each modelling step (model validity) and LR-Tests to compare the models of each step with the previous model. The patients' sex and age had a weak effect (maximum regression coefficient 1.09, CI 0.39; 1.80), and the patients' self-rated health had the strongest positive effect (maximum regression coefficient 7.66, CI 6.69; 8.63) on satisfaction ratings. The effect of medical practice specialization was heterogeneous. All factors studied, specifically the patients' self-rated health, affected patient satisfaction. Adjustment should always be considered because it improves the comparability of patient satisfaction in medical practices with atypically varying patient populations and increases the acceptance of comparisons. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Practice nurse health checks for adults with intellectual disabilities: a cluster-design, randomised controlled trial.

PubMed

Cooper, Sally-Ann; Morrison, Jill; Allan, Linda M; McConnachie, Alex; Greenlaw, Nicola; Melville, Craig A; Baltzer, Marion C; McArthur, Laura A; Lammie, Claire; Martin, Gordon; Grieve, Eleanor A D; Fenwick, Elisabeth

2014-12-01

Adults with intellectual disabilities have substantial health inequalities and poor access to health care. We assessed whether practice nurse-delivered health checks could improve the health of adults with intellectual disabilities compared with standard care. In this cluster-design, single-blind, randomised controlled trial, we included general practices in Scotland, UK. From June to December, 2011, we randomly assigned (1:1) these general practices to either health checks plus standard care (health-checks group), or standard care only (control group), and we recruited the patients from these practices. Randomisation was done with stratification by number of GPs per practice and number of registered patients with intellectual disabilities (<20 or ≥20). Two research assistants were masked to allocation, and undertook the review of 9 month medical records and interviews. Participants and carers were not masked. The intervention was one health check designed especially for people with intellectual disabilities delivered by a practice nurse. The objective was improvement in health and health care 9 months after randomisation, and the primary outcome was the incidence of newly detected health needs being met by this timepoint. Whether needs were met was established by the investigators being masked to group allocation. The analysis was by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN43324841. Between June 26 and Dec 20, 2011, we recruited 38 practices. 85 participants (from 16 practices) were randomly assigned to intervention and 67 (from 17 practices) to standard care; five of the identified practices did not supply any participants. 83 intervention and 66 standard care participants completed the trial. More newly detected health needs were met in the intervention group than in the control standard care group (median 1 [range 0-8], 76·4% met [SD 36·5] vs 2 [0-11], 72·6% met [35·4]; odds ratio [OR] 1·73 [95% CI 0·93-3·22], p=0·085), although this difference was not significant. Significantly more health monitoring needs were met in the intervention group than standard care (median 2 [0-20], 69·9% [SD 34·2] vs 2 [0-22], 56·8% [29·4], OR 2·38 [95% CI 1·31-4·32, p=0·0053]). The probability that health checks are cost effective was between 0·6 and 0·8, irrespective of the cost-effectiveness threshold level. Costs per patient were -£71·48 for health checks and -£20·56 for standard care. The difference (-£50·92) was not significant [95% CI -434 to 362]. No adverse events were attributable to the intervention. Health checks given by practice nurses to adults with intellectual disabilities produced health-care improvements that were more conducive to longer-term health than standard care given to this population. The intervention dominated standard care, being both cheaper and more effective. Health-check programmes might therefore be indicated for adults with intellectual disabilities. Scottish Government Change Fund, NHS Greater Glasgow and Clyde Research and Development. Copyright © 2014 Elsevier Ltd. All rights reserved.

42 CFR 51c.102 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... of primary care physicians in general or family practice, internal medicine, pediatrics, or... individual. (g) Physician means a licensed doctor of medicine or doctor of osteopathy. (h) Primary health..., preventive health education, children's eye and ear examinations, prenatal and post-partum care, prenatal...

The practice of optometry: National Board of Examiners in Optometry survey of optometric patients.

PubMed

Soroka, Mort; Krumholz, David; Bennett, Amy

2006-09-01

A study commissioned by the National Board of Examiners in Optometry was designed to obtain information about patients seen in general practice. Providers completed an encounter form for patients seen during a 2-day sample. Data were obtained from 11,012 patients in rural, urban, and suburban environments from a diverse population of 480 optometrists representative of profession-wide practitioners in terms of geographic distribution and practice settings. Although practitioners were selected randomly, the response rate among those who were invited to participate was only 17.7%. Optometrists who specialized and did not classify themselves as general practitioners were excluded from the study. The study provides insights into the most common diagnostic and therapeutic procedures performed, medications prescribed, and referrals made in general practices. Seventy-one percent of all examinations were categorized as comprehensive, approximately 13% were because of disease, and 11% were for contact lens care. Almost 17% of all patients received a formal visual field test (Goldmann or automated). Refractive error was the most prevalent diagnosis, reflective of the ocular problems found in the general population, and systemic conditions were the second largest category. Although 12% of all patients were referred to an ophthalmologist for further care, other types of referrals were infrequent. Referrals to a primary care physician, laboratory, and imaging or for refractive surgery accounted for only 8% of all referrals. Ocular disease treatment was found to be an integral part of the optometrist's practice. Prescribing topical medications, both legend and "over-the-counter," was a primary treatment option. The most common medications prescribed were for glaucoma, with antibiotics, anti-inflammatory and anti-allergy drops making up the remainder, in descending order.

Professional misconduct: the case of the Medical Board of Australia v Tausif (occupational discipline).

PubMed

Colton, Caroline

2015-03-01

In 2014, the Australian Capital Territory Civil and Administrative Appeals Tribunal (ACAT) made a finding of professional misconduct against a Canberra general practitioner working in two bulk-billing medical practices established by a corporate medical practice service company, Primary Health Care Limited (Medical Board of Australia v Tausif (Occupational Discipline) [2015] ACAT 4). This column analyses that case, particularly in relation to the ACAT finding that the practitioner's professional misconduct was substantially contributed to by an unsafe system of care, specifically, the failure of Primary Health Care to provide supervision and mentoring for clinicians working at its medical centres. The case highlights the professional pressures carried by general practitioners who practise medicine within the framework of corporate bulk-billing business models. The column also examines the related issue of general practitioner co-payments in Australia and their impact on business models built around doctors purportedly characterised as independent contractors, bulk-billing large numbers of patients each day for short consultations.

[Four years of specialized outpatient palliative care in a rural area : Cooperation and acceptability from general practitioners' view].

PubMed

Kaiser, Florian; Sohm, Michael; Illig, Daniela; Vehling-Kaiser, Ursula; Haas, Michael

2016-07-01

In 2011, a specialized palliative home care was introduced in the counties of Landshut and Dingolfing. The aim of the current survey was to evaluate the cooperation, acceptance and need of palliative measures for patients particulary from the general practitioner's perspective. From January to March 2015, 198 general practitioners from the counties of Landshut and Dingolfing were contacted with questionnaires. The questionnaires consisted of 16 questions covering five different issues, and drew upon the practical experiences of the authors and earlier surveys from the literature. The questionnaires were sent by post containing a self-addressed and postpaid envelope. Completed questionnaires from 40 out of 198 contacted general practitioners (33 % female and 53 % male). Of these 85 % had cooperated with a SAPV team, 23 % had taken part in training for palliative medicine, 10 % intended to acquire a qualification and 10 % could imagine working in a SAPV team. In addition, 75 % stated that hospitalizations were avoided through the use of SAPV while 73 % felt that time and costs were saved for their own practices. The majority of general practitioners were satisfied with the work provided by the SAPV and the cooperation. Regarding additional palliative care for geriatric patients, 60 % believed that this was sensible. One main critique was that the information about including a patient in the SAPV program was transferred to the general practitioner too late. The current data show that general practitioners recognize the need for palliative medicine skills and predominately welcome the work of a specialized palliative care team in treating their patients. However, close cooperation and communication is necessary for a successful network between generalists and specialists in palliative care.

A multifaceted implementation strategy versus passive implementation of low back pain guidelines in general practice: a cluster randomised controlled trial.

PubMed

Riis, Allan; Jensen, Cathrine Elgaard; Bro, Flemming; Maindal, Helle Terkildsen; Petersen, Karin Dam; Bendtsen, Mette Dahl; Jensen, Martin Bach

2016-10-21

Guidelines are often slowly adapted into clinical practice. However, actively supporting healthcare professionals in evidence-based treatment may speed up guideline implementation. Danish low back pain (LBP) guidelines focus on primary care treatment of LBP, to reduce referrals from primary care to secondary care. The primary aim of this project was to reduce secondary care referral within 12 weeks by a multifaceted implementation strategy (MuIS). In a cluster randomised design, 189 general practices from the North Denmark Region were invited to participate. Practices were randomised (1:1) and stratified by practice size to MuIS (28 practices) or a passive implementation strategy (PaIS; 32 practices). Included were patients with LBP aged 18 to 65 years who were able to complete questionnaires, had no serious underlying pathology, and were not pregnant. We developed a MuIS including outreach visits, quality reports, and the STarT Back Tool for subgrouping patients with LBP. Both groups were offered the usual dissemination of guidelines, guideline-concordant structuring of the medical record, and a new referral opportunity for patients with psycho-social problems. In an intention-to-treat analysis, the primary and secondary outcomes pertained to the patient, and a cost-effectiveness analysis was performed from a healthcare sector perspective. Patients and the assessment of outcomes were blinded. Practices and caregivers delivering the interventions were not blinded. Between January 2013 and July 2014, 60 practices were included, of which 54 practices (28 MuIS, 26 PaIS) included 1101 patients (539 MuIS, 562 PaIS). Follow-up data for the primary outcome were available on 100 % of these patients. Twenty-seven patients (5.0 %) in the MuIS group were referred to secondary care vs. 59 patients (10.5 %) in the PaIS group. The adjusted odds ratio (AOR) was 0.52 [95 % CI 0.30 to 0.90; p = 0.020]. The MuIS was cost-saving £-93.20 (£406.51 vs. £499.71 per patient) after 12 weeks. Conversely, the MuIS resulted in less satisfied patients after 52 weeks (AOR 0.50 [95 % CI 0.31 to 0.81; p = 0.004]). Using a MuIS changed general practice referral behaviour and was cost effective, but patients in the MuIS group were less satisfied. This study supports the application of a MuIS when implementing guidelines. ClinicalTrials.gov, NCT01699256.

Consensus process to develop a best-practice document on the role of chiropractic care in health promotion, disease prevention, and wellness.

PubMed

Hawk, Cheryl; Schneider, Michael; Evans, Marion Willard; Redwood, Daniel

2012-09-01

The purposes of this project were to develop consensus definitions for a set of best practices that doctors of chiropractic may use for promoting health and wellness and preventing disease and to describe the appropriate components and procedures for these practices. A multidisciplinary steering committee of 10 health care professionals developed seed statements based on their clinical experience and relevant literature. A Delphi consensus process was conducted from January to July 2011, following the RAND methodology. Consensus was reached when at least 80% of the panelists were in agreement. There were 44 Delphi panelists (36 doctors of chiropractic, 6 doctors of philosophy, 1 doctor of naturopathy, 1 registered nurse). The statements developed defined the terms and practices for chiropractic care to promote health and wellness and prevent disease. This document describes the procedures and features of wellness care that represent a reasonable approach to wellness care and disease prevention in chiropractic clinical practice. This living document provides a general framework for an evidence-based approach to chiropractic wellness care. Copyright © 2012 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.

Safer handling practice: influence of staff education on older people.

PubMed

Wilson, Christine Brown

The purpose of this small-scale survey was to explore the level of moving and handling training undertaken by nurses within private sector continuing care environments and the potential this training had to influence the care of older people. This study uses a definition of safer handling practice derived from existing literature to examine how nurses report the application of this training and whether they observe changes to the mobility of older people within their care. The limitations of this study indicate that generalizations must be made cautiously. However, this study tentatively suggests that potential exists to influence positively the use of safer handling practice as defined within this study. Recommendations for further study are made.

Understanding the treatment of attention deficit hyperactivity disorder in newly diagnosed adult patients in general practice: a UK database study

PubMed Central

Bushe, Christopher; Wilson, Bernard; Televantou, Foula; Belger, Mark; Watson, Louise

2015-01-01

Background Adult attention deficit hyperactivity disorder (ADHD) has been largely ignored in psychiatric and general practice guidance until recently. Adult ADHD has a high social and medical burden, but health care is not well described in the UK. The main study objective was to evaluate a primary care adult ADHD population in terms of prescribing and health care contact rates. Methods This was a retrospective observational study using data from the Clinical Practice Research Database from January 1, 2002 to July 31, 2011. Adult patients with an incident ADHD diagnosis or ADHD medication were identified as having been free of ADHD medication or diagnoses in the previous 2 years. Patients were followed for 12–24 months after diagnosis. Results Of the 663 patients with ADHD in the cohort, 54.1% were prescribed ADHD medication during the observation period. During the first 6 months, 34.2% of patients initiated methylphenidates and 14.0% atomoxetine. In total, 36.3% patients were referred to secondary care psychiatry during observation, with the remaining population (63.7%) never having a referral. Most of the referrals were before diagnosis in primary care. At the end of the observation period, 16.2% of patients were on antipsychotics, 17.3% hypnotics, and 34.8% antidepressants or anxiolytics; however, some patients appeared to be prescribed antipsychotic or antidepressant medications even if they did not have an observable diagnosis in their records. Health care contact rates (general practitioner or hospital) increased by 39.2% post-diagnosis (incidence rate ratio: 1.39; 95% confidence interval: 1.32, 1.47), which may be related to the need for medication monitoring and titration. Conclusion This study has shown in primary care that there is relatively low use of ADHD medication, low referrals into secondary care, high rates of usage of psychiatric non-ADHD medications for different indications, and an increasing burden in terms of health care contacts in adult ADHD patients post-diagnosis. PMID:27774030

Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY.

PubMed

Hunter, David J; Hinman, Rana S; Bowden, Jocelyn L; Egerton, Thorlene; Briggs, Andrew M; Bunker, Stephen J; Kasza, Jessica; Forbes, Andrew B; French, Simon D; Pirotta, Marie; Schofield, Deborah J; Zwar, Nicholas A; Bennell, Kim L

2018-04-30

To increase the uptake of key clinical recommendations for non-surgical management of knee osteoarthritis (OA) and improve patient outcomes, we developed a new model of service delivery (PARTNER model) and an intervention to implement the model in the Australian primary care setting. We will evaluate the effectiveness and cost-effectiveness of this model compared to usual general practice care. We will conduct a mixed-methods study, including a two-arm, cluster randomised controlled trial, with quantitative, qualitative and economic evaluations. We will recruit 44 general practices and 572 patients with knee OA in urban and regional practices in Victoria and New South Wales. The interventions will target both general practitioners (GPs) and their patients at the practice level. Practices will be randomised at a 1:1 ratio. Patients will be recruited if they are aged ≥45 years and have experienced knee pain ≥4/10 on a numerical rating scale for more than three months. Outcomes are self-reported, patient-level validated measures with the primary outcomes being change in pain and function at 12 months. Secondary outcomes will be assessed at 6 and 12 months. The implementation intervention will support and provide education to intervention group GPs to deliver effective management for patients with knee OA using tailored online training and electronic medical record support. Participants with knee OA will have an initial GP visit to confirm their diagnosis and receive management according to GP intervention or control group allocation. As part of the intervention group GP management, participants with knee OA will be referred to a centralised multidisciplinary service: the PARTNER Care Support Team (CST). The CST will be trained in behaviour change support and evidence-based knee OA management. They will work with patients to develop a collaborative action plan focussed on key self-management behaviours, and communicate with the patients' GPs. Patients receiving care by intervention group GPs will receive tailored OA educational materials, a leg muscle strengthening program, and access to a weight-loss program as appropriate and agreed. GPs in the control group will receive no additional training and their patients will receive usual care. This project aims to address a major evidence-to-practice gap in primary care management of OA by evaluating a new service delivery model implemented with an intervention targeting GP practice behaviours to improve the health of people with knee OA. Australian New Zealand Clinical Trials Registry: ACTRN12617001595303 , date of registration 1/12/2017.