Assessing primary care in Austria: room for improvement.

PubMed

Stigler, Florian L; Starfield, Barbara; Sprenger, Martin; Salzer, Helmut J F; Campbell, Stephen M

2013-04-01

There is emerging evidence that strong primary care achieves better health at lower costs. Although primary care can be measured, in many countries, including Austria, there is little understanding of primary care development. Assessing the primary care development in Austria. A primary care assessment tool developed by Barbara Starfield in 1998 was implemented in Austria. This tool defines 15 primary care characteristics and distinguishes between system and practice characteristics. Each characteristic was evaluated by six Austrian primary care experts and rated as 2 (high), 1 (intermediate) or 0 (low) points, respectively, to their primary care strength (maximum score: n = 30). Austria received 7 out of 30 points; no characteristic was rated as '2' but 8 were rated as '0'. Compared with the 13 previously assessed countries, Austria ranks 10th of 14 countries and is classified as a 'low primary care' country. This study provides the first evidence concerning primary care in Austria, benchmarking it as weak and in need of development. The practicable application of an existing assessment tool can be encouraging for other countries to generate evidence about their primary care system as well.

Measures of quality, costs and equity in primary health care instruments developed to analyse and compare primary care in 35 countries.

PubMed

Schäfer, Willemijn L A; Boerma, Wienke G W; Kringos, Dionne S; De Ryck, Evelyne; Greß, Stefan; Heinemann, Stephanie; Murante, Anna Maria; Rotar-Pavlic, Danica; Schellevis, François G; Seghieri, Chiara; Van den Berg, Michael J; Westert, Gert P; Willems, Sara; Groenewegen, Peter P

2013-01-01

The Quality and Costs of Primary Care in Europe (QUALICOPC) study aims to analyse and compare how primary health care systems in 35 countries perform in terms of quality, costs and equity. This article answers the question 'How can the organisation and delivery of primary health care and its outcomes be measured through surveys of general practitioners (GPs) and patients?' It will also deal with the process of pooling questions and the subsequent development and application of exclusion criteria to arrive at a set of appropriate questions for a broad international comparative study. The development of the questionnaires consisted of four phases: a search for existing validated questionnaires, the classification and selection of relevant questions, shortening of the questionnaires in three consensus rounds and the pilot survey. Consensus was reached on the basis of exclusion criteria (e.g. the applicability for international comparison). Based on the pilot survey, comprehensibility increased and the number of questions was further restricted, as the questionnaires were too long. Four questionnaires were developed: one for GPs, one for patients about their experiences with their GP, another for patients about what they consider important, and a practice questionnaire. The GP questionnaire mainly focused on the structural aspects (e.g. economic conditions) and care processes (e.g. comprehensiveness of services of primary care). The patient experiences questionnaire focused on the care processes and outcomes (e.g. how do patients experience access to care?). The questionnaire about what patients consider important was complementary to the experiences questionnaire, as it enabled weighing the answers from the latter. Finally, the practice questionnaire included questions on practice characteristics. The QUALICOPC researchers have developed four questionnaires to characterise the organisation and delivery of primary health care and to compare and analyse the outcomes. Data collected with these instruments will allow us not only to show in detail the variation in process and outcomes of primary health care, but also to explain the differences from features of the (primary) health care system.

Effectiveness of collaborative care depression treatment in Veterans' Affairs primary care.

PubMed

Hedrick, Susan C; Chaney, Edmund F; Felker, Bradford; Liu, Chuan-Fen; Hasenberg, Nicole; Heagerty, Patrick; Buchanan, Jan; Bagala, Rocco; Greenberg, Diane; Paden, Grady; Fihn, Stephan D; Katon, Wayne

2003-01-01

To compare collaborative care for treatment of depression in primary care with consult-liaison (CL) care. In collaborative care, a mental health team provided a treatment plan to the primary care provider, telephoned patients to support adherence to the plan, reviewed treatment results, and suggested modifications to the provider. In CL care, study clinicians informed the primary care provider of the diagnosis and facilitated referrals to psychiatry residents practicing in the primary care clinic. Patients were randomly assigned to treatment model by clinic firm. VA primary care clinic. One hundred sixty-eight collaborative care and 186 CL patients who met criteria for major depression and/or dysthymia. Hopkins Symptom Checklist (SCL-20), Short Form (SF)-36, Sheehan Disability Scale. Collaborative care produced greater improvement than CL in depressive symptomatology from baseline to 3 months (SCL-20 change scores), but at 9 months there was no significant difference. The intervention increased the proportion of patients receiving prescriptions and cognitive behavioral therapy. Collaborative care produced significantly greater improvement on the Sheehan at 3 months. A greater proportion of collaborative care patients exhibited an improvement in SF-36 Mental Component Score of 5 points or more from baseline to 9 months. Collaborative care resulted in more rapid improvement in depression symptomatology, and a more rapid and sustained improvement in mental health status compared to the more standard model. Mounting evidence indicates that collaboration between primary care providers and mental health specialists can improve depression treatment and supports the necessary changes in clinic structure and incentives.

Curricula and Organization of Primary Care Residencies in Internal Medicine.

ERIC Educational Resources Information Center

Eisenberg, John M.

1980-01-01

The organization and curricula of internal medicine residencies programs that emphasize primary care are described and compared with traditional residencies in internal medicine. It is noted that primary care residents spend more time in ambulatory care and are allowed more electives in specialties outside of internal medicine. Out-of-hospital…

[Perceptions of primary health care among users and health professionals: a comparison of units with and without family health care in Central-West Brazil].

PubMed

van Stralen, Cornelis Johannes; Belisário, Soraya Almeida; van Stralen, Terezinha Berenice de Sousa; Lima, Angela Maria Dayrell de; Massote, Alice Werneck; Oliveira, Cláudia di Lorenzo

2008-01-01

This study analyzes perceptions of performance by primary health care facilities with and without the Family Health Program in municipalities with more than 100,000 inhabitants. Questionnaires from the Primary Care Assessment Tool developed by John Hopkins University and adapted to Brazil, contemplating eight dimensions of primary health care, were applied to users and professionals from a sample of 36 family health care facilities and 28 traditional primary care facilities. Thirty health professionals with university education, 207 with secondary education, 490 adult users, and 133 family members answered the questionnaires. The overall result did not show significant differences between perceptions of family health care facilities as compared to traditional primary health care facilities, but perceptions of health professionals were consistently more favorable than those of users. Comparing the scores for each dimension, family health care facilities always scored better (with the exception of level of access), but the difference in scores between facilities with and without the Family Health Strategy was only statistically significant for all three categories of respondents in relation to the items "family focus" and "community orientation".

Reducing barriers to mental health and social services for Iraq and Afghanistan veterans: outcomes of an integrated primary care clinic.

PubMed

Seal, Karen H; Cohen, Greg; Bertenthal, Daniel; Cohen, Beth E; Maguen, Shira; Daley, Aaron

2011-10-01

Despite high rates of post-deployment psychosocial problems in Iraq and Afghanistan veterans, mental health and social services are under-utilized. To evaluate whether a Department of Veterans Affairs (VA) integrated care (IC) clinic (established in April 2007), offering an initial three-part primary care, mental health and social services visit, improved psychosocial services utilization in Iraq and Afghanistan veterans compared to usual care (UC), a standard primary care visit with referral for psychosocial services as needed. Retrospective cohort study using VA administrative data. Five hundred and twenty-six Iraq and Afghanistan veterans initiating primary care at a VA medical center between April 1, 2005 and April 31, 2009. Multivariable models compared the independent effects of primary care clinic type (IC versus UC) on mental health and social services utilization outcomes. After 2007, compared to UC, veterans presenting to the IC primary care clinic were significantly more likely to have had a within-30-day mental health evaluation (92% versus 59%, p < 0.001) and social services evaluation [77% (IC) versus 56% (UC), p < 0.001]. This exceeded background system-wide increases in mental health services utilization that occurred in the UC Clinic after 2007 compared to before 2007. In particular, female veterans, younger veterans, and those with positive mental health screens were independently more likely to have had mental health and social service evaluations if seen in the IC versus UC clinic. Among veterans who screened positive for  ≥ 1 mental health disorder(s), there was a median of 1 follow-up specialty mental health visit within the first year in both clinics. Among Iraq and Afghanistan veterans new to primary care, an integrated primary care visit further improved the likelihood of an initial mental health and social services evaluation over background increases, but did not improve retention in specialty mental health services.

Comparing Homeless Persons’ Care Experiences in Tailored Versus Nontailored Primary Care Programs

PubMed Central

Holt, Cheryl L.; Steward, Jocelyn L.; Jones, Richard N.; Roth, David L.; Stringfellow, Erin; Gordon, Adam J.; Kim, Theresa W.; Austin, Erika L.; Henry, Stephen Randal; Kay Johnson, N.; Shanette Granstaff, U.; O’Connell, James J.; Golden, Joya F.; Young, Alexander S.; Davis, Lori L.; Pollio, David E.

2013-01-01

Objectives. We compared homeless patients’ experiences of care in health care organizations that differed in their degree of primary care design service tailoring. Methods. We surveyed homeless-experienced patients (either recently or currently homeless) at 3 Veterans Affairs (VA) mainstream primary care settings in Pennsylvania and Alabama, a homeless-tailored VA clinic in California, and a highly tailored non-VA Health Care for the Homeless Program in Massachusetts (January 2011-March 2012). We developed a survey, the “Primary Care Quality-Homeless Survey," to reflect the concerns and aspirations of homeless patients. Results. Mean scores at the tailored non-VA site were superior to those from the 3 mainstream VA sites (P < .001). Adjusting for patient characteristics, these differences remained significant for subscales assessing the patient–clinician relationship (P < .001) and perceptions of cooperation among providers (P = .004). There were 1.5- to 3-fold increased odds of an unfavorable experience in the domains of the patient–clinician relationship, cooperation, and access or coordination for the mainstream VA sites compared with the tailored non-VA site; the tailored VA site attained intermediate results. Conclusions. Tailored primary care service design was associated with a superior service experience for patients who experienced homelessness. PMID:24148052

Comorbidities, risk factors and outcomes in patients with heart failure and an ejection fraction of more than or equal to 40% in primary care- and hospital care-based outpatient clinics.

PubMed

Eriksson, B; Wändell, P; Dahlström, U; Näsman, P; Lund, L H; Edner, M

2018-06-01

The aim of this study is to describe patients with heart failure and an ejection fraction (EF) of more than or equal to 40%, managed in both Primary- and Hospital based outpatient clinics separately with their prognosis, comorbidities and risk factors. Further to compare the heart failure medication in the two groups. We used the prospective Swedish Heart Failure Registry to include 9654 out-patients who had HF and EF ≥40%, 1802 patients were registered in primary care and 7852 in hospital care. Descriptive statistical tests were used to analyze base line characteristics in the two groups and multivariate logistic regression analysis to assess mortality rate in the groups separately. The prospective Swedish Heart Failure Registry. Patients with heart failure and an ejection fraction (EF) of more than or equal to 40%. Comorbidities, risk factors and mortality. Mean-age was 77.5 (primary care) and 70.3 years (hospital care) p < 0.0001, 46.7 vs. 36.3% women respectively (p < 0.0001) and EF ≥50% 26.1 vs. 13.4% (p < 0.0001). Co-morbidities were common in both groups (97.2% vs. 92.3%), the primary care group having more atrial fibrillation, hypertension, ischemic heart disease and COPD. According to the multivariate logistic regression analysis smoking, COPD and diabetes were the most important independent risk factors in the primary care group and valvular disease in the hospital care group. All-cause mortality during mean follow-up of almost 4 years was 31.5% in primary care and 27.8% in hospital care. One year-mortality rates were 7.8%, and 7.0% respectively. Any co-morbidity was noted in 97% of the HF-patients with an EF of more than or equal to 40% managed at primary care based out-patient clinics and these patients had partly other independent risk factors than those patients managed in hospital care based outpatients clinics. Our results indicate that more attention should be payed to manage COPD in the primary care group. KEY POINTS 97% of heart failure patients with an ejection fraction of more than or equal to 40% managed at primary care based out-patient clinics had any comorbidity. Patients in primary care had partly other independent risk factors than those in hospital care. All-cause mortality during mean follow-up of almost 4 years was higher in primary care compared to hospital care. In matched HF-patients RAS-antagonists, beta-blockers as well as the combination of the two drugs were more seldom prescribed when managed in primary care compared with hospital care.

Private ownership of primary care providers associated with patient perceived quality of care: A comparative cross-sectional survey in three big Chinese cities.

PubMed

Wei, Xiaolin; Yin, Jia; Wong, Samuel Y S; Griffiths, Sian M; Zou, Guanyang; Shi, Leiyu

2017-01-01

Ownership of primary care providers varies in different cities in China. Shanghai represented the full public ownership model of primary providers; Shenzhen had public-owned but private-operated providers; and Hong Kong represented the full private ownership. The study aims to assess the association of primary care ownership and patient perceived quality of care in 3 Chinese megacities.We conducted multistage stratified random surveys in 2013 in the 3 cities. Quality scores of primary care were measured using the validated primary care assessment tools. Multivariate linear regression models were used to compare quality scores after controlling potential confounders of patient demographic, socioeconomic, and healthcare utilization factors.Overall, 797 primary care users in Shanghai, 802 in Shenzhen, and 1325 in Hong Kong participated in the study. The mean total quality scores were reported the highest in Shanghai (28.39), followed by Shenzhen (25.82) and then Hong Kong (25.21) (P < 0.001). Shanghai participants reported the highest scores for 1st contact accessibility, coordination of information, comprehensiveness of service availability, and culture competence, while Hong Kong participants reported the lowest for these domains (P < 0.001). Hong Kong participants from rich households reported higher total scores than those from poor households (P < 0.05); however, this was not found in Shanghai and Shenzhen.The study suggests that private primary care ownership may be associated with lower quality and less equitable care distribution. In China, it suggests that it may be beneficial to promote public-owned and nonprofit providers. Promoting privatization in primary care may be at the cost of quality and equity of primary care.

After-hours access to primary care practices linked with lower emergency department use and less unmet medical need.

PubMed

O'Malley, Ann S

2013-01-01

One goal of the Affordable Care Act is to improve patients' access to primary care and the coordination of that care. An important ingredient in achieving that goal is ensuring that patients have access to their primary care practice outside of regular business hours. This analysis of the 2010 Health Tracking Household Survey found that among people with a usual source of primary care, 40.2 percent reported that their practice offered extended hours, such as at night or on weekends. The analysis also found that one in five people who attempted after-hours contact with their primary care provider reported it was "very difficult" or "somewhat difficult" to reach a clinician. Those who reported less difficulty contacting a clinician after hours had significantly fewer emergency department visits (30.4 percent compared to 37.7 percent) and lower rates of unmet medical need (6.1 percent compared to 13.7 percent) than people who experienced more difficulty. The findings provide a valuable baseline on after-hours access, especially as patient-centered medical homes and accountable care organizations expand. Increasing support to primary care practices to offer or coordinate after-hours care may help reduce rates of emergency department use and unmet medical need.

Primary Care Provider Perceptions of the Effectiveness of Two Self-Management Support Programs for Vulnerable Patients with Diabetes

PubMed Central

Ratanawongsa, Neda; Bhandari, Vijay K; Handley, Margaret; Rundall, Thomas; Hammer, Hali; Schillinger, Dean

2012-01-01

Background Primary care providers (PCPs) in safety net settings face barriers to optimizing care for patients with diabetes. We conducted this study to assess PCPs' perspectives on the effectiveness of two language-concordant diabetes self-management support programs. Methods One year postintervention, we surveyed PCPs whose patients with diabetes participated in a three-arm multiclinic randomized controlled trial comparing usual care (UC), weekly automated telephone self-management (ATSM) support with nurse care management, and monthly group medical visits (GMVs). We compared PCP perspectives on patient activation to create and achieve goals, quality of care, and barriers to care using regression models accounting for within-PCP clustering. Results Of 113 eligible PCPs caring for 330 enrolled patients, 87 PCPs (77%) responded to surveys about 245 (74%) enrolled patients. Intervention patients were more likely to be perceived by PCPs as activated to create and achieve goals for chronic care when compared with UC patients (standardized effect size, ATSM vs UC, +0.41, p = 0.01; GMV vs UC, +0.31, p = 0.05). Primary care providers rated quality of care as higher for patients exposed to ATSM compared to UC (odds ratio 3.6, p < 0.01). Compared with GMV patients, ATSM patients were more likely to be perceived by PCPs as overcoming barriers related to limited English proficiency (82% ATSM vs 44% GMV, p = 0.01) and managing medications (80% ATSM vs 53% GMV, p = 0.01). Conclusions Primary care providers perceived that patients receiving ATSM support had overcome barriers, participated more actively, and received higher quality diabetes care. These views of clinician stakeholders lend additional evidence for the potential to upscale ATSM more broadly to support PCPs in their care of diverse, multilinguistic populations. PMID:22401329

Are attributes of organizational performance in large health care organizations relevant in primary care practices?

PubMed

Orzano, A John; Tallia, Alfred F; Nutting, Paul A; Scott-Cawiezell, Jill; Crabtree, Benjamin F

2006-01-01

Are organizational attributes associated with better health outcomes in large health care organizations applicable to primary care practices? In comparative case studies of two community family practices, it was found that attributes of organizational performance identified in larger health care organizations must be tailored to their unique context of primary care. Further work is required to adapt or establish the significance of the attributes of management infrastructure and information mastery.

Primary Care Outcomes Questionnaire: psychometric testing of a new instrument.

PubMed

Murphy, Mairead; Hollinghurst, Sandra; Cowlishaw, Sean; Salisbury, Chris

2018-06-01

Patients attend primary care for many reasons and to achieve a range of possible outcomes. There is currently no Patient Reported Outcome Measure (PROM) designed to capture these diverse outcomes, and trials of interventions in primary care may thus fail to detect beneficial effects. This study describes the psychometric testing of the Primary Care Outcomes Questionnaire (PCOQ), which was designed to capture a broad range of outcomes relevant to primary care. Questionnaires were administered in primary care in South West England. Patients completed the PCOQ in GP waiting rooms before a consultation, and a second questionnaire, including the PCOQ and seven comparator PROMs, after 1 week. Psychometric testing included exploratory factor analysis on the PCOQ, internal consistency, correlation coefficients between domain scores and comparator measures, and repeated measures effect sizes indicating change across 1 week. In total, 602 patients completed the PCOQ at baseline, and 264 (44%) returned the follow-up questionnaire. Exploratory factor analysis suggested four dimensions underlying the PCOQ items: health and wellbeing, health knowledge and self-care, confidence in health provision, and confidence in health plan. Each dimension was internally consistent and correlated as expected with comparator PROMs, providing evidence of construct validity. Patients reporting an improvement in their main problem exhibited small to moderate improvements in relevant domain scores on the PCOQ. The PCOQ was acceptable, feasible, showed strong psychometric properties, and was responsive to change. It is a promising new tool for assessment of outcomes of primary care interventions from a patient perspective. © British Journal of General Practice 2018.

Is initial excision of cutaneous melanoma by General Practitioners (GPs) dangerous? Comparing patient outcomes following excision of melanoma by GPs or in hospital using national datasets and meta-analysis.

PubMed

Murchie, Peter; Amalraj Raja, Edwin; Brewster, David H; Iversen, Lisa; Lee, Amanda J

2017-11-01

Melanomas are initially excised in primary care, and rates vary internationally. Until now, there has been no strong evidence one way or the other that excising melanomas in primary care is safe or unsafe. European guidelines make no recommendations, and the United Kingdom (UK) melanoma guidelines require all suspicious skin lesions to be initially treated in secondary care based on an expert consensus, which lacks supporting evidence, that primary care excision represents substandard care. Despite this, studies have found that up to 20% of melanomas in the UK are excised by general practitioners (GPs). Patients receiving primary care melanoma excision may fear that their care is substandard and their long-term survival threatened, neither of which may be justified. Scottish cancer registry data from 9367 people diagnosed with melanoma in Scotland between 2005 and 2013 were linked to pathology records, hospital data and death records. A Cox proportional hazards regression analysis, adjusting for key confounders, explored the association between morbidity and mortality and setting of primary melanoma excision (primary versus secondary care). A pooled estimate of the relative hazard of death of having a melanoma excised in primary versus secondary care including 7116 patients from a similar Irish study was also performed. The adjusted hazard ratio (95% CI) of death from melanoma for those having primary care excision was 0.82 (0.61-1.10). Those receiving primary care excision had a median (IQR) of 8 (3-14) out-patient attendances compared to 10 (4-17) for the secondary care group with an adjusted relative risk (RR) (95% CI) of 0.98 (0.96-1.01). Both groups had a median of 1 (0-2) hospital admissions with an adjusted rate ratio of 1.05 (0.98-1.13). In the meta-analysis, with primary care as the reference, the pooled adjusted hazard ratio (HR, 95% CI) was 1.26 (1.07-1.50) indicating a significantly higher all-cause mortality among those with excision in secondary care. The results of the Scottish and pooled analyses suggest that those receiving an initial excision for melanoma in primary care do not have poorer survival or increased morbidity compared to those being initially treated in secondary care. A randomised controlled trial to inform a greater role for GPs in the initial excision of melanoma is justified in the light of these results. Copyright © 2017 Elsevier Ltd. All rights reserved.

A comparison of UK primary care data with other national data sources for monitoring the prevalence of smoking during pregnancy.

PubMed

Dhalwani, Nafeesa N; Tata, Laila J; Coleman, Tim; Fiaschi, Linda; Szatkowski, Lisa

2015-09-01

We aimed to assess the potential usefulness of primary care data in the UK for estimating smoking prevalence in pregnancy by comparing the primary care data estimates with those obtained from other data sources. In The Health Improvement Network (THIN) primary care database, we identified pregnant smokers using smoking information recorded during pregnancy. Where this information was missing, we used smoking information recorded prior to pregnancy. We compared annual smoking prevalence from 2000 to 2012 in THIN with measures from the Infant Feeding Survey (IFS), Smoking At Time of Delivery (SATOD), Child Health Systems Programme (CHSP) and Scottish Morbidity Record (SMR). Smoking estimates from THIN data converged with estimates from other sources after 2004, though still do not agree completely. For example, in 2012 smoking prevalence at booking was 11.6% in THIN using data recorded only during pregnancy, compared with 19.6% in SMR data. However, the use of smoking data recorded up to 27 months before conception increased the THIN prevalence to 20.3%, improving the comparability. Under-recording of smoking status during pregnancy results in unreliable prevalence estimates from primary care data and needs improvement. However, in the absence of gestational smoking data, the inclusion of pre-conception smoking records may increase the utility of primary care data. One strategy to improve gestational smoking status recording in primary care could be the inclusion of pregnancy in the Quality and Outcome's Framework as a condition for which smoking status and smoking cessation advice must be recorded electronically in patient records. © The Author 2014. Published by Oxford University Press on behalf of Faculty of Public Health.

Health Care Use and Spending for Medicaid Enrollees in Federally Qualified Health Centers Versus Other Primary Care Settings

PubMed Central

Lee, Sang Mee; Sharma, Ravi; Ngo-Metzger, Quyen; Mukamel, Dana B.; Gao, Yue; White, Laura M.; Shi, Leiyu; Chin, Marshall H.; Laiteerapong, Neda; Huang, Elbert S.

2016-01-01

Objectives. To compare health care use and spending of Medicaid enrollees seen at federally qualified health centers versus non–health center settings in a context of significant growth. Methods. Using fee-for-service Medicaid claims from 13 states in 2009, we compared patients receiving the majority of their primary care in federally qualified health centers with propensity score–matched comparison groups receiving primary care in other settings. Results. We found that health center patients had lower use and spending than did non–health center patients across all services, with 22% fewer visits and 33% lower spending on specialty care and 25% fewer admissions and 27% lower spending on inpatient care. Total spending was 24% lower for health center patients. Conclusions. Our analysis of 2009 Medicaid claims, which includes the largest sample of states and more recent data than do previous multistate claims studies, demonstrates that the health center program has provided a cost-efficient setting for primary care for Medicaid enrollees. PMID:27631748

Identification of Causes of the Occupational Stress for Health Providers at Different Levels of Health Care.

PubMed

Trifunovic, Natasa; Jatic, Zaim; Kulenovic, Alma Dzubur

2017-06-01

To identify and compare the stressors in the work environment experienced by employees in primary health care and secondary health care, amongphysiciansand nurses. The survey was conducted to identify types of stressors by assessing health care workers employed in the primary and secondary health care services of the Public Institution, the Health Centre of the Sarajevo Canton, using a questionnaire about stress in the workplace. Among all study participants stressors connected to the organization of work, finance and communication were found to affect their mental health most strongly. The results show a significant difference between primary and secondary health care in experience of stressors related to the organization of work, communication, and stressors related to the emotional and physical risks. Primary health care physicians report a significantly higher experience of stress and impact on mental health compared with other physicians related to emotional difficulties when working in the field of palliative care. Our results also indicate a significant difference between primary and secondary health providers in experiencing stressors related to the organization of work, such as: on-call duty shifts, an inadequate working environment and in the assessment of administrative work overload. The survey identified the most intense stressors for doctors and nurses at primary and secondary levels of health care services. The results of the study indicate that doctors and nurses have a different hierarchy of stressors, as well as subjects at Primary and Secondary Health Care. The results of the study indicate that subjects et Primary Health Care perceive more stressful organizational, emotional and communicational problems.

Medical homes versus individual practice in primary care: impact on health care expenditures.

PubMed

Perelman, Julian; Roch, Isabelle; Heymans, Isabelle; Moureaux, Catherine; Lagasse, Raphael; Annemans, Lieven; Closon, Marie-Christine

2013-08-01

The medical home (MH) model has prompted increasing attention given its potential to improve quality of care while reducing health expenditures. We compare overall and specific health care expenditures in Belgium, from the third-party payer perspective (compulsory social insurance), between patients treated at individual practices (IP) and at MHs. We compare the sociodemographic profile of MH and IP users. This is a retrospective study using public insurance claims data. Generalized linear models estimate the impact on health expenditures of being treated at a MH versus IP, controlling for individual, and area-based sociodemographic characteristics. The choice of primary care setting is modeled using logistic regressions. A random sample of 43,678 persons followed during the year 2004. Third-party payer expenditures for primary care, secondary care consultations, pharmaceuticals, laboratory tests, acute and long-term inpatient care. Overall third-party payer expenditures do not differ significantly between MH and IP users (€+27). Third-party payer primary care expenditures are higher for MH than for IP users (€+129), but this difference is offset by lower expenditures for secondary care consultations (€-11), drugs (€-40), laboratory tests (€-5) and acute and long-term inpatient care (€-53). MHs attract younger and more underprivileged populations. MHs induce a shift in expenditures from secondary care, drugs, and laboratory tests to primary care, while treating a less economically favored population. Combined with positive results regarding quality, MH structures are a promising way to tackle the challenges of primary care.

Systematic review of integrated models of health care delivered at the primary-secondary interface: how effective is it and what determines effectiveness?

PubMed

Mitchell, Geoffrey K; Burridge, Letitia; Zhang, Jianzhen; Donald, Maria; Scott, Ian A; Dart, Jared; Jackson, Claire L

2015-01-01

Integrated multidisciplinary care is difficult to achieve between specialist clinical services and primary care practitioners, but should improve outcomes for patients with chronic and/or complex chronic physical diseases. This systematic review identifies outcomes of different models that integrate specialist and primary care practitioners, and characteristics of models that delivered favourable clinical outcomes. For quality appraisal, the Cochrane Risk of Bias tool was used. Data are presented as a narrative synthesis due to marked heterogeneity in study outcomes. Ten studies were included. Publication bias cannot be ruled out. Despite few improvements in clinical outcomes, significant improvements were reported in process outcomes regarding disease control and service delivery. No study reported negative effects compared with usual care. Economic outcomes showed modest increases in costs of integrated primary-secondary care. Six elements were identified that were common to these models of integrated primary-secondary care: (1) interdisciplinary teamwork; (2) communication/information exchange; (3) shared care guidelines or pathways; (4) training and education; (5) access and acceptability for patients; and (6) a viable funding model. Compared with usual care, integrated primary-secondary care can improve elements of disease control and service delivery at a modestly increased cost, although the impact on clinical outcomes is limited. Future trials of integrated care should incorporate design elements likely to maximise effectiveness.

Environmental factors associated with primary care access among urban older adults.

PubMed

Ryvicker, Miriam; Gallo, William T; Fahs, Marianne C

2012-09-01

Disparities in primary care access and quality impede optimal chronic illness prevention and management for older adults. Although research has shown associations between neighborhood attributes and health, little is known about how these factors - in particular, the primary care infrastructure - inform older adults' primary care use. Using geographic data on primary care physician supply and surveys from 1260 senior center attendees in New York City, we examined factors that facilitate and hinder primary care use for individuals living in service areas with different supply levels. Supply quartiles varied in primary care use (visit within the past 12 months), racial and socio-economic composition, and perceived neighborhood safety and social cohesion. Primary care use did not differ significantly after controlling for compositional factors. Individuals who used a community clinic or hospital outpatient department for most of their care were less likely to have had a primary care visit than those who used a private doctor's office. Stratified multivariate models showed that within the lowest-supply quartile, public transit users had a higher odds of primary care use than non-transit users. Moreover, a higher score on the perceived neighborhood social cohesion scale was associated with a higher odds of primary care use. Within the second-lowest quartile, nonwhites had a lower odds of primary care use compared to whites. Different patterns of disadvantage in primary care access exist that may be associated with - but not fully explained by - local primary care supply. In lower-supply areas, racial disparities and inadequate primary care infrastructure hinder access to care. However, accessibility and elder-friendliness of public transit, as well as efforts to improve social cohesion and support, may facilitate primary care access for individuals living in low-supply areas. Copyright © 2012 Elsevier Ltd. All rights reserved.

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.

Integrated, Accountable Care For Medicaid Expansion Enrollees: A Comparative Evaluation of Hennepin Health.

PubMed

Vickery, Katherine D; Shippee, Nathan D; Menk, Jeremiah; Owen, Ross; Vock, David M; Bodurtha, Peter; Soderlund, Dana; Hayward, Rodney A; Davis, Matthew M; Connett, John; Linzer, Mark

2018-05-01

Hennepin Health, a Medicaid accountable care organization, began serving early expansion enrollees (very low-income childless adults) in 2012. It uses an integrated care model to address social and behavioral needs. We compared health care utilization in Hennepin Health with other Medicaid managed care in the same area from 2012 to 2014, controlling for demographics, chronic conditions, and enrollment patterns. Homelessness and substance use were higher in Hennepin Health. Overall adjusted results showed Hennepin Health had 52% more emergency department visits and 11% more primary care visits than comparators. Over time, modeling a 6-month exposure to Hennepin Health, emergency department and primary care visits decreased and dental visits increased; hospitalizations decreased nonsignificantly but increased among comparators. Subgroup analysis of high utilizers showed lower hospitalizations in Hennepin Health. Integrated, accountable care under Medicaid expansion showed some desirable trends and subgroup benefits, but overall did not reduce acute health care utilization versus other managed care.

Coordination Program Reduced Acute Care Use And Increased Primary Care Visits Among Frequent Emergency Care Users.

PubMed

Capp, Roberta; Misky, Gregory J; Lindrooth, Richard C; Honigman, Benjamin; Logan, Heather; Hardy, Rose; Nguyen, Dong Q; Wiler, Jennifer L

2017-10-01

Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities. Project HOPE—The People-to-People Health Foundation, Inc.

Improving Primary Care Provider Practices in Youth Concussion Management.

PubMed

Arbogast, Kristy B; Curry, Allison E; Metzger, Kristina B; Kessler, Ronni S; Bell, Jeneita M; Haarbauer-Krupa, Juliet; Zonfrillo, Mark R; Breiding, Matthew J; Master, Christina L

2017-08-01

Primary care providers are increasingly providing youth concussion care but report insufficient time and training, limiting adoption of best practices. We implemented a primary care-based intervention including an electronic health record-based clinical decision support tool ("SmartSet") and in-person training. We evaluated consequent improvement in 2 key concussion management practices: (1) performance of a vestibular oculomotor examination and (2) discussion of return-to-learn/return-to-play (RTL/RTP) guidelines. Data were included from 7284 primary care patients aged 0 to 17 years with initial concussion visits between July 2010 and June 2014. We compared proportions of visits pre- and post-intervention in which the examination was performed or RTL/RTP guidelines provided. Examinations and RTL/RTP were documented for 1.8% and 19.0% of visits pre-intervention, respectively, compared with 71.1% and 72.9% post-intervention. A total of 95% of post-intervention examinations were documented within the SmartSet. An electronic clinical decision support tool, plus in-person training, may be key to changing primary care provider behavior around concussion care.

Does Integrated Behavioral Health Care Reduce Mental Health Disparities for Latinos? Initial Findings

PubMed Central

Bridges, Ana J.; Andrews, Arthur R.; Villalobos, Bianca T.; Pastrana, Freddie A.; Cavell, Timothy A.; Gomez, Debbie

2014-01-01

Integrated behavioral health care (IBHC) is a model of mental health care service delivery that seeks to reduce stigma and service utilization barriers by embedding mental health professionals into the primary care team. This study explored whether IBHC service referrals, utilization, and outcomes were comparable for Latinos and non-Latino White primary care patients. Data for the current study were collected from 793 consecutive patients (63.8% Latino; M age = 29.02 years [SD = 17.96]; 35.1% under 18 years; 65.3% women; 54.3% uninsured) seen for behavioral health services in 2 primary care clinics during a 10.5 month period. The most common presenting concerns were depression (21.6%), anxiety (18.5%), adjustment disorder (13.0%), and externalizing behavior problems (9.8%). Results revealed that while Latino patients had significantly lower self-reported psychiatric distress, significantly higher clinician-assigned global assessment of functioning scores, and fewer received a psychiatric diagnosis at their initial visit compared to non-Latino White patients, both groups had comparable utilization rates, comparable and clinically significant improvements in symptoms (Cohen’s d values > .50), and expressed high satisfaction with integrated behavioral services. These data provide preliminary evidence suggesting integration of behavioral health services into primary care clinics may help reduce mental health disparities for Latinos. PMID:25309845

Comparing the application of Health Information Technology in primary care in Denmark and Andalucía, Spain.

PubMed

Protti, Denis; Johansen, Ib; Perez-Torres, Francisco

2009-04-01

It is generally acknowledged that Denmark is one, if not the, leading country in terms of the use of information technology by its primary care physicians. Other countries, notably excluding the United States and Canada, are also advanced in terms of electronic medical records in general practitioner offices and clinics. This paper compares the status of primary care physician office computing in Andalucía to that of Denmark by contrasting the functionality of electronic medical records (EMRs) and the ability to electronically communicate clinical information in both jurisdictions. A novel scoring system has been developed based on data gathered from databases held by the respective jurisdictional programs, and interviews with individuals involved in the deployment of the systems. The scoring methodology was applied for the first time in a comparison of the degree of automation in primary care physician offices in Denmark and the province of Alberta in Canada. It was also used to compare Denmark and New Zealand. This paper is the third offering of this method of scoring the adoption of electronic medical records in primary care office settings which hopefully may be applicable to other health jurisdictions at national, state, or provincial levels. Although similar in many respects, there are significant differences between these two relatively autonomous health systems which have led to the rates of uptake of physician office computing. Particularly notable is the reality that the Danish primary care physicians have individual "Electronic Medical Records" while in Andalucía, the primary care physicians share a common record which when secondary care is fully implemented will indeed be an "Electronic Health Record". It is clear that the diffusion of technology, within the primary care physician sector of the health care market, is subject to historical, financial, legal, cultural, and social factors. This tale of two places illustrates the issues, and different ways that they have been addressed.

Characteristics of nurses providing diabetes community and outpatient care in Auckland.

PubMed

Daly, Barbara; Arroll, Bruce; Sheridan, Nicolette; Kenealy, Timothy; Scragg, Robert

2013-03-01

There is a worldwide trend for diabetes care to be undertaken in primary care. Nurses are expected to take a leading role in diabetes management, but their roles in primary care are unclear in New Zealand, as are the systems of care they work in as well as their training. To describe and compare demographic details, education and diabetes experience, practice setting and facilities available for the three main groups of primary health care nurses working in the largest urban area in New Zealand. Of the total number of practice nurses, district nurses and specialist nurses working in Auckland (n=1091), 31% were randomly selected to undertake a self-administered questionnaire and telephone interview in 2006-2008. Overall response was 86% (n=284 self-administered questionnaires, n=287 telephone interviews). Almost half (43%) of primary care nurses were aged over 50 years. A greater proportion of specialist nurses (89%) and practice nurses (84%) had post-registration diabetes education compared with district nurses (65%, p=0.005), from a range of educational settings including workshops, workplaces, conferences and tertiary institutions. More district nurses (35%) and practice nurses (32%) had worked in their current workplace for >10 years compared with specialist nurses (14%, p=0.004). Over 20% of practice nurses and district nurses lacked access to the internet, and the latter group had the least administrative facilities and felt least valued. These findings highlight an ageing primary health care nursing workforce, lack of a national primary health care post-registration qualification and a lack of internet access.

A Case for Telestroke in Military Medicine: A Retrospective Analysis of Stroke Cost and Outcomes in U.S. Military Health-Care System.

PubMed

Dave, Ajal; Cagniart, Kendra; Holtkamp, Matthew D

2018-06-07

The development of primary stroke centers has improved outcomes for stroke patients. Telestroke networks have expanded the reach of stroke experts to underserved, geographically remote areas. This study illustrates the outcome and cost differences between neurology and primary care ischemic stroke admissions to demonstrate a need for telestroke networks within the Military Health System (MHS). All adult admissions with a primary diagnosis of ischemic stroke in the MHS Military Mart database from calendar years 2010 to 2015 were reviewed. Neurology, primary care, and intensive care unit (ICU) admissions were compared across primary outcomes of (1) disposition status and (2) intravenous tissue plasminogen activator administration and for secondary outcomes of (1) total cost of hospitalization and (2) length of stay (LOS). A total of 3623 admissions met the study's parameters. The composition was neurology 462 (12.8%), primary care 2324 (64.1%), ICU 677 (18.7%), and other/unknown 160 (4.4%). Almost all neurology admissions (97%) were at the 3 neurology training programs, whereas a strong majority of primary care admissions (80%) were at hospitals without a neurology admitting service. Hospitals without a neurology admitting service had more discharges to rehabilitation facilities and higher rates of in-hospital mortality. LOS was also longer in primary care admissions. Ischemic stroke admissions to neurology had better outcomes and decreased LOS when compared to primary care within the MHS. This demonstrates a possible gap in care. Implementation of a hub and spoke telestroke model is a potential solution. Published by Elsevier Inc.

Costs of health care across primary care models in Ontario.

PubMed

Laberge, Maude; Wodchis, Walter P; Barnsley, Jan; Laporte, Audrey

2017-08-01

The purpose of this study is to analyze the relationship between newly introduced primary care models in Ontario, Canada, and patients' primary care and total health care costs. A specific focus is on the payment mechanisms for primary care physicians, i.e. fee-for-service (FFS), enhanced-FFS, and blended capitation, and whether providers practiced as part of a multidisciplinary team. Utilization data for a one year period was measured using administrative databases for a 10% sample selected at random from the Ontario adult population. Primary care and total health care costs were calculated at the individual level and included costs from physician services, hospital visits and admissions, long term care, drugs, home care, lab tests, and visits to non-medical health care providers. Generalized linear model regressions were conducted to assess the differences in costs between primary care models. Patients not enrolled with a primary care physicians were younger, more likely to be males and of lower socio-economic status. Patients in blended capitation models were healthier and wealthier than FFS and enhanced-FFS patients. Primary care and total health care costs were significantly different across Ontario primary care models. Using the traditional FFS as the reference, we found that patients in the enhanced-FFS models had the lowest total health care costs, and also the lowest primary care costs. Patients in the blended capitation models had higher primary care costs but lower total health care costs. Patients that were in multidisciplinary teams (FHT), where physicians are also paid on a blended capitation basis, had higher total health care costs than non-FHT patients but still lower than the FFS reference group. Primary care and total health care costs increased with patients' age, morbidity, and lower income quintile across all primary care payment types. The new primary care models were associated with lower total health care costs for patients compared to the traditional FFS model, despite higher primary care costs in some models.

Primary care quality between Traditional Tibetan Medicine and Western Medicine Hospitals: a pilot assessment in Tibet.

PubMed

Wang, Wenhua; Shi, Leiyu; Yin, Aitian; Mao, Zongfu; Maitland, Elizabeth; Nicholas, Stephen; Liu, Xiaoyun

2015-05-14

This paper assesses both patients' perspectives on the differences in primary care quality between traditional Tibetan medicine (TTM) hospitals and western medicine (WM) hospitals and the efficacy of the government's investment in these two Prefecture-level primary care structures in Tibet. A validated Tibetan version of the Primary Care Assessment Tool (PCAT-T) was used to collect data on 692 patients aged over 18 years old, who reported the sampling site was their regular source of health care. T-tests were performed to compare the separate and total primary care attributes between WM hospitals and TTM hospitals. Multiple linear regression analysis was conducted to examine the association of the health care setting with primary care attributes while controlling for socio-demographic, health service use and health status characteristics. Compared to WM hospitals, the results showed that TTM hospitals had patients who were older (15.8 % versus 8.4 % over 60 years); with lower education levels (66.0 % versus 35.8 % with below junior high school ) and income levels (46.9 % versus 26.5 % with annual household income below 30,000RMB); more likely to be married (79.2 % versus 60.5 %); made less frequent health care visits; and had higher self-rated health status. Overall, patients assessed the primary care performance in TTM hospitals significantly higher (80.0) than WM hospitals (74.63). There were no differences in health care assessment by patient gender, age, income, education, marital status and occupation. TTM patients reported better primary care experiences than patients using WM hospitals, which validated the government's investment in traditional Tibetan medicine.

Physician wages across specialties: informing the physician reimbursement debate.

PubMed

Leigh, J Paul; Tancredi, Daniel; Jerant, Anthony; Kravitz, Richard L

2010-10-25

Disparities in remuneration between primary care and other physician specialties may impede health care reform by undermining the sustainability of a primary care workforce. Previous studies have compared annual incomes across specialties unadjusted for work hours. Wage (earnings-per-hour) comparisons could better inform the physician payment debate. In a cross-sectional analysis of data from 6381 physicians providing patient care in the 2004-2005 Community Tracking Study (adjusted response rate, 53%), we compared wages across broad and narrow categories of physician specialties. Tobit and linear regressions were run. Four broad specialty categories (primary care, surgery, internal medicine and pediatric subspecialties, and other) and 41 specific specialties were analyzed together with demographic, geographic, and market variables. In adjusted analyses on broad categories, wages for surgery, internal medicine and pediatric subspecialties, and other specialties were 48%, 36%, and 45% higher, respectively, than for primary care specialties. In adjusted analyses for 41 specific specialties, wages were significantly lower for the following than for the reference group of general surgery (wage near median, $85.98): internal medicine and pediatrics combined (-$24.36), internal medicine (-$24.27), family medicine (-$23.70), and other pediatric subspecialties (-$23.44). Wage rankings were largely impervious to adjustment for control variables, including age, race, sex, and region. Wages varied substantially across physician specialties and were lowest for primary care specialties. The primary care wage gap was likely conservative owing to exclusion of radiologists, anesthesiologists, and pathologists. In light of low and declining medical student interest in primary care, these findings suggest the need for payment reform aimed at increasing incomes or reducing work hours for primary care physicians.

Potential Role of Neuroimaging Markers for Early Diagnosis of Dementia in Primary Care.

PubMed

Teipel, Stefan; Kilimann, Ingo; Thyrian, Jochen R; Kloppel, Stefan; Hoffmann, Wolfgang

2018-01-01

The use of imaging markers for the diagnosis of predementia and early dementia stages of Alzheimer's disease (AD) has widely been explored in research settings and specialized care. The use of these markers in primary care has yet to be established. Summarize current evidence for the usefulness of imaging markers for AD in primary compared to specialized care settings. Selective overview of the literature, and pilot data on the use of MRI-based hippocampus and basal forebrain volumetry for the discrimination of AD dementia and mild cognitive impairment (MCI) cases from healthy controls in 58 cases from a primary care cohort and 58 matched cases from a memory clinic's sample. Molecular imaging marker of amyloid pathology, and volumetric markers of regional and whole brain atrophy support the diagnosis of AD dementia and MCI due to AD, and contribute to confidence in the differential diagnosis of AD and non-AD related dementias in specialized care. Limited evidence from the literature and our primary care cohort suggests that the diagnostic accuracy of volumetric imaging markers may be similar in the dementia stage of AD, but may be inferior for cases with MCI in primary compared with specialized care. Evidence is still widely lacking on the use of imaging markers for early and differential diagnosis of AD dementia, and detection of prodromal AD in primary care. Further progress to fill this gap will depend on the availability of international multimodal data from well-defined primary care cohorts. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

Psychological and behavioral differences between low back pain populations: a comparative analysis of chiropractic, primary and secondary care patients.

PubMed

Eklund, Andreas; Bergström, Gunnar; Bodin, Lennart; Axén, Iben

2015-10-19

Psychological, behavioral and social factors have long been considered important in the development of persistent pain. Little is known about how chiropractic low back pain (LBP) patients compare to other LBP patients in terms of psychological/behavioral characteristics. In this cross-sectional study, the aim was to investigate patients with LBP as regards to psychosocial/behavioral characteristics by describing a chiropractic primary care population and comparing this sample to three other populations using the MPI-S instrument. Thus, four different samples were compared. A: Four hundred eighty subjects from chiropractic primary care clinics. B: One hundred twenty-eight subjects from a gainfully employed population (sick listed with high risk of developing chronicity). C: Two hundred seventy-three subjects from a secondary care rehabilitation clinic. D: Two hundred thirty-five subjects from secondary care clinics. The Swedish version of the Multidimensional Pain Inventory (MPI-S) was used to collect data. Subjects were classified using a cluster analytic strategy into three pre-defined subgroups (named adaptive copers, dysfunctional and interpersonally distressed). The data show statistically significant overall differences across samples for the subgroups based on psychological and behavioral characteristics. The cluster classifications placed (in terms of the proportions of the adaptive copers and dysfunctional subgroups) sample A between B and the two secondary care samples C and D. The chiropractic primary care sample was more affected by pain and worse off with regards to psychological and behavioral characteristics compared to the other primary care sample. Based on our findings from the MPI-S instrument the 4 samples may be considered statistically and clinically different. Sample A comes from an ongoing trial registered at clinical trials.gov; NCT01539863 , February 22, 2012.

Problem-Solving Treatment and Coping Styles in Primary Care for Minor Depression

ERIC Educational Resources Information Center

Oxman, Thomas E.; Hegel, Mark T.; Hull, Jay G.; Dietrich, Allen J.

2008-01-01

Research was undertaken to compare problem-solving treatment for primary care (PST-PC) with usual care for minor depression and to examine whether treatment effectiveness was moderated by coping style. PST-PC is a 6-session, manual-based, psychosocial skills intervention. A randomized controlled trial was conducted in 2 academic, primary care…

Reduced Stress in Medical Education: An Outcome of Altered Learning Environment.

ERIC Educational Resources Information Center

Moore-West, Maggi; And Others

1983-01-01

An experimental curricular track (Primary Care Curriculum) was instituted at the University of New Mexico School of Medicine to educate more students to enter rural primary care and to better develop skills in life-long, self-motivated learning. A study comparing characteristics and results of the Primary Care Curriculum and of a conventional…

Foot examinations of diabetes patients by primary health care nurses in Auckland, New Zealand.

PubMed

Daly, Barbara; Arroll, Bruce; Sheridan, Nicolette; Kenealy, Timothy; Stewart, Alistair; Scragg, Robert

2014-07-01

To identify factors associated with patients receiving foot examinations by primary health care nurses. A cross-sectional survey of 287 randomly sampled primary health care nurses, from a total of 1091 in Auckland, completed a postal self-administered questionnaire and telephone interview. Biographical and diabetes management details were collected for 265 diabetes patients consulted by the nurses on a randomly selected day. A response rate of 86% was achieved. Nurses examined patient's feet in 46% of consultations. Controlling for demographic variables, foot examinations were associated with age, odds ratio (1.25, 95% CI 0.57-2.74) for patients aged 51-65 years and >66 years (2.50, 1.08-5.75) compared with those ≤50 years, consultations by district compared with practice nurses (14.23, 95% CI 3.82-53.05), special programme consultations compared with usual follow-up consults (8.81, 95% CI 2.99-25.93) and length of consultation (1.89, 0.72-4.97) for 15-30 min and (4.45, 95% CI 1.48-13.41) >30 min compared with consultations ≤15 min, or for wound care (2.58, 1.01-6.61). Diabetes foot examinations by primary health care nurses varies greatly, and are associated with characteristics of the patient (age, need for wound care) and the consultation (district nurses, diabetes programme and duration). Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Estimating the residency expansion required to avoid projected primary care physician shortages by 2035.

PubMed

Petterson, Stephen M; Liaw, Winston R; Tran, Carol; Bazemore, Andrew W

2015-03-01

The purpose of this study was to calculate the projected primary care physician shortage, determine the amount and composition of residency growth needed, and estimate the impact of retirement age and panel size changes. We used the 2010 National Ambulatory Medical Care Survey to calculate utilization of ambulatory primary care services and the US Census Bureau to project demographic changes. To determine the baseline number of primary care physicians and the number retiring at 66 years, we used the 2014 American Medical Association Masterfile. Using specialty board and American Osteopathic Association figures, we estimated the annual production of primary care residents. To calculate shortages, we subtracted the accumulated primary care physician production from the accumulated number of primary care physicians needed for each year from 2015 to 2035. More than 44,000 primary care physicians will be needed by 2035. Current primary care production rates will be unable to meet demand, resulting in a shortage in excess of 33,000 primary care physicians. Given current production, an additional 1,700 primary care residency slots will be necessary by 2035. A 10% reduction in the ratio of population per primary care physician would require more than 3,000 additional slots by 2035, whereas changing the expected retirement age from 66 years to 64 years would require more than 2,400 additional slots. To eliminate projected shortages in 2035, primary care residency production must increase by 21% compared with current production. Delivery models that shift toward smaller ratios of population to primary care physicians may substantially increase the shortage. © 2015 Annals of Family Medicine, Inc.

Clinic Services for Persons with AIDS

PubMed Central

Markson, Leona E; Turner, Barbara J; Cocroft, Jim; Houchens, Robert; Fanning, Thomas R

1997-01-01

OBJECTIVE To profile characteristics of clinics caring for persons with advanced HIV infection. DESIGN AND SETTING Survey of clinic directors in New York State. PARTICIPANTS Newly diagnosed Medicaid-enrolled AIDS patients in New York state in federal fiscal years 1987–1992 (n = 6,184) managed by 62 HIV specialty, 53 hospital-based general medicine/primary care, 36 community-based primary care, and 28 other clinics. MEASUREMENTS AND MAIN RESULTS Telephone survey about clinic hours, emphasis on HIV, staffing, procedures, and directors’ rating of care. Estimates of the number of newly diagnosed, Medicaid-enrolled AIDS patients treated in surveyed clinics were obtained from claims data. We found that community-based clinics were significantly more likely to have longer hours, a physician on call, or to accommodate unscheduled care than were hospital-based general medicine/primary care or other types of clinics. Compared with HIV specialty clinics, general medicine/primary care clinics were less likely to have HIV-specific care attributes such as a director of HIV care (98% vs 72%), multidisciplinary conferences on HIV care (83% vs 32%), or a standard initial HIV workup (90% vs 70%). Of general medicine/primary care clinics, most (83%) were staffed by residents and fellows compared with only 68% of HIV or 25% of community-based clinics (p < .001). General medicine/primary care clinics were less likely than community-based clinics to perform Pap smears (75% vs 94%) or to have case managers on payroll (21% vs 81%). CONCLUSIONS In this sample of clinics, hospital-based general medicine/primary care clinics managing the care of Medicaid enrollees with AIDS appeared to have more limited hours and availability of specific services than HIV specialty or community-based clinics.

Meeting the demand of the future: a curriculum to stimulate interest in careers in primary care internal medicine

PubMed Central

Hawthorne, Mary R.; Dinh, An

2017-01-01

ABSTRACT Background: There is a growing need for primary care physicians, but only a small percentage of graduating medical students enter careers in primary care. Purpose: To assess whether a Primary Care Intraclerkship within the Medicine clerkship can significantly improve students’ attitudes by analyzing scores on pre- and post-tests. Methods: Students on the Medicine clerkship at the University of Massachusetts Medical School participated in full-day ‘intraclerkships’,to demonstrate the importance of primary care and the management of chronic illness in various primary care settings. Pre-and post-tests containing students’ self-reported, five-point Likert agreement scale evaluations to 26 items (measuring perceptions about the roles of primary care physicians in patient care and treatment) were collected before and after each session. Eleven intraclerkships with 383 students were held between June 2010 and June 2013. Responses were analyzed using the GLM Model Estimate. Results: Results from the survey analysis showed significantly more positive attitudes toward primary care in the post-tests compared to the pre-tests. Students who were satisfied with their primary care physicians were significantly more likely to show an improvement in post-test attitudes toward primary care in the areas of physicians improving the quality of patient care, making a difference in overall patient health, finding primary care as an intellectually challenging field, and in needing to collaborate with specialists. Older students were more likely than younger students to show more favorable answers on questions concerning the relative value of primary care vs. specialty care. Conclusions: A curriculum in Primary Care Internal Medicine can provide a framework to positively influence students’ attitudes toward the importance of primary care, and potentially to influence career decisions to enter careers in Primary Care Internal Medicine. Ensuring that medical students receive excellent primary care for themselves can also positively influence attitudes toward primary care. PMID:28670982

Primary care physician workforce and Medicare beneficiaries' health outcomes.

PubMed

Chang, Chiang-Hua; Stukel, Therese A; Flood, Ann Barry; Goodman, David C

2011-05-25

Despite a widespread interest in increasing the numbers of primary care physicians to improve care and to moderate costs, the relationship of the primary care physician workforce to patient-level outcomes remains poorly understood. To measure the association between the adult primary care physician workforce and individual patient outcomes. A cross-sectional analysis of the outcomes of a 2007 20% sample of fee-for-service Medicare beneficiaries aged 65 years or older (N = 5,132,936), which used 2 measures of adult primary care physicians (general internists and family physicians) across Primary Care Service Areas (N = 6542): (1) American Medical Association (AMA) Masterfile nonfederal, office-based physicians per total population and (2) office-based primary care clinical full-time equivalents (FTEs) per Medicare beneficiary derived from Medicare claims. Annual individual-level outcomes (mortality, ambulatory care sensitive condition [ACSC] hospitalizations, and Medicare program spending), adjusted for individual patient characteristics and geographic area variables. Marked variation was observed in the primary care physician workforce across areas, but low correlation was observed between the 2 primary care workforce measures (Spearman r = 0.056; P < .001). Compared with areas with the lowest quintile of primary care physician measure using AMA Masterfile counts, beneficiaries in the highest quintile had fewer ACSC hospitalizations (74.90 vs 79.61 per 1000 beneficiaries; relative rate [RR], 0.94; 95% confidence interval [CI], 0.93-0.95), lower mortality (5.38 vs 5.47 per 100 beneficiaries; RR, 0.98; 95% CI, 0.97-0.997), and no significant difference in total Medicare spending ($8722 vs $8765 per beneficiary; RR, 1.00; 95% CI, 0.99-1.00). Beneficiaries residing in areas with the highest quintile of primary care clinician FTEs compared with those in the lowest quintile had lower mortality (5.19 vs 5.49 per 100 beneficiaries; RR, 0.95; 95% CI, 0.93-0.96), fewer ACSC hospitalizations (72.53 vs 79.48 per 1000 beneficiaries; RR, 0.91; 95% CI, 0.90-0.92), and higher overall Medicare spending ($8857 vs $8769 per beneficiary; RR, 1.01; 95% CI, 1.004-1.02). A higher level of primary care physician workforce, particularly with an FTE measure that may more accurately reflect ambulatory primary care, was generally associated with favorable patient outcomes.

[Differences and similarities of primary care in the German and Spanish health care systems].

PubMed

Salvador Comino, María Rosa; Krane, Sibylla; Schelling, Jörg; Regife García, Víctor

2016-02-01

An efficient primary care is of particular importance for any countries' health care system. Many differences exist on how distinctive countries try to obtain the goal of an efficient, cost-effective primary care for its population. In this article we conducted a selective literature review, which includes both scientific and socio-political publications. The findings are complemented with the experience of a Spanish physician from Seville in her last year of training in family medicine, who completed a four months long rotation in the German health care system. We highlighted different features by comparing both countries, including their health care expenditure, the relation between primary and secondary care, the organization in the academic field and the training of future primary care physicians. It is clear that primary care in both countries plays a central role, have to deal with shortcomings, and in some points one system can learn from the other. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

Are Anxiety and Depression Addressed in Primary Care Patients With Chronic Obstructive Pulmonary Disease? A Chart Review

PubMed Central

Roundy, Kent; Cully, Jeffrey A.; Stanley, Melinda A.; Veazey, Connie; Souchek, Julianne; Wray, Nelda P.; Kunik, Mark E.

2005-01-01

Objective: Screening for mental illness in primary care is widely recommended, but little is known about the evaluation, treatment, and long-term management processes that follow screening. The aim of this study was to examine and describe the quality of mental health care for persons with chronic obstructive pulmonary disease (COPD) and anxiety/depressive disorders, as measured by adherence to practice guidelines. Method: This retrospective chart review examined data for 102 primary care and mental health care patients with COPD who were diagnosed, using Structured Clinical Interview for DSM-IV criteria, with major depressive disorder, dysthymia, depression not otherwise specified, generalized anxiety disorder, or anxiety not otherwise specified. Data were gathered from primary care progress notes from the year prior to enrollment in a randomized controlled trial (enrollment was from July 2002 to April 2004). We compared the care received by these patients over 1 year with that recommended by practice guidelines. Charts were abstracted using a checklist of recommended practice guidelines for diagnostic evaluation, acute treatment, and long-term management of anxiety and depressive disorders. Results: Fifty (49%) of the 102 patients were recognized during the review year as having an anxiety or depressive disorder. Eighteen patients were newly assessed for depressive or anxiety disorders during the chart review year. Patients followed in primary care alone, compared with those who were comanaged by mental health care providers, were less likely to have guideline-adherent care. Conclusion: Depressive and anxiety disorders are recognized in about half of patients; however, guideline-supported diagnostic evaluation, acute treatment (except for medications), and long-term management rarely occur in the primary care setting. To improve the treatment of depressive and anxiety disorders in primary care, the process of care delivery must be understood and changed. PMID:16308576

Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions.

PubMed

Campbell, Duncan G; Felker, Bradford L; Liu, Chuan-Fen; Yano, Elizabeth M; Kirchner, JoAnn E; Chan, Domin; Rubenstein, Lisa V; Chaney, Edmund F

2007-06-01

Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe psychiatric symptomatology and factors that complicate treatment. To estimate PTSD prevalence among depressed military veteran primary care patients and compare demographic/illness characteristics of PTSD screen-positive depressed patients (MDD-PTSD+) to those with depression alone (MDD). Cross-sectional comparison of MDD patients versus MDD-PTSD+ patients. Six hundred seventy-seven randomly sampled depressed patients with at least 1 primary care visit in the previous 12 months. Participants composed the baseline sample of a group randomized trial of collaborative care for depression in 10 VA primary care practices in 5 states. The Patient Health Questionnaire-9 assessed MDD. Probable PTSD was defined as a Primary Care PTSD Screen > or = 3. Regression-based techniques compared MDD and MDD-PTSD+ patients on demographic/illness characteristics. Thirty-six percent of depressed patients screened positive for PTSD. Adjusting for sociodemographic differences and physical illness comorbidity, MDD-PTSD+ patients reported more severe depression (P < .001), lower social support (P < .001), more frequent outpatient health care visits (P < .001), and were more likely to report suicidal ideation (P < .001) than MDD patients. No differences were observed in alcohol consumption, self-reported general health, and physical illness comorbidity. PTSD is more common among depressed primary care patients than previously thought. Comorbid PTSD among depressed patients is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment. Providers should consider recommending psychotherapeutic interventions for depressed patients with PTSD.

Family medicine patients who use retail clinics have lower continuity of care.

PubMed

Rohrer, James E; Angstman, Kurt B; Garrison, Gregory M; Maxson, Julie A; Furst, Joseph W

2013-04-01

The purpose of this study was to compare continuity of care for family medicine patients using retail medicine clinics to continuity for patients not using retail clinics. Retail medicine clinics have become popular in some markets. However, their impact on continuity of care has not been studied. Electronic medical records of adult primary care patients seen in a large group practice in Minnesota in 2011 were analyzed for this study. Two randomly chosen groups of patients were selected (N = 400): those using 1 of 3 retail walk-in clinics staffed by nurse practitioners in addition to standard office care and a comparison group that only used standard office care. Continuity was measured as the percentage of visits that involved the primary care provider. We also compared patients who made zero visits to their primary care providers with those who made some visits to their primary care providers. Continuity of care was lower for patients who used retail clinics than for patients who did not use retail clinics (0.17 vs 0.44, mean difference 0.27). The percentage of patients who made zero visits to their primary care providers was 54.5 for users of retail clinics versus 31.0 for those who did not use retail clinics. Continuity of care should be monitored as retail medicine continues to expand.

Retail clinics versus traditional primary care: Employee satisfaction guaranteed?

PubMed

Lelli, Vanessa R; Hickman, Ronald L; Savrin, Carol L; Peterson, Rachel A

2015-09-01

To examine if differences exist in the levels of autonomy and job satisfaction among primary care nurse practitioners (NPs) employed in retail clinics versus traditional primary care settings. Data were collected from 310 primary care NPs who attended the American Association of NP's 28th Annual Conference in June 2013. Participants completed a demographic form, the Misener NP Job Satisfaction Scale, and the Dempster Practice Behavior Scale. Overall, there were no differences in job satisfaction or autonomy among NPs by practice setting. Retail NPs felt less valued and were less satisfied with social interaction, but more satisfied with benefits compared to NPs in traditional settings. NPs working in retail clinics were less likely to have intentions to leave current position compared to NPs in traditional practice settings. The results of this study enhance our current understanding of the linkages between levels of autonomy, job satisfaction, and practice setting among primary care NPs. The findings of this descriptive study offer valuable insights for stakeholders devoted to the development of the primary care workforce and identify modifiable factors that may influence retention and turnover rates among NPs. ©2015 American Association of Nurse Practitioners.

Patient, Primary Care Provider, and Specialist Perspectives on Specialty Care Coordination in an Integrated Health Care System.

PubMed

Vimalananda, Varsha G; Dvorin, Kelly; Fincke, B Graeme; Tardiff, Nicole; Bokhour, Barbara G

Successful coordination of specialty care requires understanding the perspectives of patients, primary care providers, and specialists-that is, the specialty care "triad." This study used qualitative methods to compare these perspectives in an integrated health care system, using diabetes specialty care as an exemplar. Primary care providers and endocrinologists relied on interclinician relationships to coordinate care. Clinicians rarely included patients or other staff in their conceptualization of specialty care coordination. Patients often assumed responsibility for specialty care coordination but struggled to succeed. We identified several opportunities to improve coordination across the triad. In an integrated medical system, the shared organizational structure can facilitate these efforts.

Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study.

PubMed

Stokes, Tim; Tumilty, Emma; Doolan-Noble, Fiona; Gauld, Robin

2017-04-05

Multimorbidity is a major issue for primary care. We aimed to explore primary care professionals' accounts of managing multimorbidity and its impact on clinical decision making and regional health care delivery. Qualitative interviews with 12 General Practitioners and 4 Primary Care Nurses in New Zealand's Otago region. Thematic analysis was conducted using the constant comparative method. Primary care professionals encountered challenges in providing care to patients with multimorbidity with respect to both clinical decision making and health care delivery. Clinical decision making occurred in time-limited consultations where the challenges of complexity and inadequacy of single disease guidelines were managed through the use of "satisficing" (care deemed satisfactory and sufficient for a given patient) and sequential consultations utilising relational continuity of care. The New Zealand primary care co-payment funding model was seen as a barrier to the delivery of care as it discourages sequential consultations, a problem only partially addressed through the use of the additional capitation based funding stream of Care Plus. Fragmentation of care also occurred within general practice and across the primary/secondary care interface. These findings highlight specific New Zealand barriers to the delivery of primary care to patients living with multimorbidity. There is a need to develop, implement and nationally evaluate a revised version of Care Plus that takes account of these barriers.

Antibiotic prescribing for respiratory infections at retail clinics, physician practices, and emergency departments.

PubMed

Mehrotra, Ateev; Gidengil, Courtney A; Setodji, Claude M; Burns, Rachel M; Linder, Jeffrey A

2015-04-01

To compare antibiotic prescribing among retail clinics, primary care practices, and emergency departments (EDs) for acute respiratory infections (ARIs): antibiotics-may-be-appropriate ARIs (eg, sinusitis) and antibiotics-never-appropriate ARIs (eg, acute bronchitis). We analyzed retail clinic data from the electronic health records of the 3 largest retail clinic chains in the United States, and data on visits to primary care practices and EDs from the nationally representative National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Using multivariate models, we estimated an adjusted antibiotic prescribing rate for each site of care, controlling for differences in patient characteristics and diagnosis. From 2007 to 2009 in the United States, there were 3 million, 167 million, and 29 million ARI visits at retail clinics, primary care practices, and EDs, respectively. For all ARI visits, the adjusted antibiotic prescribing rate at retail clinics (58%) was similar to the rate at primary care practices (62%; P=.09) and EDs (59%; P=.48). For antibiotics-may-be-appropriate ARI visits, the adjusted antibiotic prescribing rate (95%) at retail clinics was higher than at primary care practices (85%; P<.01) and EDs (83%; P<.01). For antibiotics-never-appropriate ARI visits, the adjusted antibiotic prescribing rate (34%) at retail clinics was lower than at primary care practices (51%; P<.01) and EDs (48%; P<.01). Compared with primary care practices and EDs, there was no difference at retail clinics in overall ARI antibiotic prescribing. At retail clinics, antibiotic prescribing was more diagnosis-appropriate.

Small Cash Incentives Can Encourage Primary Care Visits By Low-Income People With New Health Care Coverage.

PubMed

Bradley, Cathy J; Neumark, David

2017-08-01

In a randomized controlled trial, we studied low-income adults newly covered by a primary care program to determine whether a cash incentive could encourage them to make an initial visit to a primary care provider. Subjects were randomly assigned to one of four groups: three groups whose members received $10 to complete a baseline survey during an interview and who were randomized to incentives of $50, $25, or $0 to visit their assigned primary care provider within six months after enrolling in the study; and a nonincentivized control group not contacted by the research team. Subjects in the $50 and $25 incentive groups were more likely to see a primary care provider (77 percent and 74 percent, respectively), compared to subjects in the $0 incentive group (68 percent). The effects of the intervention were about twice as large when we compared the proportions of subjects in the $50 and $25 incentive groups who visited their providers and the proportion in the nonincentivized group (61 percent). Cash incentive programs may steer newly covered low-income patients toward primary care, which could result in improved health outcomes and lower costs. Project HOPE—The People-to-People Health Foundation, Inc.

Strength of primary care service delivery: a comparative study of European countries, Australia, New Zealand, and Canada.

PubMed

Pavlič, Danica R; Sever, Maja; Klemenc-Ketiš, Zalika; Švab, Igor; Vainieri, Milena; Seghieri, Chiara; Maksuti, Alem

2018-05-01

AimWe sought to examine strength of primary care service delivery as measured by selected process indicators by general practitioners from 31 European countries plus Australia, Canada, and New Zealand. We explored the relation between strength of service delivery and healthcare expenditures. The strength of a country's primary care is determined by the degree of development of a combination of core primary care dimensions in the context of its healthcare system. This study analyses the strength of service delivery in primary care as measured through process indicators in 31 European countries plus Australia, New Zealand, and Canada. A comparative cross-sectional study design was applied using the QUALICOPC GP database. Data on the strength of primary healthcare were collected using a standardized GP questionnaire, which included 60 questions divided into 10 dimensions related to process, structure, and outcomes. A total of 6734 general practitioners participated. Data on healthcare expenditure were obtained from World Bank statistics. We conducted a correlation analysis to analyse the relationship between strength and healthcare expenditures.FindingsOur findings show that the strength of service delivery parameters is less than optimal in some countries, and there are substantial variations among countries. Continuity and comprehensiveness of care are significantly positively related to national healthcare expenditures; however, coordination of care is not.

Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis.

PubMed

Whittaker, William; Anselmi, Laura; Kristensen, Søren Rud; Lau, Yiu-Shing; Bailey, Simon; Bower, Peter; Checkland, Katherine; Elvey, Rebecca; Rothwell, Katy; Stokes, Jonathan; Hodgson, Damian

2016-09-01

Health services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators. Throughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in "minor" patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for "minor" problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184). There was an insignificant relative reduction of 3.1% in total emergency department visits (95% CI -6.4% to 0.2%). Our results were robust to several sensitivity checks. A lack of detailed cost reporting of the running costs of extended access and an inability to capture health outcomes and other health service impacts constrain the study from assessing the full cost-effectiveness of extended access to primary care. The study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.

Behavioral Health and the Comprehensive Primary Care (CPC) Initiative: findings from the 2014 CPC behavioral health survey.

PubMed

Zivin, Kara; Miller, Benjamin F; Finke, Bruce; Bitton, Asaf; Payne, Perry; Stowe, Edith C; Reddy, Ashok; Day, Timothy J; Lapin, Pauline; Jin, Janel L; Sessums, Laura L

2017-08-29

Incorporating behavioral health care into patient centered medical homes is critical for improving patient health and care quality while reducing costs. Despite documented effectiveness of behavioral health integration (BHI) in primary care settings, implementation is limited outside of large health systems. We conducted a survey of BHI in primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a four-year multi-payer initiative of the Centers for Medicare and Medicaid Services (CMS). We sought to explore associations between practice characteristics and the extent of BHI to illuminate possible factors influencing successful implementation. We fielded a survey that addressed six substantive domains (integrated space, training, access, communication and coordination, treatment planning, and available resources) and five behavioral health conditions (depression, anxiety, pain, alcohol use disorder, and cognitive function). Descriptive statistics compared BHI survey respondents to all CPC practices, documented the availability of behavioral health providers, and primary care and behavioral health provider communication. Bivariate relationships compared provider and practice characteristics and domain scores. One hundred sixty-one of 188 eligible primary care practices completed the survey (86% response rate). Scores indicated basic to good baseline implementation of BHI in all domains, with lowest scores on communication and coordination and highest scores for depression. Higher scores were associated with: having any behavioral health provider, multispecialty practice, patient-centered medical home designation, and having any communication between behavioral health and primary care providers. This study provides useful data on opportunities and challenges of scaling BHI integration linked to primary care transformation. Payment reform models such as CPC can assist in BHI promotion and development.

Delivery system integration and health care spending and quality for Medicare beneficiaries.

PubMed

McWilliams, J Michael; Chernew, Michael E; Zaslavsky, Alan M; Hamed, Pasha; Landon, Bruce E

2013-08-12

The Medicare accountable care organization (ACO) programs rely on delivery system integration and health care provider risk sharing to lower spending while improving quality of care. To compare spending and quality between larger and smaller provider groups and examine how size-related differences vary by 2 factors considered central to ACO performance: group primary care orientation and financial risk sharing by health care providers. Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to health care provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5000 assigned beneficiaries) and Pioneer (≥15,000) ACO programs and distinguished hospital-based from independent groups. We assessed the primary care orientation of larger groups' specialty mix and used health maintenance organization market penetration and data from the Community Tracking Study to measure the extent of financial risk accepted by different types of provider groups in different areas for managed care patients. We estimated linear regression models comparing spending and quality between larger and smaller health care provider groups, allowing size-related differences to vary by measures of group primary care orientation and risk sharing. Spending and quality measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics. Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference, +$849), higher 30-day readmission rates (+1.3 percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (-$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care. Spending was lower and quality of care better for Medicare beneficiaries served by larger independent physician groups with strong primary care orientations in environments where health care providers accepted greater risk.

Innovations in primary care behavioral health: a pilot study across the U.S. Air Force.

PubMed

Landoll, Ryan R; Nielsen, Matthew K; Waggoner, Kathryn K; Najera, Elizabeth

2018-05-04

Integrated primary care services have grown in popularity in recent years and demonstrated significant benefits to the patient experience, patient health, and health care operations. However, broader systems-level factors for health care organizations, such as utilization, access, and cost, have been understudied. The current study reviews the results of quality improvement project conducted by the U.S. Air Force, which has practiced integrated primary care behavioral health for over 20 years. This study focuses on exploring how shifting the access point for behavioral from specialty mental health clinics to primary care, along with the use of technicians in patient care, can improve a range of health outcomes. Retrospective data analysis was conducted on an internal Air Force quality improvement project implemented at three military treatment facilities from October 2014 to September 2015. Positive preliminary support for these innovations was seen in the form of expanded patient populations, decreased time to first appointment, increased patient encounters, and decreased purchased community care compared with non-participating sites. Incorporation of behavioral health technicians further increased number of patient encounters while maintaining high levels of patient satisfaction across diverse clinical settings; in fact, patients preferred appointments with both technicians and behavioral health providers, compared with appointments with behavioral health providers only. These findings encourage further systematic review of systems-level factors in primary care behavioral health and adoption of the use of provider extenders in primary care behavioral health clinics.

Electrocardiogram interpretation and arrhythmia management: a primary and secondary care survey.

PubMed

Begg, Gordon; Willan, Kathryn; Tyndall, Keith; Pepper, Chris; Tayebjee, Muzahir

2016-05-01

There is increasing desire among service commissioners to treat arrhythmia in primary care. Accurate interpretation of the electrocardiogram (ECG) is fundamental to this. ECG interpretation has previously been shown to vary widely but there is little recent data. To examine the interpretation of ECGs in primary and secondary care. A cross-sectional survey of participants' interpretation of six ECGs and hypothetical management of patients based on those ECGs, at primary care educational events, and a cardiology department in Leeds. A total of 262 primary care clinicians and 20 cardiology clinicians were surveyed via questionnaire. Answers were compared with expert electrophysiologist opinion. In primary care, abnormal ECGs were interpreted as normal by 23% of responders. ST elevation and prolonged QT were incorrectly interpreted as normal by 1% and 22%, respectively. In cardiology, abnormal ECGs were interpreted as normal by 3%. ECG provision and interpretation remains inconsistent in both primary and secondary care. Primary care practitioners are less experienced and less confident with ECG interpretation than cardiologists, and require support in this area. © British Journal of General Practice 2016.

Primary care quality: community health center and health maintenance organization.

PubMed

Shi, Leiyu; Starfield, Barbara; Xu, Jiahong; Politzer, Robert; Regan, Jerrilyn

2003-08-01

This study compares the primary health care quality of community health centers (CHCs) and health maintenance organizations (HMOs) in South Carolina to elucidate the quality of CHC performance relative to mainstream settings such as the HMO. Mail surveys were used to obtain data from 350 randomly selected HMO users. Surveys with follow-up interviews were conducted to obtain data from 540 randomly selected CHC users. A validated adult primary care assessment tool was used in both surveys. Multivariate analyses were performed to assess the association of health care setting (HMO versus CHC) with primary care quality while controlling for sociodemographic and health care characteristics. After controlling for sociodemographic and health care use measures, CHC patients demonstrated higher scores in several primary care domains (ongoing care, coordination of service, comprehensiveness, and community orientation) as well as total primary care performance. Users of CHC are more likely than HMO users to rate their primary health care provider as good, except in the area of ease of first contact. The positive rating of the CHC is particularly impressive after taking into account that many CHC users have characteristics associated with poorer ratings of care.

Primary care closed claims experience of Massachusetts malpractice insurers.

PubMed

Schiff, Gordon D; Puopolo, Ann Louise; Huben-Kearney, Anne; Yu, Winnie; Keohane, Carol; McDonough, Peggy; Ellis, Bonnie R; Bates, David W; Biondolillo, Madeleine

Despite prior focus on high-impact inpatient cases, there are increasing data and awareness that malpractice in the outpatient setting, particularly in primary care, is a leading contributor to malpractice risk and claims. To study patterns of primary care malpractice types, causes, and outcomes as part of a Massachusetts ambulatory malpractice risk and safety improvement project. Retrospective review of pooled closed claims data of 2 malpractice carriers covering most Massachusetts physicians during a 5-year period (January 1, 2005, through December 31, 2009). Data were harmonized between the 2 insurers using a standardized taxonomy. Primary care practices in Massachusetts. All malpractice claims that involved primary care practices insured by the 2 largest insurers in the state were screened. A total of 551 claims from primary care practices were identified for the analysis. Numbers and types of claims, including whether claims involved primary care physicians or practices; classification of alleged malpractice (eg, misdiagnosis or medication error); patient diagnosis; breakdown in care process; and claim outcome (dismissed, settled, verdict for plaintiff, or verdict for defendant). During a 5-year period there were 7224 malpractice claims of which 551 (7.7%) were from primary care practices. Allegations were related to diagnosis in 397 (72.1%), medications in 68 (12.3%), other medical treatment in 41 (7.4%), communication in 15 (2.7%), patient rights in 11 (2.0%), and patient safety or security in 8 (1.5%). Leading diagnoses were cancer (n = 190), heart diseases (n = 43), blood vessel diseases (n = 27), infections (n = 22), and stroke (n = 16). Primary care cases were significantly more likely to be settled (35.2% vs 20.5%) or result in a verdict for the plaintiff (1.6% vs 0.9%) compared with non-general medical malpractice claims (P < .001). In Massachusetts, most primary care claims filed are related to alleged misdiagnosis. Compared with malpractice allegations in other settings, primary care ambulatory claims appear to be more difficult to defend, with more cases settled or resulting in a verdict for the plaintiff.

Crossing the border for health care: access and primary care characteristics for young children of Latino farm workers along the US-Mexico border.

PubMed

Seid, Michael; Castañeda, Donna; Mize, Ronald; Zivkovic, Mirjana; Varni, James W

2003-01-01

To examine prevalence and correlates of cross-border health care for children of Latino farm workers in counties near the US-Mexico border and to compare access and primary care in the United States and Mexico. Two hundred ninety-seven parents at Head Start centers in San Diego and Imperial counties were surveyed regarding percentage of health care received in Mexico and the United States, access, and primary care characteristics. More than half of all health care was reported as received in Mexico. Reasons for Mexican use revolved around cost, accessibility, and perceptions of effectiveness. Parents of insured children reported slightly more US care, yet even this group reported approximately half of health care in Mexico. Insurance status was related to having a regular source of care, while uninsured children reporting most care in Mexico were less likely than uninsured children in the United States to have had a routine health care visit. Primary care characteristics were related to insurance status and source of care. Uninsured children reporting most care in Mexico fared better in some aspects of primary care than uninsured children reporting most care in the United States and as well as children with insurance receiving care in the United States or Mexico. Children of farm workers living along the US-Mexico border, almost irrespective of insurance status, receive a large proportion of care in Mexico. Especially for uninsured children, parent reports of Mexican care characteristics compare favorably with that received in the United States. Mexican health care might be a buffer against vulnerability to poor health outcomes for these children.

Association of Structured Virtual Visits for Hypertension Follow-Up in Primary Care with Blood Pressure Control and Use of Clinical Services.

PubMed

Levine, David Michael; Dixon, Ronald F; Linder, Jeffrey A

2018-04-23

Optimal management of hypertension requires frequent monitoring and follow-up. Novel, pragmatic interventions have the potential to engage patients, maintain blood pressure control, and enhance access to busy primary care practices. "Virtual visits" are structured asynchronous online interactions between a patient and a clinician to extend medical care beyond the initial office visit. To compare blood pressure control and healthcare utilization between patients who received virtual visits compared to usual hypertension care. Propensity score-matched, retrospective cohort study with adjustment by difference-in-differences. Primary care patients with hypertension. Patient participation in at least one virtual visit for hypertension. Usual care patients did not use a virtual visit but were seen in-person for hypertension. Adjusted difference in mean systolic blood pressure, primary care office visits, specialist office visits, emergency department visits, and inpatient admissions in the 180 days before and 180 days after the in-person visit. Of the 1051 virtual visit patients and 24,848 usual care patients, we propensity score-matched 893 patients from each group. Both groups were approximately 61 years old, 44% female, 85% White, had about five chronic conditions, and about 20% had a mean pre-visit systolic blood pressure of 140-160 mmHg. Compared to usual care, virtual visit patients had an adjusted 0.8 (95% CI, 0.3 to 1.2) fewer primary care office visits. There was no significant adjusted difference in systolic blood pressure control (0.6 mmHg [95% CI, - 2.0 to 3.1]), specialist visits (0.0 more visits [95% CI, - 0.3 to 0.3]), emergency department visits (0.0 more visits [95% CI, 0.0 to 0.01]), or inpatient admissions (0.0 more admissions [95% CI, 0.0 to 0.1]). Among patients with reasonably well-controlled hypertension, virtual visit participation was associated with equivalent blood pressure control and reduced in-office primary care utilization.

Evaluation of the treatment patterns and economic burden of dysmenorrhea in Japanese women, using a claims database.

PubMed

Akiyama, Sayako; Tanaka, Erika; Cristeau, Olivier; Onishi, Yoshie; Osuga, Yutaka

2017-01-01

This study aimed to describe treatment patterns and estimate health care resource utilization and associated costs among Japanese women with dysmenorrhea, using a claims database. This was a retrospective analysis using health insurance data from the Japan Medical Data Center, assessing female patients aged 18-49 years with newly diagnosed primary or secondary dysmenorrhea. Treatment pattern analyses focused on hormonal medications, analgesics, hemostatic agents, traditional Chinese medicine (TCM), and gynecological surgeries. Data were collected on health care resource utilization and costs associated with medications, imaging procedures, and inpatient and outpatient care in both patients and matched controls. The analysis included 6,315 women with dysmenorrhea (3,441 primary; 2,874 secondary). The most commonly prescribed initial therapies were low-dose estrogen progestins (LEPs, 37.7%) and TCM (30.0%), with substantial differences between primary (LEPs: 27.4%, TCM: 38.8%) and secondary (LEPs: 50.2%, TCM: 19.5%) dysmenorrhea cohorts. Surgery was conducted in <5% of all patients. Both primary and secondary cohorts of dysmenorrhea had significantly higher mean total health care costs compared to controls within the 1-year period following diagnosis (Case-primary: 191,680 JPY [1,916 USD]; secondary: 246,488 JPY [2,465 USD], Control-primary: 83,615 JPY [836 USD]; secondary: 90,711 JPY [907 USD]) ( p <0.0001). After adjusting for baseline characteristics, these costs were 2.2 and 2.9 times higher for primary and secondary dysmenorrhea cohorts, respectively, compared with matched controls, (both p <0.0001). The main driver of these excess costs was outpatient care, with eight additional physician visits per year among dysmenorrhea patients compared to controls ( p <0.0001). Considerable heterogeneity in treatment patterns was observed, with relatively low utilization of LEPs in patients with primary dysmenorrhea and those treated by internal medicine physicians. Total annual health care costs were approximately 2-3 times higher in patients with dysmenorrhea compared to women without the condition.

Evaluation of the treatment patterns and economic burden of dysmenorrhea in Japanese women, using a claims database

PubMed Central

Akiyama, Sayako; Tanaka, Erika; Cristeau, Olivier; Onishi, Yoshie; Osuga, Yutaka

2017-01-01

Purpose This study aimed to describe treatment patterns and estimate health care resource utilization and associated costs among Japanese women with dysmenorrhea, using a claims database. Methods This was a retrospective analysis using health insurance data from the Japan Medical Data Center, assessing female patients aged 18–49 years with newly diagnosed primary or secondary dysmenorrhea. Treatment pattern analyses focused on hormonal medications, analgesics, hemostatic agents, traditional Chinese medicine (TCM), and gynecological surgeries. Data were collected on health care resource utilization and costs associated with medications, imaging procedures, and inpatient and outpatient care in both patients and matched controls. Results The analysis included 6,315 women with dysmenorrhea (3,441 primary; 2,874 secondary). The most commonly prescribed initial therapies were low-dose estrogen progestins (LEPs, 37.7%) and TCM (30.0%), with substantial differences between primary (LEPs: 27.4%, TCM: 38.8%) and secondary (LEPs: 50.2%, TCM: 19.5%) dysmenorrhea cohorts. Surgery was conducted in <5% of all patients. Both primary and secondary cohorts of dysmenorrhea had significantly higher mean total health care costs compared to controls within the 1-year period following diagnosis (Case-primary: 191,680 JPY [1,916 USD]; secondary: 246,488 JPY [2,465 USD], Control-primary: 83,615 JPY [836 USD]; secondary: 90,711 JPY [907 USD]) (p<0.0001). After adjusting for baseline characteristics, these costs were 2.2 and 2.9 times higher for primary and secondary dysmenorrhea cohorts, respectively, compared with matched controls, (both p<0.0001). The main driver of these excess costs was outpatient care, with eight additional physician visits per year among dysmenorrhea patients compared to controls (p<0.0001). Conclusion Considerable heterogeneity in treatment patterns was observed, with relatively low utilization of LEPs in patients with primary dysmenorrhea and those treated by internal medicine physicians. Total annual health care costs were approximately 2–3 times higher in patients with dysmenorrhea compared to women without the condition. PMID:28579813

Cost-utility analysis of searching electronic health records and cascade testing to identify and diagnose familial hypercholesterolaemia in England and Wales.

PubMed

Crosland, Paul; Maconachie, Ross; Buckner, Sara; McGuire, Hugh; Humphries, Steve E; Qureshi, Nadeem

2018-05-17

The cost effectiveness of cascade testing for familial hypercholesterolaemia (FH) is well recognised. Less clear is the cost effectiveness of FH screening when it includes case identification strategies that incorporate routinely available data from primary and secondary care electronic health records. Nine strategies were compared, all using cascade testing in combination with different index case approaches (primary care identification, secondary care identification, and clinical assessment using the Simon Broome (SB) or Dutch Lipid Clinic Network (DLCN) criteria). A decision analytic model was informed by three systematic literature reviews and expert advice provided by a NICE Guideline Committee. The model found that the addition of primary care case identification by database search for patients with recorded total cholesterol >9.3 mmol/L was more cost effective than cascade testing alone. The incremental cost-effectiveness ratio (ICER) of clinical assessment using the DLCN criteria was £3254 per quality-adjusted life year (QALY) compared with case-finding with no genetic testing. The ICER of clinical assessment using the SB criteria was £13,365 per QALY (compared with primary care identification using the DLCN criteria), indicating that the SB criteria was preferred because it achieved additional health benefits at an acceptable cost. Secondary care identification, with either the SB or DLCN criteria, was not cost effective, alone (dominated and dominated respectively) or combined with primary care identification (£63, 514 per QALY, and £82,388 per QALY respectively). Searching primary care databases for people at high risk of FH followed by cascade testing is likely to be cost-effective. Copyright © 2018 Elsevier B.V. All rights reserved.

The Impact of Electronic Health Records and Teamwork on Diabetes Care Quality

PubMed Central

Graetz, Ilana; Huang, Jie; Brand, Richard; Shortell, Stephen M.; Rundall, Thomas G.; Bellows, Jim; Hsu, John; Jaffe, Marc; Reed, Mary E.

2016-01-01

Objective Evidence of the impact Electronic Health Records (EHR) on clinical outcomes remains mixed. The impact EHRs likely depends on the organizational context in which they are used. We focus on one aspect of the organizational context: cohesion of primary care teams. We examined whether team cohesion among primary care team members changed the association of EHR use and changes in clinical outcomes for patients with diabetes. Study Design We combined provider-reported primary care team cohesion with lab values for patients with diabetes collected during the staggered EHR implementation (2005–2009). We used multivariate regression models with patient-level fixed effects to assess whether team cohesion levels changed the association between outpatient EHR use and clinical outcomes for patients with diabetes. Subjects 80,611 patients with diabetes mellitus. Measures Changes in hemoglobin A1c (HbA1c) and low-density lipoprotein cholesterol (LDL-C) Results For HbA1c, EHR use was associated with an average decrease of 0.11% for patients with higher cohesion primary care teams compared with a decrease of 0.08% for patients with lower cohesion teams (difference 0.02% in HbA1c, 95%CI: 0.01–0.03). For LDL-C, EHR use was associated with a decrease of 2.15 mg/dL for patients with higher cohesion primary teams compared with a decrease of 1.42 mg/dL for patients with lower cohesion teams (difference 0.73 mg/dL, 95%CI: 0.41–1.11 mg/dL). Conclusions Patients cared for by higher cohesion primary care teams experienced modest but statistically significantly greater EHR-related health outcome improvements, compared with patients cared for by providers practicing in lower cohesion teams. PMID:26671699

Care of adults with developmental disabilities: Effects of a continuing education course for primary care providers.

PubMed

Balogh, Robert; Wood, Jessica; Lunsky, Yona; Isaacs, Barry; Ouellette-Kuntz, Hélène; Sullivan, William

2015-07-01

To evaluate the effects of an interdisciplinary, guideline-based continuing education course on measures related to the care of adults with developmental disabilities (DD). Before-and-after study with a control group. Ontario. Forty-seven primary care providers (physicians, registered nurses, and nurse practitioners). Participants either only received reference material about primary care of people with DD (control group) or participated in a continuing education course on primary care of people with DD in addition to receiving the reference material (intervention group). Participants reported on 5 key measures related to care of adults with DD: frequency of using guidelines, frequency of performing periodic health examinations, frequency of assessing patients who present with behaviour changes, level of comfort while caring for adults with DD, and knowledge of primary care related to adults with DD. Over time, the intervention group showed significant increases in 4 of the 5 key measures of care compared with the control group: the frequency of guideline use (P < .001), frequency of assessment of patients' behaviour change (P = .03), comfort level in caring for people with DD (P = .01), and knowledge of primary care related to adults with DD (P = .01). A continuing education course on primary care of adults with DD is a useful interdisciplinary model to train health professionals who provide primary care services to these patients.

Spatial Access to Primary Care Providers in Appalachia

PubMed Central

Donohoe, Joseph; Marshall, Vince; Tan, Xi; Camacho, Fabian T.; Anderson, Roger T.; Balkrishnan, Rajesh

2016-01-01

Purpose: The goal of this research was to examine spatial access to primary care physicians in Appalachia using both traditional access measures and the 2-step floating catchment area (2SFCA) method. Spatial access to care was compared between urban and rural regions of Appalachia. Methods: The study region included Appalachia counties of Pennsylvania, Ohio, Kentucky, and North Carolina. Primary care physicians during 2008 and total census block group populations were geocoded into GIS software. Ratios of county physicians to population, driving time to nearest primary care physician, and various 2SFCA approaches were compared. Results: Urban areas of the study region had shorter travel times to their closest primary care physician. Provider to population ratios produced results that varied widely from one county to another because of strict geographic boundaries. The 2SFCA method produced varied results depending on the distance decay weight and variable catchment size techniques chose. 2SFCA scores showed greater access to care in urban areas of Pennsylvania, Ohio, and North Carolina. Conclusion: The different parameters of the 2SFCA method—distance decay weights and variable catchment sizes—have a large impact on the resulting spatial access to primary care scores. The findings of this study suggest that using a relative 2SFCA approach, the spatial access ratio method, when detailed patient travel data are unavailable. The 2SFCA method shows promise for measuring access to care in Appalachia, but more research on patient travel preferences is needed to inform implementation. PMID:26906524

Quality of Primary Health Care for children and adolescents living with HIV 1

PubMed Central

do Nascimento, Leticia; de Paula, Cristiane Cardoso; Magnago, Tania Solange Bosi de Souza; Padoin, Stela Maris de Mello; Harzheim, Erno; da Silva, Clarissa Bohrer

2016-01-01

Abstract Objective: to evaluate the quality of health care for children and adolescents living with HIV, among the different types of Primary Health Care services of Santa Maria, Rio Grande do Sul. Method: cross-sectional study, developed with 118 Primary Health Care professionals. The Primary Care Evaluation Instrument, Professional version, was used. For verification of the variables associated with the high score, Poisson Regression was used. Results: the professionals of the Family Health Strategy, when compared to those of the Primary Health Units, obtained a greater degree of orientation to primary care, both for the overall score and for the derived attributes score, as well as for the integrality and community orientation attributes. A specialization in Primary Health Care, other employment and a statutory work contract were associated with quality of care. Conclusion: the Family Health Strategy was shown to provide higher quality health care for children and adolescents living with HIV, however, the coverage is still low. The need was highlighted to expand this coverage and invest in vocational training directed toward Primary Care and making the professionals effective, through public selection procedure, as well as an improvement program that recognizes the care requirements, in these settings, of children and adolescents infected with HIV. PMID:27579927

[A historical and conceptual model for Primary Health Care: challenges for the organization of primary care and the Family Health Strategy in large Brazilian cities].

PubMed

Conill, Eleonor Minho

2008-01-01

This paper focuses on the experience with Primary Health Care as a strategy for reorganizing the health care model, based on reforms in this direction and their implementation in the Brazilian case. The article identifies a shift in the discourse concerning health sector reforms, with a return to emphasis on primary care and integration of services. The Brazilian context demands reflection on the possibilities for synergy between this strategy and other social policies and the factors needed to ensure adequate performance. Evaluation research has suggested that primary care activities are slightly superior as compared to traditional health care units, despite persistent difficulties in access, physical infrastructure, team formation, management, and organization of the network. These difficulties correlate with a low level of public financing, persistent segmentation of the system, and weak integration of primary care services with other levels of care. From the technical perspective, a reasonable target is to guarantee the strategy's continuity with the necessary adjustments, conditioned by the dynamics of the health care technical models involved in the dispute.

Medical students' attitudes toward underserved populations: changing associations with choice of primary care versus non-primary care residency.

PubMed

Wayne, Sharon; Timm, Craig; Serna, Lisa; Solan, Brian; Kalishman, Summers

2010-05-01

The number of medical students entering primary care residencies continues to decrease. The association between student attitudes toward underserved populations and residency choice has received little attention even though primary care physicians see a larger proportion of underserved patients than most other specialists. We evaluated attitudes toward underserved populations in 826 medical students using a standardized survey, and used logistic regression to assess the effect of attitudes, along with other variables, on selection of a primary care residency. We compared results between two groups defined by year of entry to medical school (1993-99 and 2000-05) to determine whether associations differed by time period. Students' attitudes regarding professional responsibility toward underserved populations remained high over the study period; however, there was a statistically. significant association between positive attitudes and primary care residency in the early cohort only. This association was not found in the more recent group.

A survivorship care plan for breast cancer survivors: extended results of a randomized clinical trial.

PubMed

Boekhout, Annelies H; Maunsell, Elizabeth; Pond, Gregory R; Julian, Jim A; Coyle, Doug; Levine, Mark N; Grunfeld, Eva

2015-12-01

Prevailing wisdom suggests that implementation of a survivorship care plan (SCP) will address deficits in survivorship care planning and delivery for cancer patients. Here, we present 24-month results of a randomized clinical trial on health service and patient-reported outcomes among breast cancer patients transferred to their primary care physician for follow-up care. The 24-month assessments represent the long-term benefit and sustainability of the implantation of a SCP. In all, 408 patients with early-stage breast cancer were randomized to the SCP or control group. Patient self-completed questionnaires, supplemented with telephone interviews, during the 24-month study period assessed health service and patient-reported outcomes. The primary outcome was cancer-specific distress. Secondary outcomes included health-related quality of life, patient satisfaction, continuity and coordination of care, and health service outcomes such as adherence to guidelines. Over the course of 24 months, there were no differences between both groups in health service and patient-reported outcomes. Women from Quebec compared to those from Western Canada (p < 0.001), women within 2 years of completion of primary treatment compared to a longer period (p = 0.013), and those with a higher SF-36 mental component score compared to a lower score (p = 0.044) were positively associated with adherence to guidelines. The implementation of a SCP in the transition of survivorship care from cancer center to primary care did not contribute to improved health service or patient-reported outcomes in this study population. Therefore, additional research is needed before widespread implementation of a SCP in clinical practice. The transition of survivorship care from cancer center to the primary care setting showed no negative effect on health service and patient-reported outcomes.

The psychotic patient.

PubMed

Hilty, D M; Lim, R F; Hales, R E

1999-06-01

Psychotic disorders are relatively rare in the primary care setting, compared with depressive and anxiety disorders, but patient suffering is significantly higher for patients with psychotic symptoms. Primary care physicians are assuming more responsibility for the area of these patients in today's managed care environment. The practitioner needs to eliminate medical, substance, and mood origins of the psychotic symptoms before assuming a patient has a psychotic disorder (e.g., schizophrenia). This article outlines a diagnostic and treatment approach for patients with psychotic symptoms who are managed in the primary care setting.

Towards efficient use of research resources: a nationwide database of ongoing primary care research projects in the Netherlands.

PubMed

Kortekaas, Marlous F; van de Pol, Alma C; van der Horst, Henriëtte E; Burgers, Jako S; Slort, Willemjan; de Wit, Niek J

2014-04-01

PURPOSE. Although in the last decades primary care research has evolved with great success, there is a growing need to prioritize the topics given the limited resources available. Therefore, we constructed a nationwide database of ongoing primary care research projects in the Netherlands, and we assessed if the distribution of research topics matched with primary care practice. We conducted a survey among the main primary care research centres in the Netherlands and gathered details of all ongoing primary care research projects. We classified the projects according to research topic, relation to professional guidelines and knowledge deficits, collaborative partners and funding source. Subsequently, we compared the frequency distribution of clinical topics of research projects to the prevalence of problems in primary care practice. We identified 296 ongoing primary care research projects from 11 research centres. Most projects were designed as randomized controlled trial (35%) or observational cohort (34%), and government funded mostly (60%). Thematically, most research projects addressed chronic diseases, mainly cardiovascular risk management (8%), depressive disorders (8%) and diabetes mellitus (7%). One-fifth of the projects was related to defined knowledge deficits in primary care guidelines. From a clinical primary care perspective, research projects on dermatological problems were significantly underrepresented (P = 0.01). This survey of ongoing projects demonstrates that primary care research has a firm basis in the Netherlands, with a strong focus on chronic disease. The fit with primary care practice can improve, and future research should address knowledge deficits in professional guidelines more.

Equity in patient experiences of primary care in community health centers using primary care assessment tool: a comparison of rural-to-urban migrants and urban locals in Guangdong, China.

PubMed

Zhong, Chenwen; Kuang, Li; Li, Lina; Liang, Yuan; Mei, Jie; Li, Li

2018-04-27

The equity of rural-to-urban migrants' health care utilization is already on China's agenda. The Chinese government has been embarking on efforts to improve the financial and geographical accessibility of health care for migrants by strengthening primary care services and providing universal coverage. Patient experiences are equally vital to migrants' health care utilization. To our knowledge, no studies have focused on equity in the patient experiences between migrants and locals. Based on a patient survey from Guangdong, China, which has a large number of rural-to-urban migrants, our study assessed the equity in the primary care patient experiences between rural-to-urban migrants and urban locals in the same health insurance context, since different forms of insurance can affect the patient experiences of primary care. We stratified our samples by different insurance types into three layers. We assessed primary care patient experiences using a validated Chinese version of the Primary Care Assessment Tool (PCAT), including eight primary care attributes. A 'PCAT total score' was calculated. Data were collected through face-to-face and one-on-one surveys in 2014. Propensity score matching (PSM) was used for each layer to generate comparable samples between rural-to-urban migrants and urban locals. Based on the matched dataset, a t-test was employed to compare the primary care patient experiences of the two groups. Using PSM, 220 patients in the rural-to-urban migrants group were matched to 220 patients in the urban locals group. After the matching, the observed confounding variables were balanced, and the PCAT scores were almost equal between the two groups. The only slight differences existed in the Urban Employee Basic Medical Insurance layer and in the without basic medical insurance coverage layer. Equity in the primary care patient experiences between rural-to-urban migrants and urban locals seems to have been achieved to some extent. However, there is room for improvement in the equity of coordination of care and comprehensiveness. Policy makers should consider strengthening these two dimensions by integrating the health care system. More attention should be focused on helping migrants break down language and cultural barriers and improving the patient-physician communication process.

Using discrete event simulation to compare the performance of family health unit and primary health care centre organizational models in Portugal.

PubMed

Fialho, André S; Oliveira, Mónica D; Sá, Armando B

2011-10-15

Recent reforms in Portugal aimed at strengthening the role of the primary care system, in order to improve the quality of the health care system. Since 2006 new policies aiming to change the organization, incentive structures and funding of the primary health care sector were designed, promoting the evolution of traditional primary health care centres (PHCCs) into a new type of organizational unit--family health units (FHUs). This study aimed to compare performances of PHCC and FHU organizational models and to assess the potential gains from converting PHCCs into FHUs. Stochastic discrete event simulation models for the two types of organizational models were designed and implemented using Simul8 software. These models were applied to data from nineteen primary care units in three municipalities of the Greater Lisbon area. The conversion of PHCCs into FHUs seems to have the potential to generate substantial improvements in productivity and accessibility, while not having a significant impact on costs. This conversion might entail a 45% reduction in the average number of days required to obtain a medical appointment and a 7% and 9% increase in the average number of medical and nursing consultations, respectively. Reorganization of PHCC into FHUs might increase accessibility of patients to services and efficiency in the provision of primary care services.

Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention.

PubMed

Morriss, Richard; Kai, Joe; Atha, Christopher; Avery, Anthony; Bayes, Sara; Franklin, Matthew; George, Tracey; James, Marilyn; Malins, Samuel; McDonald, Ruth; Patel, Shireen; Stubley, Michelle; Yang, Min

2012-07-06

The top 3% of frequent attendance in primary care is associated with 15% of all appointments in primary care, a fivefold increase in hospital expenditure, and more mental disorder and functional somatic symptoms compared to normal attendance. Although often temporary if these rates of attendance last more than two years, they may become persistent (persistent frequent or regular attendance). However, there is no long-term study of the economic impact or clinical characteristics of regular attendance in primary care. Cognitive behaviour formulation and treatment (CBT) for regular attendance as a motivated behaviour may offer an understanding of the development, maintenance and treatment of regular attendance in the context of their health problems, cognitive processes and social context. A case control design will compare the clinical characteristics, patterns of health care use and economic costs over the last 10 years of 100 regular attenders (≥30 appointments with general practitioner [GP] over 2 years) with 100 normal attenders (6-22 appointments with GP over 2 years), from purposefully selected primary care practices with differing organisation of care and patient demographics. Qualitative interviews with regular attending patients and practice staff will explore patient barriers, drivers and experiences of consultation, and organisation of care by practices with its challenges. Cognitive behaviour formulation analysed thematically will explore the development, maintenance and therapeutic opportunities for management in regular attenders. The feasibility, acceptability and utility of CBT for regular attendance will be examined. The health care costs, clinical needs, patient motivation for consultation and organisation of care for persistent frequent or regular attendance in primary care will be explored to develop training and policies for service providers. CBT for regular attendance will be piloted with a view to developing this approach as part of a multifaceted intervention.

Chronic disease management interventions for people with chronic kidney disease in primary care: a systematic review and meta-analysis.

PubMed

Galbraith, Lauren; Jacobs, Casey; Hemmelgarn, Brenda R; Donald, Maoliosa; Manns, Braden J; Jun, Min

2018-01-01

Primary care providers manage the majority of patients with chronic kidney disease (CKD), although the most effective chronic disease management (CDM) strategies for these patients are unknown. We assessed the efficacy of CDM interventions used by primary care providers managing patients with CKD. The Medline, Embase and Cochrane Central databases were systematically searched (inception to November 2014) for randomized controlled trials (RCTs) assessing education-based and computer-assisted CDM interventions targeting primary care providers managing patients with CKD in the community. The efficacy of CDM interventions was assessed using quality indicators [use of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), proteinuria measurement and achievement of blood pressure (BP) targets] and clinical outcomes (change in BP and glomerular filtration rate). Two independent reviewers evaluated studies for inclusion, quality and extracted data. Random effects models were used to estimate pooled odds ratios (ORs) and weighted mean differences for outcomes of interest. Five studies (188 clinics; 494 physicians; 42 852 patients with CKD) were included. Two studies compared computer-assisted intervention strategies with usual care, two studies compared education-based intervention strategies with computer-assisted intervention strategies and one study compared both these intervention strategies with usual care. Compared with usual care, computer-assisted CDM interventions did not increase the likelihood of ACEI/ARB use among patients with CKD {pooled OR 1.00 [95% confidence interval (CI) 0.83-1.21]; I2 = 0.0%}. Similarly, education-related CDM interventions did not increase the likelihood of ACEI/ARB use compared with computer-assisted CDM interventions [pooled OR 1.12 (95% CI 0.77-1.64); I2 = 0.0%]. Inconsistencies in reporting methods limited further pooling of data. To date, there have been very few randomized trials testing CDM interventions targeting primary care providers with the goal of improving care of people with CKD. Those conducted to date have shown minimal impact, suggesting that other strategies, or multifaceted interventions, may be required to enhance care for patients with CKD in the community. © The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use.

PubMed

Bartels, Stephen J; Coakley, Eugenie H; Zubritsky, Cynthia; Ware, James H; Miles, Keith M; Areán, Patricia A; Chen, Hongtu; Oslin, David W; Llorente, Maria D; Costantino, Giuseppe; Quijano, Louise; McIntyre, Jack S; Linkins, Karen W; Oxman, Thomas E; Maxwell, James; Levkoff, Sue E

2004-08-01

The authors sought to determine whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in mental health/substance abuse services by older primary care patients. This multisite randomized trial included 10 sites consisting of primary care and specialty mental health/substance abuse clinics. Primary care patients 65 years old or older (N=24,930) were screened. The final study group consisted of 2,022 patients (mean age=73.5 years; 26% female; 48% ethnic minority) with depression (N=1,390), anxiety (N=70), at-risk alcohol use (N=414), or dual diagnosis (N=148) who were randomly assigned to integrated care (mental health and substance abuse providers co-located in primary care; N=999) or enhanced referral to specialty mental health/substance abuse clinics (i.e., facilitated scheduling, transportation, payment; N=1,023). Seventy-one percent of patients engaged in treatment in the integrated model compared with 49% in the enhanced referral model. Integrated care was associated with more mental health and substance abuse visits per patient (mean=3.04) relative to enhanced referral (mean=1.91). Overall, greater engagement was predicted by integrated care and higher mental distress. For depression, greater engagement was predicted by integrated care and more severe depression. For at-risk alcohol users, greater engagement was predicted by integrated care and more severe problem drinking. For all conditions, greater engagement was associated with closer proximity of mental health/substance abuse services to primary care. Older primary care patients are more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services.

Profiling for primary-care presentation, investigation and referral for liver cancers: evidence from a national audit.

PubMed

Hughes, Daniel L; Neal, Richard D; Lyratzopoulos, Georgios; Rubin, Greg

2016-04-01

The incidence of liver cancer across Europe is increasing. There is a lack of evidence within the current literature on the identification and investigation of liver cancer within primary care. We aimed to profile liver cancer recognition and assessment as well as the timeliness of liver cancer diagnosis from within the primary-care setting in the UK. Data were obtained from the National Audit of Cancer Diagnosis in Primary Care 2009-2010 and analysed. We calculated the patient interval, the primary-care interval and the number of prereferral consultations for liver cancer. We then compared these data with prior data on the respective indicators for other common cancers. The median patient interval was 9 days (interquartile range 0-31 days), and the median primary-care interval for liver cancer was 11 days (interquartile range 0-40 days). Of the 90 patients, 21 (23.3%) had three or more consultations with their general practitioner before specialist referral. For the three metrics (patient interval, primary-care interval and number of prereferral consultations), liver cancer has average or longer intervals when compared with other cancers. The most common symptomatic presentation of liver cancer within the primary-care setting was right upper quadrant pain (11%), followed by decompensated liver failure (9%). Of the patients, 12% were diagnosed with liver cancer on the basis of an incidental finding of an abnormal liver function test. This study provides a detailed and thorough overview of the recognition of liver cancer and the promptness of liver cancer identification in an English context, and should inform strategies for improving the timeliness of diagnosis.

Distribution of essential medicines to primary care institutions in Hubei of China: effects of centralized procurement arrangements.

PubMed

Yang, Lianping; Huang, Cunrui; Liu, Chaojie

2017-11-14

Poor distribution of essential medicines to primary care institutions has attracted criticism since China adopted provincial centralized regional tendering and procurement systems. This study evaluated the impact of new procurement arrangements that limit the number of distributors at the county level in Hubei province, China. Procurement ordering and distribution data were collected from four counties that pioneered a new distribution arrangement (commencing September 2012) compared with six counties that continued the existing arrangement over the period from August 2011 to September 2013. The new arrangement allowed primary care institutions and/or suppliers to select a local distributor from a limited panel (from 3 to 5) of government nominated distributors. Difference-in-differences analyses were performed to assess the impact of the new arrangements on delivery and receipt of essential medicines. Overall, the new distribution arrangement has not improved distribution of essential medicines to primary care institutions. On the contrary, we found a 7.78-19.85 percentage point (p < 0.01) decrease in distribution rates to rural primary care institutions. Similar results were demonstrated using the indicator of received rates, with a 7.89-19.65 percentage point (p < 0.01) decrease. Simply limiting the number of distributors does not offer a solution to the poor performance of delivery of essential medicines for primary care institutions, especially those located in rural areas. Procurement arrangements need to consider the special characteristics of rural facilities. In a county, there are more rural primary care institutions than urban ones. On average, rural primary care institutions demand more and are more geographically dispersed compared to their urban counterparts, which may impose increased distribution costs.

Comparison of Cardiovascular Risk Screening Methods and Mortality Data among Hungarian Primary Care Population: Preliminary Results of the First Government-Financed Managed Care Program.

PubMed

Móczár, Csaba; Rurik, Imre

2015-09-01

Besides participation in the primary prevention, screening as secondary prevention is an important requirement for primary care services. The effect of this work is influenced by the characteristics of individual primary care practices and doctors' screening habits, as well as by the regulation of screening processes and available financial resources. Between 1999 and 2009, a managed care program was introduced and carried out in Hungary, financed by the government. This financial support and motivation gave the opportunity to increase the number of screenings. 4,462 patients of 40 primary care practices were screened on the basis of SCORE risk assessment. The results of the screening were compared on the basis of two groups of patients, namely: those who had been pre-screened (pre-screening method) for known risk factors in their medical history (smoking, BMI, age, family cardiovascular history), and those randomly screened. The authors also compared the mortality data of participating primary care practices with the regional and national data. The average score was significantly higher in the pre-screened group of patients, regardless of whether the risk factors were considered one by one or in combination. Mortality was significantly lower in the participating primary practices than had been expected on the basis of the national mortality data. This government-financed program was a big step forward to establish a proper screening method within Hungarian primary care. Performing cardiovascular screening of a selected target group is presumably more appropriate than screening within a randomly selected population. Both methods resulted in a visible improvement in regional mortality data, though it is very likely that with pre-screening a more cost-effective selection for screening may be obtained.

Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis

PubMed Central

Whittaker, William; Anselmi, Laura; Lau, Yiu-Shing; Bower, Peter; Checkland, Katherine; Elvey, Rebecca; Stokes, Jonathan

2016-01-01

Background Health services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators. Methods and Findings Throughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in “minor” patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for “minor” problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184). There was an insignificant relative reduction of 3.1% in total emergency department visits (95% CI -6.4% to 0.2%). Our results were robust to several sensitivity checks. A lack of detailed cost reporting of the running costs of extended access and an inability to capture health outcomes and other health service impacts constrain the study from assessing the full cost-effectiveness of extended access to primary care. Conclusions The study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable. PMID:27598248

Counting on commitment; the quality of primary care-led diabetes management in a system with minimal incentives.

PubMed

Mc Hugh, Sheena; Marsden, Paul; Brennan, Carmel; Murphy, Katie; Croarkin, Celine; Moran, Joe; Harkins, Velma; Perry, Ivan J

2011-12-28

The aim of the present study was to assess the performance of three primary care-led initiatives providing structured care to patients with Type 2 diabetes in Ireland, a country with minimal incentives to promote the quality of care. Data, from three primary care initiatives, were available for 3010 adult patients with Type 2 diabetes. Results were benchmarked against the national guidelines for the management of Type 2 diabetes in the community and results from the National Diabetes Audit (NDA) for England (2008/2009) and the Scottish Diabetes Survey (2009). The recording of clinical processes of care was similar to results in the UK however the recording of lifestyle factors was markedly lower. Recording of HbA1c, blood pressure and lipids exceeded 85%. Recording of retinopathy screening (71%) was also comparable to England (77%) and Scotland (90%). Only 63% of patients had smoking status recorded compared to 99% in Scotland while 70% had BMI recorded compared to 89% in England. A similar proportion of patients in this initiative and the UK achieved clinical targets. Thirty-five percent of patients achieved a target HbA1c of < 6.5% (< 48 mmol/mol) compared to 25% in England. Applying the NICE target for blood pressure (≤ 140/80 mmHg), 54% of patients reached this target comparable to 60% in England. Slightly less patients were categorised as obese (> 30 kg/m²) in Ireland (50%, n = 1060) compared to Scotland (54%). This study has demonstrated what can be achieved by proactive and interested health professionals in the absence of national infrastructure to support high quality diabetes care. The quality of primary care-led diabetes management in the three initiatives studied appears broadly consistent with results from the UK with the exception of recording lifestyle factors. The challenge facing health systems is to establish quality assurance a responsibility for all health care professionals rather than the subject of special interest for a few.

Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare? A systematic review

PubMed Central

Hone, Thomas; Lee, John Tayu; Majeed, Azeem; Conteh, Lesong; Millett, Christopher

2017-01-01

Abstract Policy-makers are increasingly considering charging users different fees between primary and secondary care (differential user charges) to encourage utilisation of primary health care in health systems with limited gate keeping. A systematic review was conducted to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published in MEDLINE, EMBASE, the Cochrane library, EconLIT, HMIC, and WHO library databases from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively. Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care. Overall, the impact of introducing differential user-charges on primary care utilisation remains uncertain. Further research is required to understand their impact as a demand side intervention, including implications for health system costs and on utilisation among low-income patients. PMID:28453713

Assessing the impact of general practitioner team service on perceived quality of care among patients with non-communicable diseases in China: a natural experimental study.

PubMed

Yin, Jia; Wei, Xiaolin; Li, Haitao; Jiang, Yanling; Mao, Chunfang

2016-10-01

China issued the national primary care policy of promoting general practitioner (GP) team service in 2011. We conducted this study to assess the impact of the GP team service on quality of primary care as perceived by patients with non-communicable diseases (NCDs). Natural experimental study. This study was conducted in Shanghai, where the policy was effectively implemented, and Kunming, where the policy was not implemented. In both cities, NCD patients were interviewed with primary care assessment tool (PCAT) after their clinical consultations in their community health centers. The implementation of GP team service policy. Multiple linear regressions were employed to compare PCAT scores between the two rounds of the surveys in each city. Difference-in-difference (DID) analysis was used to identify the changes between two cities over time. A total of 663 and 587 patients in Shanghai, and 400 and 441 patients in Kunming were surveyed in 2011 and 2013, respectively. The DID analysis showed that the total primary care quality scores improved in Shanghai compared with Kunming between 2011 and 2013 (β = 1.30, 95% CI: 0.74, 1.87). In Shanghai, care quality in 2013 improved significantly for the total score and the six components when compared with those in 2011. No significant changes were observed in Kunming in the same period. Primary care policies that promote long-term provider-patient relationships, coordinated service with hospitals and capitation payment for the GP team may contribute to the improvement of care quality in Shanghai. © 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.

Improving Services for Women with Depression in Primary Care Settings

ERIC Educational Resources Information Center

Katon, Wayne J.; Ludman, Evette J.

2003-01-01

Women have a higher prevalence of depressive disorders compared to men. The current system of care for women with depressive disorders provides significant financial barriers for patients with lower incomes to access mental health services. Primary care systems are used extensively by women and have the potential to diagnose patients at early…

Increasing the Screening and Counseling of Adolescents for Risky Health Behaviors: A Primary Care Intervention

ERIC Educational Resources Information Center

Ozer, Elizabeth M.; Adams, Sally H.; Lustig, Julie L.; Gee, Scott; Garber, Andrea K.; Gardner, Linda Rieder; Rehbein, Michael; Addison, Louise; Irwin, Charles E., Jr.

2005-01-01

Objective: To determine whether a systems intervention for primary care providers resulted in increased preventive screening and counseling of adolescent patients, compared with the usual standard of care. Methods: The intervention was conducted in 2 out-patient pediatric clinics; 2 other pediatric clinics in the same health maintenance…

Effectiveness of Psychological and Educational Interventions to Prevent Depression in Primary Care: A Systematic Review and Meta-Analysis.

PubMed

Conejo-Cerón, Sonia; Moreno-Peral, Patricia; Rodríguez-Morejón, Alberto; Motrico, Emma; Navas-Campaña, Desirée; Rigabert, Alina; Martín-Pérez, Carlos; Rodríguez-Bayón, Antonina; Ballesta-Rodríguez, María Isabel; Luna, Juan de Dios; García-Campayo, Javier; Roca, Miquel; Bellón, Juan Ángel

2017-05-01

Although evidence exists for the efficacy of psychosocial interventions to prevent the onset of depression, little is known about its prevention in primary care. We aimed to evaluate the effectiveness of psychological and educational interventions to prevent depression in primary care. We conducted a systematic review and meta-analysis of relevant randomized controlled trials (RCTs) examining the effect of psychological and educational interventions to prevent depression in nondepressed primary care attendees. We searched MEDLINE, PsycINFO, Web of Science, OpenGrey Repository, Cochrane Central Register of Controlled Trials, and other sources up to May 2016. At least 2 reviewers independently evaluated the eligibility criteria, extracted data, and assessed the risk of bias. We calculated standardized mean differences (SMD) using random-effects models. We selected 14 studies (7,365 patients) that met the inclusion criteria, 13 of which were valid to perform a meta-analysis. Most of the interventions had a cognitive-behavioral orientation, and in only 4 RCTs were the intervention clinicians primary care staff. The pooled SMD was -0.163 (95%CI, -0.256 to -0.070; P = .001). The risk of bias and the heterogeneity (I 2 = 20.6%) were low, and there was no evidence of publication bias. Meta-regression detected no association between SMD and follow-up times or SMD and risk of bias. Subgroup analysis suggested greater effectiveness when the RCTs used care as usual as the comparator compared with those using placebo. Psychological and educational interventions to prevent depression had a modest though statistically significant preventive effect in primary care. Further RCTs using placebo or active comparators are needed. © 2017 Annals of Family Medicine, Inc.

Effectiveness of Psychological and Educational Interventions to Prevent Depression in Primary Care: A Systematic Review and Meta-Analysis

PubMed Central

Conejo-Cerón, Sonia; Moreno-Peral, Patricia; Rodríguez-Morejón, Alberto; Motrico, Emma; Navas-Campaña, Desirée; Rigabert, Alina; Martín-Pérez, Carlos; Rodríguez-Bayón, Antonina; Ballesta-Rodríguez, María Isabel; Luna, Juan de Dios; García-Campayo, Javier; Roca, Miquel; Bellón, Juan Ángel

2017-01-01

PURPOSE Although evidence exists for the efficacy of psychosocial interventions to prevent the onset of depression, little is known about its prevention in primary care. We aimed to evaluate the effectiveness of psychological and educational interventions to prevent depression in primary care. METHODS We conducted a systematic review and meta-analysis of relevant randomized controlled trials (RCTs) examining the effect of psychological and educational interventions to prevent depression in nondepressed primary care attendees. We searched MEDLINE, PsycINFO, Web of Science, OpenGrey Repository, Cochrane Central Register of Controlled Trials, and other sources up to May 2016. At least 2 reviewers independently evaluated the eligibility criteria, extracted data, and assessed the risk of bias. We calculated standardized mean differences (SMD) using random-effects models. RESULTS We selected 14 studies (7,365 patients) that met the inclusion criteria, 13 of which were valid to perform a meta-analysis. Most of the interventions had a cognitive-behavioral orientation, and in only 4 RCTs were the intervention clinicians primary care staff. The pooled SMD was −0.163 (95%CI, −0.256 to −0.070; P = .001). The risk of bias and the heterogeneity (I2 = 20.6%) were low, and there was no evidence of publication bias. Meta-regression detected no association between SMD and follow-up times or SMD and risk of bias. Subgroup analysis suggested greater effectiveness when the RCTs used care as usual as the comparator compared with those using placebo. CONCLUSIONS Psychological and educational interventions to prevent depression had a modest though statistically significant preventive effect in primary care. Further RCTs using placebo or active comparators are needed. PMID:28483893

Mechanisms that Trigger a Good Health-Care Response to Intimate Partner Violence in Spain. Combining Realist Evaluation and Qualitative Comparative Analysis Approaches.

PubMed

Goicolea, Isabel; Vives-Cases, Carmen; Hurtig, Anna-Karin; Marchal, Bruno; Briones-Vozmediano, Erica; Otero-García, Laura; García-Quinto, Marta; San Sebastian, Miguel

2015-01-01

Health care professionals, especially those working in primary health-care services, can play a key role in preventing and responding to intimate partner violence. However, there are huge variations in the way health care professionals and primary health care teams respond to intimate partner violence. In this study we tested a previously developed programme theory on 15 primary health care center teams located in four different Spanish regions: Murcia, C Valenciana, Castilla-León and Cantabria. The aim was to identify the key combinations of contextual factors and mechanisms that trigger a good primary health care center team response to intimate partner violence. A multiple case-study design was used. Qualitative and quantitative information was collected from each of the 15 centers (cases). In order to handle the large amount of information without losing familiarity with each case, qualitative comparative analysis was undertaken. Conditions (context and mechanisms) and outcomes, were identified and assessed for each of the 15 cases, and solution formulae were calculated using qualitative comparative analysis software. The emerging programme theory highlighted the importance of the combination of each team's self-efficacy, perceived preparation and women-centredness in generating a good team response to intimate partner violence. The use of the protocol and accumulated experience in primary health care were the most relevant contextual/intervention conditions to trigger a good response. However in order to achieve this, they must be combined with other conditions, such as an enabling team climate, having a champion social worker and having staff with training in intimate partner violence. Interventions to improve primary health care teams' response to intimate partner violence should focus on strengthening team's self-efficacy, perceived preparation and the implementation of a woman-centred approach. The use of the protocol combined with a large working experience in primary health care, and other factors such as training, a good team climate, and having a champion social worker on the team, also played a key role. Measures to sustain such interventions and promote these contextual factors should be encouraged.

The Evidence Base for Interventions Delivered to Children in Primary Care: An Overview of Cochrane Systematic Reviews

PubMed Central

Gill, Peter J.; Wang, Kay Yee; Mant, David; Hartling, Lisa; Heneghan, Carl; Perera, Rafael; Klassen, Terry; Harnden, Anthony

2011-01-01

Background As a first step in developing a framework to evaluate and improve the quality of care of children in primary care there is a need to identify the evidence base underpinning interventions relevant to child health. Our objective was to identify all Cochrane systematic reviews relevant to the management of childhood conditions in primary care and to assess the extent to which Cochrane reviews reflect the burden of childhood illness presenting in primary care. Methodology/Principal Findings We used the Cochrane Child Health Field register of child-relevant systematic reviews to complete an overview of Cochrane reviews related to the management of children in primary care. We compared the proportion of systematic reviews with the proportion of consultations in Australia, US, Dutch and UK general practice in children. We identified 396 relevant systematic reviews; 358 included primary studies on children while 251 undertook a meta-analysis. Most reviews (n = 218, 55%) focused on chronic conditions and over half (n = 216, 57%) evaluated drug interventions. Since 2000, the percentage of pediatric primary care relevant reviews only increased by 2% (7% to 9%) compared to 18% (10% to 28%) in all child relevant reviews. Almost a quarter of reviews (n = 78, 23%) were published on asthma treatments which only account for 3–5% of consultations. Conversely, 15–23% of consultations are due to skin conditions yet they represent only 7% (n = 23) of reviews. Conclusions/Significance Although Cochrane systematic reviews focus on clinical trials and do not provide a comprehensive picture of the evidence base underpinning the management of children in primary care, the mismatch between the focus of the published research and the focus of clinical activity is striking. Clinical trials are an important component of the evidence base and the lack of trial evidence to demonstrate intervention effectiveness in substantial areas of primary care for children should be addressed. PMID:21829691

Why Aren't More Primary Care Residents Going into Primary Care? A Qualitative Study.

PubMed

Long, Theodore; Chaiyachati, Krisda; Bosu, Olatunde; Sircar, Sohini; Richards, Bradley; Garg, Megha; McGarry, Kelly; Solomon, Sonja; Berman, Rebecca; Curry, Leslie; Moriarty, John; Huot, Stephen

2016-12-01

Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine. We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices. This was a qualitative study based on semi-structured, in-person interviews. Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed. We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis. We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program. Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care.

Urine sampling techniques in symptomatic primary-care patients: a diagnostic accuracy review.

PubMed

Holm, Anne; Aabenhus, Rune

2016-06-08

Choice of urine sampling technique in urinary tract infection may impact diagnostic accuracy and thus lead to possible over- or undertreatment. Currently no evidencebased consensus exists regarding correct sampling technique of urine from women with symptoms of urinary tract infection in primary care. The aim of this study was to determine the accuracy of urine culture from different sampling-techniques in symptomatic non-pregnant women in primary care. A systematic review was conducted by searching Medline and Embase for clinical studies conducted in primary care using a randomized or paired design to compare the result of urine culture obtained with two or more collection techniques in adult, female, non-pregnant patients with symptoms of urinary tract infection. We evaluated quality of the studies and compared accuracy based on dichotomized outcomes. We included seven studies investigating urine sampling technique in 1062 symptomatic patients in primary care. Mid-stream-clean-catch had a positive predictive value of 0.79 to 0.95 and a negative predictive value close to 1 compared to sterile techniques. Two randomized controlled trials found no difference in infection rate between mid-stream-clean-catch, mid-stream-urine and random samples. At present, no evidence suggests that sampling technique affects the accuracy of the microbiological diagnosis in non-pregnant women with symptoms of urinary tract infection in primary care. However, the evidence presented is in-direct and the difference between mid-stream-clean-catch, mid-stream-urine and random samples remains to be investigated in a paired design to verify the present findings.

Primary care and health inequality: Difference-in-difference study comparing England and Ontario.

PubMed

Cookson, Richard; Mondor, Luke; Asaria, Miqdad; Kringos, Dionne S; Klazinga, Niek S; Wodchis, Walter P

2017-01-01

It is not known whether equity-oriented primary care investment that seeks to scale up the delivery of effective care in disadvantaged communities can reduce health inequality within high-income settings that have pre-existing universal primary care systems. We provide some non-randomised controlled evidence by comparing health inequality trends between two similar jurisdictions-one of which implemented equity-oriented primary care investment in the mid-to-late 2000s as part of a cross-government strategy for reducing health inequality (England), and one which invested in primary care without any explicit equity objective (Ontario, Canada). We analysed whole-population data on 32,482 neighbourhoods (with mean population size of approximately 1,500 people) in England, and 18,961 neighbourhoods (with mean population size of approximately 700 people) in Ontario. We examined trends in mortality amenable to healthcare by decile groups of neighbourhood deprivation within each jurisdiction. We used linear models to estimate absolute and relative gaps in amenable mortality between most and least deprived groups, considering the gradient between these extremes, and evaluated difference-in-difference comparisons between the two jurisdictions. Inequality trends were comparable in both jurisdictions from 2004-6 but diverged from 2007-11. Compared with Ontario, the absolute gap in amenable mortality in England fell between 2004-6 and 2007-11 by 19.8 per 100,000 population (95% CI: 4.8 to 34.9); and the relative gap in amenable mortality fell by 10 percentage points (95% CI: 1 to 19). The biggest divergence occurred in the most deprived decile group of neighbourhoods. In comparison to Ontario, England succeeded in reducing absolute socioeconomic gaps in mortality amenable to healthcare from 2007 to 2011, and preventing them from growing in relative terms. Equity-oriented primary care reform in England in the mid-to-late 2000s may have helped to reduce socioeconomic inequality in health, though other explanations for this divergence are possible and further research is needed on the specific causal mechanisms.

Using video-based observation research methods in primary care health encounters to evaluate complex interactions.

PubMed

Asan, Onur; Montague, Enid

2014-01-01

The purpose of this paper is to describe the use of video-based observation research methods in primary care environment and highlight important methodological considerations and provide practical guidance for primary care and human factors researchers conducting video studies to understand patient-clinician interaction in primary care settings. We reviewed studies in the literature which used video methods in health care research, and we also used our own experience based on the video studies we conducted in primary care settings. This paper highlighted the benefits of using video techniques, such as multi-channel recording and video coding, and compared "unmanned" video recording with the traditional observation method in primary care research. We proposed a list that can be followed step by step to conduct an effective video study in a primary care setting for a given problem. This paper also described obstacles, researchers should anticipate when using video recording methods in future studies. With the new technological improvements, video-based observation research is becoming a promising method in primary care and HFE research. Video recording has been under-utilised as a data collection tool because of confidentiality and privacy issues. However, it has many benefits as opposed to traditional observations, and recent studies using video recording methods have introduced new research areas and approaches.

Medical homes for children with autism: a physician survey.

PubMed

Golnik, Allison; Ireland, Marjorie; Borowsky, Iris Wagman

2009-03-01

Primary care physicians can enhance the health and quality of life of children with autism by providing high-quality and comprehensive primary care. To explore physicians' perspectives on primary care for children with autism. National mail and e-mail surveys were sent to a random sample of 2325 general pediatricians and 775 family physicians from April 2007 to October 2007. The response rate was 19%. Physicians reported significantly lower overall self-perceived competency, a greater need for primary care improvement, and a greater desire for education for children with autism compared with both children with other neurodevelopmental conditions and those with chronic/complex medical conditions. The following barriers to providing primary care were endorsed as greater for children with autism: lack of care coordination, reimbursement and physician education, family skeptical of traditional medicine and vaccines, and patients using complementary alternative medicine. Adjusting for key demographic variables, predictors of both higher perceived autism competency and encouraging an empirically supported therapy, applied behavior analysis, included having a greater number of autism patient visits, having a friend or relative with autism, and previous training about autism. Primary care physicians report a lack of self-perceived competency, a desire for education, and a need for improvement in primary care for children with autism. Physician education is needed to improve primary care for children with autism. Practice parameters and models of care should address physician-reported barriers to care.

A national evaluation of homeless and nonhomeless veterans' experiences with primary care.

PubMed

Jones, Audrey L; Hausmann, Leslie R M; Haas, Gretchen L; Mor, Maria K; Cashy, John P; Schaefer, James H; Gordon, Adam J

2017-05-01

Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons' avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration's medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth "homeless") were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

A Cross-Sectional Comparison of Perceived Quality of Primary Care by Hypertensive Patients in Shanghai and Shenzhen, China

PubMed Central

Li, Haitao; Wei, Xiaolin; Wong, Martin Chi-Sang; Wong, Samuel Yeung-Shan; Yang, Nan; Griffiths, Sian M.

2015-01-01

Abstract Hypertension should be best managed under primary care settings. This study aimed to compare, between Shanghai and Shenzhen, the perceived quality of primary care in terms of accessibility, continuity, co-ordination, and comprehensiveness among hypertensive patients. A cross-sectional study was conducted in Shanghai and Shenzhen, China. Multistage random sampling method was used to select 8 community health centers. Data from primary care users were collected through on-site face-to-face interviews using the primary care assessment tool. Good quality standard was set as a value of 3 for each attribute and a value of 18 for total score. We included 568 patients in Shanghai and 128 patients in Shenzhen. Compared with those in Shenzhen, hypertensive patients in Shanghai reported a higher score in co-ordination of information (3.37 vs 3.66; P < 0.001), but lower scores in continuity of care (3.36 vs 3.27; P < 0.001), and comprehensiveness-service provision (3.26 vs 2.79; P < 0.001). There was no statistically significant difference in total scores between the 2 cities (18.19 vs 18.15). Over 3-quarters of hypertensive patients in both cities reported accessibility (97.2% vs 91.4%) and co-ordination of services (76.1% vs 80.5%) under good quality standard, while <1-quarter of them rated continuity of care (23.6% vs 22.7%), co-ordination of information (4.8% vs 21.1%), and comprehensiveness-service availability (15.1% vs 25.0%) under that standard. Compared with Shenzhen, the perceived quality of primary care for hypertensive patients in Shanghai was better in terms of co-ordination of information, but poorer on continuity of care and comprehensiveness-service provision. Our study suggests that there is room for quality improvement in both cities. PMID:26313780

Systematic review of the effectiveness of primary care nursing.

PubMed

Keleher, Helen; Parker, Rhian; Abdulwadud, Omar; Francis, Karen

2009-02-01

This paper reports on a systematic review that sought to answer the research question: What is the impact of the primary and community care nurse on patient health outcomes compared with usual doctor-led care in primary care settings? A range of pertinent text-words with medical subject headings were combined and electronic databases were searched. Because of the volume of published articles, the search was restricted to studies with high-level evidence. Overall, 31 relevant studies were identified and included in the review. We found modest international evidence that nurses in primary care settings can provide effective care and achieve positive health outcomes for patients similar to that provided by doctors. Nurses are effective in care management and achieve good patient compliance. Nurses are also effective in a more diverse range of roles including chronic disease management, illness prevention and health promotion. Nevertheless, there is insufficient evidence about primary care nurses' roles and impact on patient health outcomes.

Primary Health Care: Comparing Public Health Nursing Models in Ireland and Norway

PubMed Central

Leahy-Warren, Patricia; Day, Mary Rose

2013-01-01

Health of populations is determined by a multitude of contextual factors. Primary Health Care Reform endeavors to meet the broad health needs of populations and remains on international health agendas. Public health nurses are key professionals in the delivery of primary health care, and it is important for them to learn from global experiences. International collaboration is often facilitated by academic exchanges. As a result of one such exchange, an international PHN collaboration took place. The aim of this paper is to analyse the similarities and differences in public health nursing in Ireland and Norway within the context of primary care. PMID:23606956

Results of the 2014 National Resident Matching Program®: family medicine.

PubMed

Kozakowski, Stanley M; Crosley, Philip W; Bentley, Ashley

2014-10-01

The 2014 National Residency Matching Program® results reveal that the number of family medicine positions offered in the Match® by programs accredited by the Accreditation Council on Graduate Medical Education has increased compared to 2013 (3,132 versus 3,062), while the total of all other primary care specialties combined has remained unchanged (784). The number of US seniors matching into family medicine also increased in 2014 over the prior year (1,416 versus 1,374). The percentage of US seniors who matched into family medicine programs grew modestly in 2014 compared to 2013 (8.6% versus 8.4%). Approximately four out of five primary care positions offered in the Match are in family medicine residency programs (3,132 versus 784). Similarly, three out of four US seniors matching into a primary care specialty match into a family medicine program (1,416 versus 520). By way of comparison, nearly five times the number of US seniors matched into family medicine as compared to medicine-pediatrics, the next largest primary care specialty.

Symptomatology and health care utilization of women primary care patients who experienced childhood sexual abuse.

PubMed

Hulme, P A

2000-11-01

The purpose of this study was to (1) determine the symptomatology of women primary care patients who experienced childhood sexual abuse (CSA), using both a self-report survey and a chart review, and (2) determine their health care utilization patterns, using chart and information system reviews. An ex post facto research design was used. Women primary care patients who experienced CSA were compared with those who reported no CSA. Participants were recruited from a random sample of women patients from a large primary care clinic. They were mailed the survey; chart and information system reviews were conducted on those who returned surveys. Of the 395 participants, 23% reported past CSA on the survey. Women who experienced CSA reported 44 out of 51 physical and psychosocial symptoms more frequently than their counterparts who reported no past CSA. Further, they experienced these symptoms more intensely and in greater number. In their charts, however, far fewer differences in symptoms between groups were found. Nonetheless, women who experienced CSA visited the primary care clinic an average of 1.33 more times than women with no CSA, and they incurred an average of $150 more in primary care charges over a 2-year period. The findings indicate that many women primary care patients who experienced CSA suffer multiple symptoms that are not reflected in their charts. In addition, the findings demonstrate that not only is CSA associated with increased primary care visits, but also increased primary care costs, as measured by charges.

Cognitive-behavioral therapy in depressed primary care patients with co-occurring problematic alcohol use: effect of telephone-administered vs. face-to-face treatment-a secondary analysis.

PubMed

Kalapatapu, Raj K; Ho, Joyce; Cai, Xuan; Vinogradov, Sophia; Batki, Steven L; Mohr, David C

2014-01-01

This secondary analysis of a larger study compared adherence to telephone-administered cognitive-behavioral therapy (T-CBT) vs. face-to-face CBT and depression outcomes in depressed primary care patients with co-occurring problematic alcohol use. To our knowledge, T-CBT has never been directly compared to face-to-face CBT in such a sample of primary care patients. Participants were randomized in a 1:1 ratio to face-to-face CBT or T-CBT for depression. Participants receiving T-CBT (n = 50) and face-to-face CBT (n = 53) were compared at baseline, end of treatment (week 18), and three-month and six-month follow-ups. Face-to-face CBT and T-CBT groups did not significantly differ in age, sex, ethnicity, marital status, educational level, severity of depression, antidepressant use, and total score on the Alcohol Use Disorders Identification Test. Face-to-face CBT and T-CBT groups were similar on all treatment adherence outcomes and depression outcomes at all time points. T-CBT and face-to-face CBT had similar treatment adherence and efficacy for the treatment of depression in depressed primary care patients with co-occurring problematic alcohol use. When targeting patients who might have difficulties in accessing care, primary care clinicians may consider both types of CBT delivery when treating depression in patients with co-occurring problematic alcohol use.

Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial.

PubMed

Khunti, Kamlesh; Stone, Margaret; Paul, Sanjoy; Baines, Jan; Gisborne, Louise; Farooqi, Azhar; Luan, Xiujie; Squire, Iain

2007-11-01

To evaluate the effect of a disease management programme for patients with coronary heart disease (CHD) and chronic heart failure (CHF) in primary care. A cluster randomised controlled trial of 1316 patients with CHD and CHF from 20 primary care practices in the UK was carried out. Care in the intervention practices was delivered by specialist nurses trained in the management of patients with CHD and CHF. Usual care was delivered by the primary healthcare team in the control practices. At follow up, significantly more patients with a history of myocardial infarction in the intervention group were prescribed a beta-blocker compared to the control group (adjusted OR 1.43, 95% CI 1.19 to 1.99). Significantly more patients with CHD in the intervention group had adequate management of their blood pressure (<140/85 mm Hg) (OR 1.61, 95% CI 1.22 to 2.13) and their cholesterol (<5 mmol/l) (OR 1.58, 95% CI 1.05 to 2.37) compared to those in the control group. Significantly more patients with an unconfirmed diagnosis of CHF had a diagnosis of left ventricular systolic dysfunction confirmed (OR 4.69, 95% CI 1.88 to 11.66) or excluded (OR 3.80, 95% CI 1.50 to 9.64) in the intervention group compared to the control group. There were significant improvements in some quality-of-life measures in patients with CHD in the intervention group. Disease management programmes can lead to improvements in the care of patients with CHD and presumed CHF in primary care.

Verbal communication among Alzheimer's disease patients, their caregivers, and primary care physicians during primary care office visits.

PubMed

Schmidt, Karen L; Lingler, Jennifer H; Schulz, Richard

2009-11-01

Primary care visits of patients with Alzheimer's disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual's verbal participation in these triadic interactions. To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty-three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed. PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver's own verbal participation. Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less. Encouraging verbal participation by AD patients and their caregivers may increase the AD patient's active role and caregiver satisfaction with primary care visits.

The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions.

PubMed

McAlister, Finlay A; Bakal, Jeffrey A; Green, Lee; Bahler, Brad; Lewanczuk, Richard

2018-03-12

Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus conventional primary care. We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months. Adults receiving care within a primary care network ( n = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care ( n = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio [RR] 0.98, 95% confidence interval [CI] 0.96-0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93-0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03-1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07-1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years. Care within a primary care network was associated with fewer emergency department visits and fewer hospital days. © 2018 Joule Inc. or its licensors.

The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions

PubMed Central

Bakal, Jeffrey A.; Green, Lee; Bahler, Brad; Lewanczuk, Richard

2018-01-01

BACKGROUND: Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus conventional primary care. METHODS: We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months. RESULTS: Adults receiving care within a primary care network (n = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care (n = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio [RR] 0.98, 95% confidence interval [CI] 0.96–0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93–0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03–1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07–1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years. INTERPRETATION: Care within a primary care network was associated with fewer emergency department visits and fewer hospital days. PMID:29530868

Primary Care, Self-rated Health, and Reductions in Social Disparities in Health

PubMed Central

Shi, Leiyu; Starfield, Barbara; Politzer, Robert; Regan, Jerri

2002-01-01

Objective To examine the extent to which good primary-care experience attenuates the adverse association of income inequality with self-reported health. Data Sources Data for the study were drawn from the Robert Wood Johnson Foundation sponsored 1996–1997 Community Tracking Study (CTS) Household Survey and state indicators of income inequality and primary care. Study Design Cross-sectional, mixed-level analysis on individuals with a primary-care physician as their usual source of care. The analyses were weighted to represent the civilian noninstitutionalized population of the continental United States. Data Collection/Extraction Methods Principal component factor analysis was used to explore the structure of the primary-care indicators and examine their construct validity. Income inequality for the state in which the community is located was measured by the Gini coefficient, calculated using income distribution data from the 1996 current population survey. Stratified analyses compared proportion of individuals reporting bad health and feeling depressed with those with good and bad primary-care experiences for each of the four income-inequality strata. A set of logistic regressions were performed to examine the relation between primary-care experience, income inequality, and self-rated health. Principal Findings Good primary-care experience, in particular enhanced accessibility and continuity, was associated with better self-reported health both generally and mentally. Good primary-care experience was able to reduce the adverse association of income inequality with general health although not with mental health, and was especially beneficial in areas with highest income inequality. Socioeconomic status attenuated, but did not eliminate, the effect of primary-care experience on health. In conclusion, good primary-care experience is associated not only with improved self-rated overall and mental health but also with reductions in disparities between more- and less-disadvantaged communities in ratings of overall health. PMID:12132594

Do primary care professionals agree about progress with implementation of primary care teams: results from a cross sectional study.

PubMed

Tierney, E; O'Sullivan, M; Hickey, L; Hannigan, A; May, C; Cullen, W; Kennedy, N; Kineen, L; MacFarlane, A

2016-11-22

Primary care is the cornerstone of healthcare reform with policies across jurisdictions promoting interdisciplinary team working. The effective implementation of such health policies requires understanding the perspectives of all actors. However, there is a lack of research about health professionals' views of this process. This study compares Primary Healthcare Professionals' perceptions of the effectiveness of the Primary Care Strategy and Primary Care Team (PCT) implementation in Ireland. Design and Setting: e-survey of (1) General Practitioners (GPs) associated with a Graduate Medical School (N = 100) and (2) Primary Care Professionals in 3 of 4 Health Service Executive (HSE) regions (N = 2309). After piloting, snowball sampling was used to administer the survey. Descriptive analysis was carried out using SPSS. Ratings across groups were compared using non-parametric tests. There were 569 responses. Response rates varied across disciplines (71 % for GPs, 22 % for other Primary Healthcare Professionals (PCPs). Respondents across all disciplines viewed interdisciplinary working as important. Respondents agreed on lack of progress of implementation of formal PCTs (median rating of 2, where 1 is no progress at all and 5 is complete implementation). GPs were more negative about the effectiveness of the Strategy to promote different disciplines to work together (median rating of 2 compared to 3 for clinical therapists and 3.5 for nurses, P = 0.001). Respondents identified resources and GP participation as most important for effective team working. Protected time for meetings and capacity to manage workload for meetings were rated as very important factors for effective team working by GPs, clinical therapists and nurses. A building for co-location of teams was rated as an important factor by nurses and clinical therapists though GPs rated it as less important. Payment to attend meetings and contractual arrangements were considered important factors by GPs but not by nurses or clinical therapists. PCPs and GPs agree there is limited PCT implementation. GPs are most negative about this implementation. There is some disagreement about which resources are most important for effective PCT working. These findings provide valuable data for clinicians and policy makers about implementation of interdisciplinary teams in primary care.

Association of the Social Determinants of Health With Quality of Primary Care.

PubMed

Katz, Alan; Chateau, Dan; Enns, Jennifer E; Valdivia, Jeff; Taylor, Carole; Walld, Randy; McCulloch, Scott

2018-05-01

In primary care, there is increasing recognition of the difficulty of treating patients' immediate health concerns when their overall well-being is shaped by underlying social determinants of health. We assessed the association of social complexity factors with the quality of care patients received in primary care settings. Eleven social complexity factors were defined using administrative data on poverty, mental health, newcomer status, and justice system involvement from the Manitoba Population Research Data Repository. We measured the distribution of these factors among primary care patients who made at least 3 visits during 2010-2013 to clinicians in Manitoba, Canada. Using generalized linear mixed modeling, we measured 26 primary care indicators to compare the quality of care received by patients with 0 to 5 or more social complexity factors. Among 626,264 primary care patients, 54% were living with at least 1 social complexity factor, and 4% were living with 5 or more. Social complexity factors were strongly associated with poorer outcomes with respect to primary care indicators for prevention (eg, breast cancer screening; odds ratio [OR] = 0.77; 99% CI, 0.73-0.81), chronic disease management (eg, diabetes management; OR = 0.86; 99% CI, 0.79-0.92), geriatric care (eg, benzodiazepine prescriptions; OR = 1.63; 99% CI, 1.48-1.80), and use of health services (eg, ambulatory visits; OR = 1.09; 99% CI, 1.08-1.09). Linking health and social data demonstrates how social determinants are associated with primary care service provision. Our findings provide insight into the social needs of primary care populations, and may support the development of focused interventions to address social complexity in primary care. © 2018 Annals of Family Medicine, Inc.

Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare? A systematic review.

PubMed

Hone, Thomas; Lee, John Tayu; Majeed, Azeem; Conteh, Lesong; Millett, Christopher

2017-06-01

Policy-makers are increasingly considering charging users different fees between primary and secondary care (differential user charges) to encourage utilisation of primary health care in health systems with limited gate keeping. A systematic review was conducted to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published in MEDLINE, EMBASE, the Cochrane library, EconLIT, HMIC, and WHO library databases from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively. Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care. Overall, the impact of introducing differential user-charges on primary care utilisation remains uncertain. Further research is required to understand their impact as a demand side intervention, including implications for health system costs and on utilisation among low-income patients. © The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Protocol for the Rural Engagement in Primary Care for Optimizing Weight Reduction (RE-POWER) Trial: Comparing three obesity treatment models in rural primary care.

PubMed

Befort, Christie A; VanWormer, Jeffrey J; DeSouza, Cyrus; Ellerbeck, Edward F; Kimminau, Kim S; Greiner, Allen; Gajewski, Byron; Huang, Terry; Perri, Michael G; Fazzino, Tera L; Christifano, Danielle; Eiland, Leslie; Drincic, Andjela

2016-03-01

Obesity disproportionately affects rural residents in the United States, and primary care has the potential to fill a major gap in the provision of weight management services for rural communities. The objective of this cluster-randomized pragmatic trial is to evaluate the comparative effectiveness of three obesity treatment models in rural primary care: the Intensive Behavior Therapy fee-for-service (FFS) model reimbursed by Medicare, a team-based model that recognizes the patient-centered medical home (PCMH) as a preferred delivery approach, and the centralized disease management (DM) model, in which phone-based counseling is provided outside of the primary care practice. We hypothesize that the PCMH and DM treatments will be more effective than FFS in reducing weight at 24 months. Thirty-six practices from the rural Midwestern U.S. are randomized to deliver one of the three interventions to 40 patients (N=1440) age 20 to 75 with a BMI 30-45 kg/m(2). In the FFS arm, primary care providers and their personnel counsel patients to follow evidence-based weight loss guidelines using the Medicare-designated treatment schedule. In the PCMH arm, patients receive a comprehensive weight management intervention delivered locally by practice personnel using a combination of in-person and phone-based group sessions. In the DM arm, the same intervention is delivered remotely by obesity treatment specialists via group conference calls. The primary outcome is weight loss at 24 months. Additional measures include fasting glucose, lipids, quality of life indicators, and implementation process measures. Findings will illuminate effective obesity treatment intervention(s) in rural primary care. Copyright © 2016. Published by Elsevier Inc.

Efficacy of nurse-led and general practitioner-led comprehensive geriatric assessment in primary care: protocol of a pragmatic three-arm cluster randomised controlled trial (CEpiA study)

PubMed Central

Ferrat, Emilie; Bastuji-Garin, Sylvie; Paillaud, Elena; Caillet, Philippe; Clerc, Pascal; Moscova, Laura; Gouja, Amel; Renard, Vincent; Attali, Claude; Breton, Julien Le; Audureau, Etienne

2018-01-01

Introduction Older patients raise therapeutic challenges, because they constitute a heterogeneous population with multimorbidity. To appraise this complexity, geriatricians have developed a multidimensional comprehensive geriatric assessment (CGA), which may be difficult to apply in primary care settings. Our primary objective was to compare the effect on morbimortality of usual care compared with two complex interventions combining educational seminars about CGA: a dedicated geriatric hotline for general practitioners (GPs) and CGA by trained nurses or GPs. Methods and analysis The Clinical Epidemiology and Ageing study is an open-label, pragmatic, multicentre, three-arm, cluster randomised controlled trial comparing two intervention groups and one control group. Patients must be 70 years or older with a long-term illness or with unscheduled hospitalisation in the past 3 months (750 patients planned). This study involves volunteering GPs practising in French primary care centres, with randomisation at the practice level. The multifaceted interventions for interventional arms comprise an educational interactive multiprofessional seminar for GPs and nurses, a geriatric hotline dedicated to GPs in case of difficulties and the performance of a CGA updated to primary care. The CGA is systematically performed by a nurse in arm 1 but is GP-led on a case-by-case basis in arm 2. The primary endpoint is a composite criterion comprising overall death, unscheduled hospitalisations, emergency admissions and institutionalisation within 12 months after inclusion. Intention-to-treat analysis will be performed using mixed-effects logistic regression models, with adjustment for potential confounders. Ethics and dissemination The protocol was approved by an appropriate ethics committee (CPP Ile-de-France IV, Paris, France, approval April 2015;15 664). This study is conducted according to principles of good clinical practice in the context of current care and will provide useful knowledge on the clinical benefits achievable by CGA in primary care. Trial registration number NCT02664454; Pre-results. PMID:29654038

Contribution of primary care to health: an individual level analysis from Tibet, China.

PubMed

Wang, Wenhua; Shi, Leiyu; Yin, Aitian; Mao, Zongfu; Maitland, Elizabeth; Nicholas, Stephen; Liu, Xiaoyun

2015-11-30

There have been significant improvements in health outcomes in Tibet, health disparities between Tibet and the rest of China has been greatly reduced. This paper tests whether there was a positive association between good primary care and better health outcomes in Tibet. A validated Tibetan version of the Primary Care Assessment Tool (PCAT-T) was used to collect data on 1386 patients aged over 18 years old accessing primary care. Self-rated health (SRH) was employed to measure health outcomes. A multiple binary logistic regression model was used to explore the association between primary care quality and self-rated health status after controlling for socio-demographic and lifestyle variables. This study found that primary care quality had a significant positive association with self-rated health status. Among the nine domains of PCAT-T, family centeredness domain had the highest Odds Ratio (OR = 1.013) with SRH. Patients located in rural area, with higher education levels, without depression, and less frequent drinking were more likely to self-rate as "good health" compared with the reference group. In Tibet, higher quality primary care was associated with better self-rated health status. Primary care should be much strengthened in future health system reform in Tibet.

Providing Family Planning Services at Primary Care Organizations after the Exclusion of Planned Parenthood from Publicly Funded Programs in Texas: Early Qualitative Evidence.

PubMed

White, Kari; Hopkins, Kristine; Grossman, Daniel; Potter, Joseph E

2017-10-20

To explore organizations' experiences providing family planning during the first year of an expanded primary care program in Texas. Between November 2014 and February 2015, in-depth interviews were conducted with program administrators at 30 organizations: 7 women's health organizations, 13 established primary care contractors (e.g., community health centers, public health departments), and 10 new primary care contractors. Interviews addressed organizational capacities to expand family planning and integrate services with primary care. Interview transcripts were analyzed using a theme-based approach. Themes were compared across the three types of organizations. Established and new primary care contractors identified several challenges expanding family planning services, which were uncommon among women's health organizations. Clinicians often lacked training to provide intrauterine devices and contraceptive implants. Organizations often recruited existing clients into family planning services, rather than expanding their patient base, and new contractors found family planning difficult to integrate because of clients' other health needs. Primary care contractors frequently described contraceptive provision protocols that were not evidence-based. Many primary care organizations in Texas initially lacked the capacity to provide evidence-based family planning services that women's health organizations already provided. © Health Research and Educational Trust.

Primary care and survival among American Indian patients with diabetes in the Southwest United States: Evaluation of a cohort study at Gallup Indian Medical Center, 2009-2016.

PubMed

King, Caroline; Atwood, Sidney; Brown, Chris; Nelson, Adrianne Katrina; Lozada, Mia; Wei, Jennie; Merino, Maricruz; Curley, Cameron; Muskett, Olivia; Sabo, Samantha; Gampa, Vikas; Orav, John; Shin, Sonya

2018-06-01

To evaluate the role of primary care healthcare delivery on survival for American Indian patients with diabetes in the southwest United States. Data from patients with diabetes admitted to Gallup Indian Medical Center between 2009 and 2016 were analyzed using a log-rank test and Cox Proportional Hazards analyses. Of the 2661 patients included in analysis, 286 patients died during the study period. Having visited a primary care provider in the year prior to first admission of the study period was protective against all-cause mortality in unadjusted analysis (HR (95% CI)=0.47 (0.31, 0.73)), and after adjustment. The log-rank test indicated there is a significant difference in overall survival by primary care engagement history prior to admission (p<0.001). The median survival time for patients who had seen a primary care provider was 2322days versus 2158days for those who had not seen a primary care provider. Compared with those who did not see a primary care provider in the year prior to admission, having seen a primary care provider was associated with improved survival after admission. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

From cottage industry to a dominant mode of primary care: stages in the diffusion of a health care innovation (retail clinics).

PubMed

McKinlay, John B; Marceau, Lisa D

2012-09-01

Primary health care is essential to population health and there is increasing need for it, especially with an aging population with multiple comorbidities. Primary health care in the U.S. is widely considered in an ever-deepening crisis. This paper presents a detailed case study of the recent rise of a "disruptive innovation" - retail clinics - which have the potential to transform the face of primary health care in the US. We describe six stages in the diffusion of retail clinics, from cottage industry to a dominant mode for the delivery of primary health care, and consider sociopolitical influences that facilitate and impede their emerging potential. Retail clinics may provide a strategic opportunity to re-engineer the primary health care system, although they may also produce worrisome unanticipated consequences. Discussion concerning the potential threats and opportunities posed by retail clinics occurs in the absence of sound evidence concerning their comparative effectiveness and quality-of-care. This case study identifies the sociopolitical influences and processes that determine whether health care innovations rise or fall, and highlights critically important points along the pathway to health system change. Copyright © 2012 Elsevier Ltd. All rights reserved.

Addressing long-term physical healthcare needs in a forensic mental health inpatient population using the UK primary care Quality and Outcomes Framework (QOF): an audit.

PubMed

Ivbijaro, Go; Kolkiewicz, LA; McGee, Lsf; Gikunoo, M

2008-03-01

Objectives This audit aims to evaluate the effectiveness of delivering an equivalent primary care service to a long-term forensic psychiatric inpatient population, using the UK primary care national Quality and Outcomes Framework (QOF).Method The audit compares the targets met by the general practitioner with special interest (GPwSI) service, using local and national QOF benchmarks (2005-2006), and determines the prevalence of chronic disease in a long-term inpatient forensic psychiatry population.Results The audit results show that the UK national QOF is a useful tool for assessment and evaluation of physical healthcare needs in a non-community based population. It shows an increased prevalence of all QOF-assessed long-term physical conditions when compared to the local East London population and national UK population, confirming previously reported elevated levels of physical healthcare need in psychiatric populations.Conclusions This audit shows that the UK General Practice QOF can be used as a standardised instrument for commissioning and monitoring the delivery of physical health services to in-patient psychiatric populations, and for the evaluation of the effectiveness of clinical interventions in long-term physical conditions. The audit also demonstrates the effectiveness of using a GPwSI in healthcare delivery in non-community based settings. We suggest that the findings may be generalisable to other long-term inpatient psychiatric and prison populations in order to further the objective of delivering an equivalent primary care service to all populations.The QOF is a set of national primary care audit standards and is freely available on the British Medical Association website or the UK Department of Health website. We suggest that primary care workers in health economies who have not yet developed their own national primary care standards can access and adapt these standards in order to improve the clinical standards of care given to the primary care populations that they serve.

Addressing long-term physical healthcare needs in a forensic mental health inpatient population using the UK primary care Quality and Outcomes Framework (QOF): an audit

PubMed Central

2008-01-01

Objectives This audit aims to evaluate the effectiveness of delivering an equivalent primary care service to a long-term forensic psychiatric inpatient population, using the UK primary care national Quality and Outcomes Framework (QOF). Method The audit compares the targets met by the general practitioner with special interest (GPwSI) service, using local and national QOF benchmarks (2005–2006), and determines the prevalence of chronic disease in a long-term inpatient forensic psychiatry population. Results The audit results show that the UK national QOF is a useful tool for assessment and evaluation of physical healthcare needs in a non-community based population. It shows an increased prevalence of all QOF-assessed long-term physical conditions when compared to the local East London population and national UK population, confirming previously reported elevated levels of physical healthcare need in psychiatric populations. Conclusions This audit shows that the UK General Practice QOF can be used as a standardised instrument for commissioning and monitoring the delivery of physical health services to in-patient psychiatric populations, and for the evaluation of the effectiveness of clinical interventions in long-term physical conditions. The audit also demonstrates the effectiveness of using a GPwSI in healthcare delivery in non-community based settings. We suggest that the findings may be generalisable to other long-term inpatient psychiatric and prison populations in order to further the objective of delivering an equivalent primary care service to all populations. The QOF is a set of national primary care audit standards and is freely available on the British Medical Association website or the UK Department of Health website. We suggest that primary care workers in health economies who have not yet developed their own national primary care standards can access and adapt these standards in order to improve the clinical standards of care given to the primary care populations that they serve. PMID:22477846

Efficacy of oral health promotion in primary care practice during early childhood: creating positive changes in parent's oral health beliefs and behaviors.

PubMed

Mattheus, Deborah J

2014-06-01

Nurse practitioners frequently provide care to children suffering from poor oral health. Creative approaches to impacting dental disease are needed due to the current lack of traditional dental providers. This study investigated the effects of oral health promotion provided by primary care providers on parental oral health beliefs and behaviors. Participants receiving standard oral care during two well child visits and two additional enhanced oral health visits (n=44) were compared to participants receiving standard oral care during two well child visits alone (n=40). Results revealed changes in parent's perception of the importance of oral care for their children's primary teeth compared to general healthcare needs (p<0.05), response to brushing their children's teeth (p<0.0001), confidence in brushing their teeth (p<0.05) and frequency of brushing (p<0.0001) in both groups. This small but important study shows that oral health programs in primary care can produce changes that can improve oral health outcomes. Parents and children exposed to oral health programs during their frequent well child care visits in the first years of life may help decrease the rate of early childhood caries and improve their quality of life.

Structuring payment to medical homes after the affordable care act.

PubMed

Edwards, Samuel T; Abrams, Melinda K; Baron, Richard J; Berenson, Robert A; Rich, Eugene C; Rosenthal, Gary E; Rosenthal, Meredith B; Landon, Bruce E

2014-10-01

The Patient-Centered Medical Home (PCMH) is a leading model of primary care reform, a critical element of which is payment reform for primary care services. With the passage of the Affordable Care Act, the Accountable Care Organization (ACO) has emerged as a model of delivery system reform, and while there is theoretical alignment between the PCMH and ACOs, the discussion of physician payment within each model has remained distinct. Here we compare payment for medical homes with that for accountable care organizations, consider opportunities for integration, and discuss implications for policy makers and payers considering ACO models. The PCMH and ACO are complementary approaches to reformed care delivery: the PCMH ultimately requires strong integration with specialists and hospitals as seen under ACOs, and ACOs likely will require a high functioning primary care system as embodied by the PCMH. Aligning payment incentives within the ACO will be critical to achieving this integration and enhancing the care coordination role of primary care in these settings.

Rural And Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners.

PubMed

Barnes, Hilary; Richards, Michael R; McHugh, Matthew D; Martsolf, Grant

2018-06-01

The use of nurse practitioners (NPs) in primary care is one way to address growing patient demand and improve care delivery. However, little is known about trends in NP presence in primary care practices, or about how state policies such as scope-of-practice laws and expansion of eligibility for Medicaid may encourage or inhibit the use of NPs. We found increasing NP presence in both rural and nonrural primary care practices in the period 2008-16. At the end of the period, NPs constituted 25.2 percent of providers in rural and 23.0 percent in nonrural practices, compared to 17.6 percent and 15.9 percent, respectively, in 2008. States with full scope-of-practice laws had the highest NP presence, but the fastest growth occurred in states with reduced and restricted scopes of practice. State Medicaid expansion status was not associated with greater NP presence. Overall, primary care practices are embracing interdisciplinary provider configurations, and including NPs as providers can strengthen health care delivery.

Cost-Effectiveness of Collaborative Care for the Treatment of Depressive Disorders in Primary Care: A Systematic Review

PubMed Central

Grochtdreis, Thomas; Brettschneider, Christian; Wegener, Annemarie; Watzke, Birgit; Riedel-Heller, Steffi; Härter, Martin; König, Hans-Helmut

2015-01-01

Background For the treatment of depressive disorders, the framework of collaborative care has been recommended, which showed improved outcomes in the primary care sector. Yet, an earlier literature review did not find sufficient evidence to draw robust conclusions on the cost-effectiveness of collaborative care. Purpose To systematically review studies on the cost-effectiveness of collaborative care, compared with usual care for the treatment of patients with depressive disorders in primary care. Methods A systematic literature search in major databases was conducted. Risk of bias was assessed using the Cochrane Collaboration’s tool. Methodological quality of the articles was assessed using the Consensus on Health Economic Criteria (CHEC) list. To ensure comparability across studies, cost data were inflated to the year 2012 using country-specific gross domestic product inflation rates, and were adjusted to international dollars using purchasing power parities (PPP). Results In total, 19 cost-effectiveness analyses were reviewed. The included studies had sample sizes between n = 65 to n = 1,801, and time horizons between six to 24 months. Between 42% and 89% of the CHEC quality criteria were fulfilled, and in only one study no risk of bias was identified. A societal perspective was used by five studies. Incremental costs per depression-free day ranged from dominance to US$PPP 64.89, and incremental costs per QALY from dominance to US$PPP 874,562. Conclusion Despite our review improved the comparability of study results, cost-effectiveness of collaborative care compared with usual care for the treatment of patients with depressive disorders in primary care is ambiguous depending on willingness to pay. A still considerable uncertainty, due to inconsistent methodological quality and results among included studies, suggests further cost-effectiveness analyses using QALYs as effect measures and a time horizon of at least 1 year. PMID:25993034

The Value of Continuity between Primary Care and Surgical Care in Colon Cancer.

PubMed

Hussain, Tanvir; Chang, Hsien-Yen; Luu, Ngoc-Phuong; Pollack, Craig Evan

2016-01-01

Improving continuity between primary care and cancer care is critical for improving cancer outcomes and curbing cancer costs. A dimension of continuity, we investigated how regularly patients receive their primary care and surgical care for colon cancer from the same hospital and whether this affects mortality and costs. Using Surveillance, Epidemiology, and End Results Program Registry (SEER)-Medicare data, we performed a retrospective cohort study of stage I-III colon cancer patients diagnosed between 2000 and 2009. There were 23,305 stage I-III colon cancer patients who received primary care in the year prior to diagnosis and underwent operative care for colon cancer. Patients were assigned to the hospital where they had their surgery and to their primary care provider's main hospital, and then classified according to whether these two hospitals were same or different. Outcomes examined were hazards for all-cause mortality, subhazard for colon cancer specific mortality, and generalized linear estimate for costs at 12 months, from propensity score matched models. Fifty-two percent of stage I-III colon patients received primary care and surgical care from the same hospital. Primary care and surgical care from the same hospital was not associated with reduced all-cause or colon cancer specific mortality, but was associated with lower inpatient, outpatient, and total costs of care. Total cost difference was $8,836 (95% CI $2,746-$14,577), a 20% reduction in total median cost of care at 12 months. Receiving primary care and surgical care at the same hospital, compared to different hospitals, was associated with lower costs but still similar survival among stage I-III colon cancer patients. Nonetheless, health care policy which encourages further integration between primary care and cancer care in order to improve outcomes and decrease costs will need to address the significant proportion of patients receiving health care across more than one hospital.

Assessment of primary care services and perceived barriers to care in persons with disabilities.

PubMed

Harrington, Amanda L; Hirsch, Mark A; Hammond, Flora M; Norton, H James; Bockenek, William L

2009-10-01

To determine what percentage of persons with disabilities have a primary care provider, participate in routine screening and health maintenance examinations, and identify perceived physical or physician barriers to receiving care. A total of 344 surveys, consisting of 66 questions, were collected from adults with disabilities receiving care at an outpatient rehabilitation clinic. A total of 89.5% (95% CI 86.3%-92.8%) of participants reported having a primary care physician. Younger persons (P < 0.0001), men (P < 0.02), persons with brain injury (P < 0.05), or persons with amputations (P < 0.05) were less likely to have a primary care physician. Participant report of screening for alcohol, nonprescription drug use, and safety with relationships at home ranged from 26.6% to 37.5% compared with screening for depression, diet, exercise, and smoking (64.5%-70%). Completion rates of age- and gender-appropriate health maintenance examinations ranged from 42.4% to 90%. A total of 2.67% of participants reported problems with physical access at their physician's office, and 36.4% (95% CI 30.8%-42.1%) of participants reported having to teach their primary care physician about their disability. Most persons with disabilities have a primary care physician. In general, completion rates for routine screening and health maintenance examinations were high. Perceived deficits in primary care physicians' knowledge of disability issues seem more prevalent than physical barriers to care.

Private ownership of primary care providers associated with patient perceived quality of care

PubMed Central

Wei, Xiaolin; Yin, Jia; Wong, Samuel Y.S.; Griffiths, Sian M.; Zou, Guanyang; Shi, Leiyu

2017-01-01

Abstract Ownership of primary care providers varies in different cities in China. Shanghai represented the full public ownership model of primary providers; Shenzhen had public-owned but private-operated providers; and Hong Kong represented the full private ownership. The study aims to assess the association of primary care ownership and patient perceived quality of care in 3 Chinese megacities. We conducted multistage stratified random surveys in 2013 in the 3 cities. Quality scores of primary care were measured using the validated primary care assessment tools. Multivariate linear regression models were used to compare quality scores after controlling potential confounders of patient demographic, socioeconomic, and healthcare utilization factors. Overall, 797 primary care users in Shanghai, 802 in Shenzhen, and 1325 in Hong Kong participated in the study. The mean total quality scores were reported the highest in Shanghai (28.39), followed by Shenzhen (25.82) and then Hong Kong (25.21) (P < 0.001). Shanghai participants reported the highest scores for 1st contact accessibility, coordination of information, comprehensiveness of service availability, and culture competence, while Hong Kong participants reported the lowest for these domains (P < 0.001). Hong Kong participants from rich households reported higher total scores than those from poor households (P < 0.05); however, this was not found in Shanghai and Shenzhen. The study suggests that private primary care ownership may be associated with lower quality and less equitable care distribution. In China, it suggests that it may be beneficial to promote public-owned and nonprofit providers. Promoting privatization in primary care may be at the cost of quality and equity of primary care. PMID:28072718

The effect of primary care interventions on children's media viewing habits and exposure to violence.

PubMed

Aragon Neely, Jill; Hudnut-Beumler, Julia; White Webb, Margaret; Chavis, Antwon; Dietrich, Mary S; Bickman, Len; Scholer, Seth J

2013-01-01

To determine if brief primary care interventions can affect children's media viewing habits and exposure to violence. English- and Spanish-speaking parents of 2- to 12-year-old children presenting to a pediatric primary care clinic participated in a randomized controlled trial. There were 2 intervention groups; one group viewed 5 minutes from the Play Nicely program and another received a handout, "Pulling the Plug on TV Violence." There were 2 control groups; the primary control group received standard primary care, and the alternative control group viewed a program about obesity prevention. The outcome measure was parental report of changes in media viewing habits and changes in exposure to violence. A total of 312 of 443 parents who were randomized completed a 2-week follow-up survey. Compared with the primary control group, parents in the video intervention group were more likely to report a change in their children's media viewing habits (odds ratio [OR] 3.29; 95% confidence interval [CI] 1.66-6.51) and a change in their children's exposure to violence (OR 4.26; 95% CI 1.95-9.27). Compared with the primary control group, parents in the handout group were more likely to report a change in their children's media viewing habits (OR 4.35; 95% CI 2.20-8.60) and a change in their children's exposure to violence (OR 3.35; 95% CI 1.52-7.35). Brief primary care interventions can affect children's media viewing habits and children's exposure to violence. These results have implications for how to improve primary care services related to decreasing children's media exposure and violence prevention. Copyright © 2013 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Older Patients' Perspectives on Quality of Serious Illness Care in Primary Care.

PubMed

Abu Al Hamayel, Nebras; Isenberg, Sarina R; Hannum, Susan M; Sixon, Joshua; Smith, Katherine Clegg; Dy, Sydney M

2018-01-01

Despite increased focus on measuring and improving quality of serious illness care, there has been little emphasis on the primary care context or incorporation of the patient perspective. To explore older patients' perspectives on the quality of serious illness care in primary care. Qualitative interview study. Twenty patients aged 60 or older who were at risk for or living with serious illness and who had participated in the clinic's quality improvement initiative. We used a semistructured, open-ended guide focusing on how older patients perceived quality of serious illness care, particularly in primary care. We transcribed interviews verbatim and inductively identified codes. We identified emergent themes using a thematic and constant comparative method. We identified 5 key themes: (1) the importance of patient-centered communication, (2) coordination of care, (3) the shared decision-making process, (4) clinician competence, and (5) access to care. Communication was an overarching theme that facilitated coordination of care between patients and their clinicians, empowered patients for shared decision-making, related to clinicians' perceived competence, and enabled access to primary and specialty care. Although access to care is not traditionally considered an aspect of quality, patients considered this integral to the quality of care they received. Patients perceived serious illness care as a key aspect of quality in primary care. Efforts to improve quality measurement and implementation of quality improvement initiatives in serious illness care should consider these aspects of care that patients deem important, particularly communication as an overarching priority.

Improving Quality of Care in Primary Health-Care Facilities in Rural Nigeria

PubMed Central

Ugo, Okoli; Ezinne, Eze-Ajoku; Modupe, Oludipe; Nicole, Spieker; Kelechi, Ohiri

2016-01-01

Background: Nigeria has a high population density but a weak health-care system. To improve the quality of care, 3 organizations carried out a quality improvement pilot intervention at the primary health-care level in selected rural areas. Objective: To assess the change in quality of care in primary health-care facilities in rural Nigeria following the provision of technical governance support and to document the successes and challenges encountered. Method: A total of 6 states were selected across the 6 geopolitical zones of the country. However, assessments were carried out in 40 facilities in only 5 states. Selection was based on location, coverage, and minimum services offered. The facilities were divided randomly into 2 groups. The treatment group received quality-of-care assessment, continuous feedback, and improvement support, whereas the control group received quality assessment and no other support. Data were collected using the SafeCare Healthcare Standards and managed on the SafeCare Data Management System—AfriDB. Eight core areas were assessed at baseline and end line, and compliance to quality health-care standards was compared. Result: Outcomes from 40 facilities were accepted and analyzed. Overall scores increased in the treatment facilities compared to the control facilities, with strong evidence of improvement (t = 5.28, P = .0004) and 11% average improvement, but no clear pattern of improvement emerged in the control group. Conclusion: The study demonstrated governance support and active community involvement offered potential for quality improvement in primary health-care facilities. PMID:28462280

Improving Quality of Care in Primary Health-Care Facilities in Rural Nigeria: Successes and Challenges.

PubMed

Ugo, Okoli; Ezinne, Eze-Ajoku; Modupe, Oludipe; Nicole, Spieker; Winifred, Ekezie; Kelechi, Ohiri

2016-01-01

Nigeria has a high population density but a weak health-care system. To improve the quality of care, 3 organizations carried out a quality improvement pilot intervention at the primary health-care level in selected rural areas. To assess the change in quality of care in primary health-care facilities in rural Nigeria following the provision of technical governance support and to document the successes and challenges encountered. A total of 6 states were selected across the 6 geopolitical zones of the country. However, assessments were carried out in 40 facilities in only 5 states. Selection was based on location, coverage, and minimum services offered. The facilities were divided randomly into 2 groups. The treatment group received quality-of-care assessment, continuous feedback, and improvement support, whereas the control group received quality assessment and no other support. Data were collected using the SafeCare Healthcare Standards and managed on the SafeCare Data Management System-AfriDB. Eight core areas were assessed at baseline and end line, and compliance to quality health-care standards was compared. Outcomes from 40 facilities were accepted and analyzed. Overall scores increased in the treatment facilities compared to the control facilities, with strong evidence of improvement ( t = 5.28, P = .0004) and 11% average improvement, but no clear pattern of improvement emerged in the control group. The study demonstrated governance support and active community involvement offered potential for quality improvement in primary health-care facilities.

Clinical Decisions Made in Primary Care Clinics Before and After Choosing Wisely.

PubMed

Kost, Amanda; Genao, Inginia; Lee, Jay W; Smith, Stephen R

2015-01-01

The Choosing Wisely campaign encourages physicians to avoid low-value care. Although widely lauded, no study has examined its impact on clinical decisions made in primary care settings. We compared clinical decisions made for 5 Choosing Wisely recommendations over two 6-month time periods before and after the campaign launch and an educational intervention to promote it at 3 primary care residency clinics. The rate of recommendations adherence was high (93.2%) at baseline but did significantly increase to 96.5% after the launch. These findings suggest primary care physicians respond to training and publicity in low-value care, though further research is needed. Given that even small decreases of physician test ordering can produce large cost savings, the Choosing Wisely project may help achieve the health care triple aim. © Copyright 2015 by the American Board of Family Medicine.

Using video-based observation research methods in primary care health encounters to evaluate complex interactions

PubMed Central

Asan, Onur; Montague, Enid

2015-01-01

Objective The purpose of this paper is to describe the use of video-based observation research methods in primary care environment and highlight important methodological considerations and provide practical guidance for primary care and human factors researchers conducting video studies to understand patient-clinician interaction in primary care settings. Methods We reviewed studies in the literature which used video methods in health care research and, we also used our own experience based on the video studies we conducted in primary care settings. Results This paper highlighted the benefits of using video techniques such as multi-channel recording and video coding and compared “unmanned” video recording with the traditional observation method in primary care research. We proposed a list, which can be followed step by step to conduct an effective video study in a primary care setting for a given problem. This paper also described obstacles researchers should anticipate when using video recording methods in future studies. Conclusion With the new technological improvements, video-based observation research is becoming a promising method in primary care and HFE research. Video recording has been under-utilized as a data collection tool because of confidentiality and privacy issues. However, it has many benefits as opposed to traditional observations, and recent studies using video recording methods have introduced new research areas and approaches. PMID:25479346

Chronic substance use and self-harm in a primary health care setting.

PubMed

Breet, Elsie; Bantjes, Jason; Lewis, Ian

2018-06-19

Chronic substance use (CSU) is associated with health problems, including selfharm, placing a significant burden on health care resources and emergency departments (EDs). This is problematic in low- and middle-income countries like South Africa (SA), where primary care facilitates and emergency departments (EDs) are often poorly resourced. To investigate the epidemiology of CSU and self-harm and to consider the implications for primary health care service delivery and suicide prevention in SA. Data were collected from 238 consecutive self-harm patients treated at the emergency department (ED) of an urban hospital in SA. The data were analysed using bivariate and multivariate analyses. Approximately 37% of self-harm patients reported CSU. The patients in the CSU subgroup, compared to other self-harm patients, were more likely to be men (odds ratio[OR] = 8.33, 95% confidence interval [CI] = 3.19-20.9, p < 0.001), to have self-harmed by inflicting damage to their body tissue OR = 4.45, 95% CI = 1.77-11.2, p < 0.01) and to have a history of self-harm (OR = 3.71, 95% CI = 1.44-9.54, p = 0.007). A significantly smaller proportion of CSU patients, compared to other self-harm patients, were referred for psychiatric assessment (OR = 8.05, 95% CI = 4.16-15.7, p < 0.001). The findings of this study confirm that CSU is associated with greater service utilisation and repetition of self-harm among patients in primary health care settings. Treating self-harm as the presenting problem within primary care settings does not necessarily ensure that patients receive the care that they need. It might be helpful to include psychiatric assessments and screening for CSU as an integral component of care for self-harm patientswho present in primary health care settings.

Differences between immigrant and non-immigrant groups in the use of primary medical care; a systematic review

PubMed Central

Uiters, Ellen; Devillé, Walter; Foets, Marleen; Spreeuwenberg, Peter; Groenewegen, Peter P

2009-01-01

Background Studies on differences between immigrant and non-immigrant groups in health care utilization vary with respect to the extent and direction of differences in use. Therefore, our study aimed to provide a systematic overview of the existing research on differences in primary care utilization between immigrant groups and the majority population. Methods For this review PubMed, PsycInfo, Cinahl, Sociofile, Web of Science and Current Contents were consulted. Study selection and quality assessment was performed using a predefined protocol by 2 reviewers independently of each other. Only original, quantitative, peer-reviewed papers were taken into account. To account for this hierarchical structure, logistic multilevel analyses were performed to examine the extent to which differences are found across countries and immigrant groups. Differences in primary care use were related to study characteristics, strength of the primary care system and methodological quality. Results A total of 37 studies from 7 countries met all inclusion criteria. Remarkably, studies performed within the US more often reported a significant lower use among immigrant groups as compared to the majority population than the other countries. As studies scored higher on methodological quality, the likelihood of reporting significant differences increased. Adjustment for health status and use of culture-/language-adjusted procedures during the data collection were negatively related to reporting significant differences in the studies. Conclusion Our review underlined the need for careful design in studies of differences in health care use between immigrant groups and the majority population. The results from studies concerning differences between immigrant and the majority population in primary health care use performed within the US might be interpreted as a reflection of a weaker primary care system in the US compared to Europe and Canada. PMID:19426567

[Local government and public dental health services: an analysis of inequality in use].

PubMed

Soares, Felipe Fagundes; Chaves, Sônia Cristina Lima; Cangussu, Maria Cristina Teixeira

2015-03-01

The aim of this study was to identify factors associated with the use of primary and specialized public dental health services and private services. A population-based household survey was conducted in two cities of Bahia State, Brazil. Key informants provided data on socioeconomic variables and use of dental health services. Organization of the local public dental health service was ranked as worse versus better. Univariate and multivariate polytomous logistic regression was performed. Of the total of 1,290 individuals, 38.76% used private services, 33.80% used public primary care, and 17.29% used both primary care and the Center for Dental Specialties. Less use of both primary care and specialized public services was associated with lower education (OR = 1.47; 95%CI: 1.03-2.10) and worse organization of services (OR = 1.74; 95%CI: 1.22-2.48), when compared to the exclusive use of primary care. The study showed inequality in the use of dental services, even when comparing more homogeneous groups, namely users of public services.

Data feedback and behavioural change intervention to improve primary care prescribing safety (EFIPPS): multicentre, three arm, cluster randomised controlled trial.

PubMed

Guthrie, Bruce; Kavanagh, Kimberley; Robertson, Chris; Barnett, Karen; Treweek, Shaun; Petrie, Dennis; Ritchie, Lewis; Bennie, Marion

2016-08-18

 To evaluate the effectiveness of feedback on safety of prescribing compared with moderately enhanced usual care.  Three arm, highly pragmatic cluster randomised trial.  262/278 (94%) primary care practices in three Scottish health boards.  Practices were randomised to: "usual care," consisting of emailed educational material with support for searching to identify patients (88 practices at baseline, 86 analysed); usual care plus feedback on practice's high risk prescribing sent quarterly on five occasions (87 practices, 86 analysed); or usual care plus the same feedback incorporating a behavioural change component (87 practices, 86 analysed).  The primary outcome was a patient level composite of six prescribing measures relating to high risk use of antipsychotics, non-steroidal anti-inflammatories, and antiplatelets. Secondary outcomes were the six individual measures. The primary analysis compared high risk prescribing in the two feedback arms against usual care at 15 months. Secondary analyses examined immediate change and change in trend of high risk prescribing associated with implementation of the intervention within each arm.  In the primary analysis, high risk prescribing as measured by the primary outcome fell from 6.0% (3332/55 896) to 5.1% (2845/55 872) in the usual care arm, compared with 5.9% (3341/56 194) to 4.6% (2587/56 478) in the feedback only arm (odds ratio 0.88 (95% confidence interval 0.80 to 0.96) compared with usual care; P=0.007) and 6.2% (3634/58 569) to 4.6% (2686/58 582) in the feedback plus behavioural change component arm (0.86 (0.78 to 0.95); P=0.002). In the pre-specified secondary analysis of change in trend within each arm, the usual care educational intervention had no effect on the existing declining trend in high risk prescribing. Both types of feedback were associated with significantly more rapid decline in high risk prescribing after the intervention compared with before.  Feedback of prescribing safety data was effective at reducing high risk prescribing. The intervention would be feasible to implement at scale in contexts where electronic health records are in general use.Trial registration Clinical trials NCT01602705. 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.

General practitioners: Between integration and co-location. The case of primary care centers in Tuscany, Italy.

PubMed

Barsanti, Sara; Bonciani, Manila

2018-01-01

Healthcare systems have followed several strategies aimed at integrating primary care services and professionals. Medical homes in the USA and Canada, and primary care centres across Europe have collocated general practitioners and other health and social professionals in the same building in order to boost coordination among services and the continuity of care for patients. However, in the literature, the impact of co-location on primary care has led to controversial results. This article analyses the possible benefits of the co-location of services in primary care focusing on the Italian model of primary care centres (Case della Salute) in terms of general practitioners' perception. We used the results of a web survey of general practitioners in Tuscany to compare the experiences and satisfaction of those general practitioners involved and not involved in a primary care centre, performed a MONAVA and ANOVA analysis. Our case study highlights the positive impact of co-location on the integration of professionals, especially with nurses and social workers, and on organizational integration, in terms of frequency of meeting to discuss about quality of care. Conversely, no significant differences were found in terms of either clinical or system integration. Furthermore, the collaboration with specialists is still weak. Considering the general practitioners' perspective in terms of experience and satisfaction towards primary care, co-location strategies is a necessary step in order to facilitate the collaboration among professionals and to prevent unintended consequences in terms of an even possible isolation of primary care as an involuntary 'disintegration of the integration'.

Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial.

PubMed

Bruce, Martha L; Ten Have, Thomas R; Reynolds, Charles F; Katz, Ira I; Schulberg, Herbert C; Mulsant, Benoit H; Brown, Gregory K; McAvay, Gail J; Pearson, Jane L; Alexopoulos, George S

2004-03-03

Suicide rates are highest in late life; the majority of older adults who die by suicide have seen a primary care physician in preceding months. Depression is the strongest risk factor for late-life suicide and for suicide's precursor, suicidal ideation. To determine the effect of a primary care intervention on suicidal ideation and depression in older patients. Randomized controlled trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) with patient recruitment from 20 primary care practices in New York City, Philadelphia, and Pittsburgh regions, May 1999 through August 2001. Two-stage, age-stratified (60-74, > or =75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of screened negative patients. This analysis included patients with a depression diagnosis (N = 598). Treatment guidelines tailored for the elderly with care management compared with usual care. Assessment of suicidal ideation and depression severity at baseline, 4 months, 8 months, and 12 months. Rates of suicidal ideation declined faster (P =.01) in intervention patients compared with usual care patients; at 4 months, in the intervention group, raw rates of suicidal ideation declined 12.9% points (29.4% to 16.5%) compared with 3.0% points (20.1% to 17.1% in usual care [P =.01]). Among patients reporting suicidal ideation, resolution of ideation was faster among intervention patients (P =.03); differences peaked at 8 months (70.7% vs 43.9% resolution; P =.005). Intervention patients had a more favorable course of depression in both degree and speed of symptom reduction; group difference peaked at 4 months. The effects on depression were not significant among patients with minor depression unless suicidal ideation was present. Evidence of the intervention's effectiveness in community-based primary care with a heterogeneous sample of depressed patients introduces new challenges related to its sustainability and dissemination. The intervention's effectiveness in reducing suicidal ideation, regardless of depression severity, reinforces its role as a prevention strategy to reduce risk factors for suicide in late life.

Cost-Effectiveness of Collaborative Care for Depression in UK Primary Care: Economic Evaluation of a Randomised Controlled Trial (CADET)

PubMed Central

Green, Colin; Richards, David A.; Hill, Jacqueline J.; Gask, Linda; Lovell, Karina; Chew-Graham, Carolyn; Bower, Peter; Cape, John; Pilling, Stephen; Araya, Ricardo; Kessler, David; Bland, J. Martin; Gilbody, Simon; Lewis, Glyn; Manning, Chris; Hughes-Morley, Adwoa; Barkham, Michael

2014-01-01

Background Collaborative care is an effective treatment for the management of depression but evidence on its cost-effectiveness in the UK is lacking. Aims To assess the cost-effectiveness of collaborative care in a UK primary care setting. Methods An economic evaluation alongside a multi-centre cluster randomised controlled trial comparing collaborative care with usual primary care for adults with depression (n = 581). Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER) were calculated over a 12-month follow-up, from the perspective of the UK National Health Service and Personal Social Services (i.e. Third Party Payer). Sensitivity analyses are reported, and uncertainty is presented using the cost-effectiveness acceptability curve (CEAC) and the cost-effectiveness plane. Results The collaborative care intervention had a mean cost of £272.50 per participant. Health and social care service use, excluding collaborative care, indicated a similar profile of resource use between collaborative care and usual care participants. Collaborative care offered a mean incremental gain of 0.02 (95% CI: –0.02, 0.06) quality-adjusted life-years over 12 months, at a mean incremental cost of £270.72 (95% CI: –202.98, 886.04), and resulted in an estimated mean cost per QALY of £14,248. Where costs associated with informal care are considered in sensitivity analyses collaborative care is expected to be less costly and more effective, thereby dominating treatment as usual. Conclusion Collaborative care offers health gains at a relatively low cost, and is cost-effective compared with usual care against a decision-maker willingness to pay threshold of £20,000 per QALY gained. Results here support the commissioning of collaborative care in a UK primary care setting. PMID:25121991

Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention

PubMed Central

2012-01-01

Background The top 3% of frequent attendance in primary care is associated with 15% of all appointments in primary care, a fivefold increase in hospital expenditure, and more mental disorder and functional somatic symptoms compared to normal attendance. Although often temporary if these rates of attendance last more than two years, they may become persistent (persistent frequent or regular attendance). However, there is no long-term study of the economic impact or clinical characteristics of regular attendance in primary care. Cognitive behaviour formulation and treatment (CBT) for regular attendance as a motivated behaviour may offer an understanding of the development, maintenance and treatment of regular attendance in the context of their health problems, cognitive processes and social context. Methods/design A case control design will compare the clinical characteristics, patterns of health care use and economic costs over the last 10 years of 100 regular attenders (≥30 appointments with general practitioner [GP] over 2 years) with 100 normal attenders (6–22 appointments with GP over 2 years), from purposefully selected primary care practices with differing organisation of care and patient demographics. Qualitative interviews with regular attending patients and practice staff will explore patient barriers, drivers and experiences of consultation, and organisation of care by practices with its challenges. Cognitive behaviour formulation analysed thematically will explore the development, maintenance and therapeutic opportunities for management in regular attenders. The feasibility, acceptability and utility of CBT for regular attendance will be examined. Discussion The health care costs, clinical needs, patient motivation for consultation and organisation of care for persistent frequent or regular attendance in primary care will be explored to develop training and policies for service providers. CBT for regular attendance will be piloted with a view to developing this approach as part of a multifaceted intervention. PMID:22607525

Antibiotics for URTI and UTI -- prescribing in Malaysian primary care settings.

PubMed

Teng, Cheong Lieng; Tong, Seng Fah; Khoo, Ee Ming; Lee, Verna; Zailinawati, Abu Hassan; Mimi, Omar; Chen, Wei Seng; Nordin, Salleh

2011-05-01

Overprescription of antibiotics is a continuing problem in primary care. This study aims to assess the antibiotic prescribing rates and antibiotic choices for upper respiratory tract infections (URTI) and urinary tract infections (UTI) in Malaysian primary care. Antibiotic prescribing data for URTI and UTI was extracted from a morbidity survey of randomly selected primary care clinics in Malaysia. Analysis was performed of 1,163 URTI and 105 UTI encounters. Antibiotic prescribing rates for URTI and UTI were 33.8% and 57.1% respectively. Antibiotic prescribing rates were higher in private clinics compared to public clinics for URTI, but not for UTI. In URTI encounters, the majority of antibiotics prescribed were penicillins and macrolides, but penicillin V was notably underused. In UTI encounters, the antibiotics prescribed were predominantly penicillins or cotrimoxazole. Greater effort is needed to bring about evidence based antibiotic prescribing in Malaysian primary care, especially for URTIs in private clinics.

Cost-effectiveness of cognitive-behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: economic evaluation of the CoBalT Trial.

PubMed

Hollinghurst, Sandra; Carroll, Fran E; Abel, Anna; Campbell, John; Garland, Anne; Jerrom, Bill; Kessler, David; Kuyken, Willem; Morrison, Jill; Ridgway, Nicola; Thomas, Laura; Turner, Katrina; Williams, Chris; Peters, Tim J; Lewis, Glyn; Wiles, Nicola

2014-01-01

Depression is expensive to treat, but providing ineffective treatment is more expensive. Such is the case for many patients who do not respond to antidepressant medication. To assess the cost-effectiveness of cognitive-behavioural therapy (CBT) plus usual care for primary care patients with treatment-resistant depression compared with usual care alone. Economic evaluation at 12 months alongside a randomised controlled trial. Cost-effectiveness assessed using a cost-consequences framework comparing cost to the health and social care provider, patients and society, with a range of outcomes. Cost-utility analysis comparing health and social care costs with quality-adjusted life-years (QALYs). The mean cost of CBT per participant was £910. The difference in QALY gain between the groups was 0.057, equivalent to 21 days a year of good health. The incremental cost-effectiveness ratio was £14 911 (representing a 74% probability of the intervention being cost-effective at the National Institute of Health and Care Excellence threshold of £20 000 per QALY). Loss of earnings and productivity costs were substantial but there was no evidence of a difference between intervention and control groups. The addition of CBT to usual care is cost-effective in patients who have not responded to antidepressants. Primary care physicians should therefore be encouraged to refer such individuals for CBT.

Hypochondriasis and panic disorder. Boundary and overlap.

PubMed

Barsky, A J; Barnett, M C; Cleary, P D

1994-11-01

To determine the nosological and phenomenological overlap and boundaries between panic disorder and hypochondriasis, we compared the symptoms, disability, comorbidity, and medical care of primary care patients with each diagnosis. Patients with DSM-III-R panic disorder were recruited by screening consecutive primary care clinic attenders and then administering a structured diagnostic interview for panic disorder. Patients also completed self-report questionnaires, and their primary care physicians completed questionnaires about them. They were then compared with patients with DSM-III-R hypochondriasis from the same setting who had been studied previously. One thousand six hundred thirty-four patients were screened; 135 (71.0% of the 190 eligible patients) completed the research battery; 100 met lifetime panic disorder criteria. Twenty-five of these had comorbid hypochondriasis. Those without comorbid hypochondriasis (n = 75) were then compared with patients with hypochondriasis without comorbid panic disorder (n = 51). Patients with panic disorder were less hypochondriacal (P < .001), somatized less (P < .05), were less disabled (P < .001), were more satisfied with their medical care (P < .001), and were rated by their physicians as less help rejecting (P < .05) and less demanding (P < .01). Major depression was more prevalent in the group with panic disorder (66.7% vs 45.1%; P < .05), as were phobias (76.0% vs 37.3%; P < .001), but somatization disorder symptoms (P < .0001) and generalized anxiety disorder were less prevalent (74.5% vs 16.0%; P < .001) in panic disorder than was hypochondriasis. While hypochondriasis and panic disorder co-occur to some extent in a primary care population, the overlap is by no means complete. These patients are phenomenologically and functionally differentiable and distinct and are viewed differently by their primary care physicians.

Verbal Communication among Alzheimer’s Disease Patients, their Caregivers, and Primary Care Physicians during Primary Care Office Visits

PubMed Central

Schmidt, Karen L.; Lingler, Jennifer H.; Schulz, Richard

2009-01-01

Objective Primary care visits of patients with Alzheimer’s disease (AD) often involve communication among patients, family caregivers, and primary care physicians (PCPs). The objective of this study was to understand the nature of each individual’s verbal participation in these triadic interactions. Methods To define the verbal communication dynamics of AD care triads, we compared verbal participation (percent of total visit speech) by each participant in patient/caregiver/PCP triads. Twenty three triads were audio taped during a routine primary care visit. Rates of verbal participation were described and effects of patient cognitive status (MMSE score, verbal fluency) on verbal participation were assessed. Results PCP verbal participation was highest at 53% of total visit speech, followed by caregivers (31%) and patients (16%). Patient cognitive measures were related to patient and caregiver verbal participation, but not to PCP participation. Caregiver satisfaction with interpersonal treatment by PCP was positively related to caregiver’s own verbal participation. Conclusion Caregivers of AD patients and PCPs maintain active, coordinated verbal participation in primary care visits while patients participate less. Practice Implications Encouraging verbal participation by AD patients and their caregivers may increase the AD patient’s active role and caregiver satisfaction with primary care visits. PMID:19395224

Diabetes Care Management Teams Did Not Reduce Utilization When Compared With Traditional Care: A Randomized Cluster Trial.

PubMed

Kearns, Patrick

2017-10-01

PURPOSE: Health services research evaluates redesign models for primary care. Care management is one alternative. Evaluation includes resource utilization as a criterion. Compare the impact of care-manager teams on resource utilization. The comparison includes entire panes of patients and the subset of patients with diabetes. DESIGN: Randomized, prospective, cohort study comparing change in utilization rates between groups, pre- and post-intervention. METHODOLOGY: Ten primary care physician panels in a safety-net setting. Ten physicians were randomized to either a care-management approach (Group 1) or a traditional approach (Group 2). Care managers focused on diabetes and the cardiovascular cluster of diseases. Analysis compared rates of hospitalization, 30-day readmission, emergency room visits, and urgent care visits. Analysis compared baseline rates to annual rates after a yearlong run-in for entire panels and the subset of patients with diabetes. RESULTS: Resource utilization showed no statistically significant change between baseline and Year 3 (P=.79). Emergency room visits and hospital readmission increased for both groups (P=.90), while hospital admissions and urgent care visits decreased (P=.73). Similarly, utilization was not significantly different for patients with diabetes (P=.69). CONCLUSIONS: A care-management team approach failed to improve resource utilization rates by entire panels and the subset of diabetic patients compared to traditional care. This reinforces the need for further evidentiary support for the care-management model's hypothesis in the safety net.

Guideline-conforming timing of invasive management in troponin-positive or high-risk ACS without persistent ST-segment elevation in German chest pain units. Urban university maximum care vs. rural regional primary care.

PubMed

Breuckmann, F; Remberg, F; Böse, D; Lichtenberg, M; Kümpers, P; Pavenstädt, H; Waltenberger, J; Fischer, D

2016-03-01

This study aimed to analyze guideline adherence in the timing of invasive management for myocardial infarction without persistent ST-segment elevation (NSTEMI) in two exemplary German centers, comparing an urban university maximum care facility and a rural regional primary care facility. All patients diagnosed as having NSTEMI during 2013 were retrospectively enrolled in two centers: (1) site I, a maximum care center in an urban university setting, and (b) site II, a primary care center in a rural regional care setting. Data acquisition included time intervals from admission to invasive management, risk criteria, rate of intervention, and medical therapy. The median time from admission to coronary angiography was 12.0 h (site I) or 17.5 h (site II; p = 0.17). Guideline-adherent timing was achieved in 88.1 % (site I) or 82.9 % (site II; p = 0.18) of cases. Intervention rates were high in both sites (site I-75.5 % vs. site II-75.3 %; p = 0.85). Adherence to recommendations of medical therapy was high and comparable between the two sites. In NSTEMI or high-risk acute coronary syndromes without persistent ST-segment elevation, guideline-adherent timing of invasive management was achieved in about 85 % of cases, and was comparable between urban maximum and rural primary care settings. Validation by the German Chest Pain Unit Registry including outcome analysis is required.

Increase in antibiotic prescriptions in out-of-hours primary care in contrast to in-hours primary care prescriptions: service evaluation in a population of 600 000 patients

PubMed Central

Hayward, G. N.; Fisher, R. F. R.; Spence, G. T.; Lasserson, D. S.

2016-01-01

Objectives The objective of this study was to describe the frequency and nature of antibiotic prescriptions issued by a primary care out-of-hours (OOH) service and compare time trends in prescriptions between OOH and in-hours primary care. Methods We performed a retrospective audit of 496 931 patient contacts with the Oxfordshire OOH primary care service. Comparison of time trends in antibiotic prescriptions from OOH primary care and in-hours primary care for the same population was made using multiple linear regression models fitted to the monthly data for OOH prescriptions, OOH contacts and in-hours prescriptions between September 2010 and August 2014. Results Compared with the overall population contacting the OOH service, younger age, female sex and patients who were less deprived were independently correlated with an increased chance of a contact resulting in prescription of antibiotics. The majority of antibiotics were prescribed to patients contacting the service at weekends. Despite a reduction in patient contacts with the OOH service [an estimated decrease of 486.5 monthly contacts each year (95% CI −676.3 to −296.8), 5.0% of the average monthly contacts], antibiotic prescriptions from this service rose during the study period [increase of 37.1 monthly prescriptions each year (95% CI 10.6–63.7), 2.5% of the average monthly prescriptions]. A matching increase was not seen for in-hours antibiotic prescriptions; the difference between the year trends was significant (Z test, P = 0.002). Conclusions We have demonstrated trends in prescribing that could represent a partial displacement of antibiotic prescribing from in-hours to OOH primary care. The possibility that the trends we describe are evident nationally should be explored. PMID:27287234

Increase in antibiotic prescriptions in out-of-hours primary care in contrast to in-hours primary care prescriptions: service evaluation in a population of 600 000 patients.

PubMed

Hayward, G N; Fisher, R F R; Spence, G T; Lasserson, D S

2016-09-01

The objective of this study was to describe the frequency and nature of antibiotic prescriptions issued by a primary care out-of-hours (OOH) service and compare time trends in prescriptions between OOH and in-hours primary care. We performed a retrospective audit of 496 931 patient contacts with the Oxfordshire OOH primary care service. Comparison of time trends in antibiotic prescriptions from OOH primary care and in-hours primary care for the same population was made using multiple linear regression models fitted to the monthly data for OOH prescriptions, OOH contacts and in-hours prescriptions between September 2010 and August 2014. Compared with the overall population contacting the OOH service, younger age, female sex and patients who were less deprived were independently correlated with an increased chance of a contact resulting in prescription of antibiotics. The majority of antibiotics were prescribed to patients contacting the service at weekends. Despite a reduction in patient contacts with the OOH service [an estimated decrease of 486.5 monthly contacts each year (95% CI -676.3 to -296.8), 5.0% of the average monthly contacts], antibiotic prescriptions from this service rose during the study period [increase of 37.1 monthly prescriptions each year (95% CI 10.6-63.7), 2.5% of the average monthly prescriptions]. A matching increase was not seen for in-hours antibiotic prescriptions; the difference between the year trends was significant (Z test, P = 0.002). We have demonstrated trends in prescribing that could represent a partial displacement of antibiotic prescribing from in-hours to OOH primary care. The possibility that the trends we describe are evident nationally should be explored. © The Author 2016. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Counting on commitment; the quality of primary care-led diabetes management in a system with minimal incentives

PubMed Central

2011-01-01

Background The aim of the present study was to assess the performance of three primary care-led initiatives providing structured care to patients with Type 2 diabetes in Ireland, a country with minimal incentives to promote the quality of care. Methods Data, from three primary care initiatives, were available for 3010 adult patients with Type 2 diabetes. Results were benchmarked against the national guidelines for the management of Type 2 diabetes in the community and results from the National Diabetes Audit (NDA) for England (2008/2009) and the Scottish Diabetes Survey (2009). Results The recording of clinical processes of care was similar to results in the UK however the recording of lifestyle factors was markedly lower. Recording of HbA1c, blood pressure and lipids exceeded 85%. Recording of retinopathy screening (71%) was also comparable to England (77%) and Scotland (90%). Only 63% of patients had smoking status recorded compared to 99% in Scotland while 70% had BMI recorded compared to 89% in England. A similar proportion of patients in this initiative and the UK achieved clinical targets. Thirty-five percent of patients achieved a target HbA1c of < 6.5% (< 48 mmol/mol) compared to 25% in England. Applying the NICE target for blood pressure (≤ 140/80 mmHg), 54% of patients reached this target comparable to 60% in England. Slightly less patients were categorised as obese (> 30 kg/m2) in Ireland (50%, n = 1060) compared to Scotland (54%). Conclusions This study has demonstrated what can be achieved by proactive and interested health professionals in the absence of national infrastructure to support high quality diabetes care. The quality of primary care-led diabetes management in the three initiatives studied appears broadly consistent with results from the UK with the exception of recording lifestyle factors. The challenge facing health systems is to establish quality assurance a responsibility for all health care professionals rather than the subject of special interest for a few. PMID:22204759

Immigrants' use of primary health care services for mental health problems.

PubMed

Straiton, Melanie; Reneflot, Anne; Diaz, Esperanza

2014-08-13

Equity in health care across all social groups is a major goal in health care policy. Immigrants may experience more mental health problems than natives, but we do not know the extent to which they seek help from primary health care services. This study aimed to determine a) the rate immigrants use primary health care services for mental health problems compared with Norwegians and b) the association between length of stay, reason for immigration and service use among immigrants. National register data covering all residents in Norway and all consultations with primary health care services were used. We conducted logistic regression analyses to compare Norwegians' with Polish, Swedish, German, Pakistani and Iraqi immigrants' odds of having had a consultation for a mental health problem (P-consultation). After accounting for background variables, all immigrants groups, except Iraqi men had lower odds of a P-consultation than their Norwegian counterparts. A shorter length of stay was associated with lower odds of a P-consultation. Service use varies by country of origin and patterns are different for men and women. There was some evidence of a possible 'healthy migrant worker' effect among the European groups. Together with previous research, our findings however, suggest that Iraqi women and Pakistanis in particular, may experience barriers in accessing care for mental health problems.

OECD Health Care Quality Indicator Project. The expert panel on primary care prevention and health promotion.

PubMed

Marshall, Martin; Klazinga, Niek; Leatherman, Sheila; Hardy, Charlie; Bergmann, Eckhard; Pisco, Luis; Mattke, Soeren; Mainz, Jan

2006-09-01

This article describes a project undertaken as part of the Organization for Economic Co-operation and Development (OECD)'s Healthcare Quality Indicator (HCQI) Project, which aimed to develop a set of quality indicators representing the domains of primary care, prevention and health promotion, and which could be used to assess the performance of primary care systems. Existing quality indicators from around the world were mapped to an organizing framework which related primary care, prevention, and health promotion. The indicators were judged against the US Institute of Medicine's assessment criteria of importance and scientific soundness, and only those which met these criteria and were likely to be feasible were included. An initial large set of indicators was reduced by the primary care expert panel using a modified Delphi process. A set of 27 indicators was produced. Six of them were related to health promotion, covering health-related behaviours that are typically targeted by health education and outreach campaigns, 13 to preventive care with a focus on prenatal care and immunizations and eight to primary clinical care mainly addressing activities related to risk reduction. The indicators selected placed a strong emphasis on the public health aspects of primary care. This project represents an important but preliminary step towards a set of measures to evaluate and compare primary care quality. Further work is required to assess the operational feasibility of the indicators and the validity of any benchmarking data drawn from international comparisons. A conceptual framework needs to be developed that comprehensively captures the complex construct of primary care as a basis for the selection of additional indicators.

Identification, summary and comparison of tools used to measure organizational attributes associated with chronic disease management within primary care settings

PubMed Central

Lukewich, Julia; Corbin, Renée; VanDenKerkhof, Elizabeth G; Edge, Dana S; Williamson, Tyler; Tranmer, Joan E

2014-01-01

Rationale, aims and objectives Given the increasing emphasis being placed on managing patients with chronic diseases within primary care, there is a need to better understand which primary care organizational attributes affect the quality of care that patients with chronic diseases receive. This study aimed to identify, summarize and compare data collection tools that describe and measure organizational attributes used within the primary care setting worldwide. Methods Systematic search and review methodology consisting of a comprehensive and exhaustive search that is based on a broad question to identify the best available evidence was employed. Results A total of 30 organizational attribute data collection tools that have been used within the primary care setting were identified. The tools varied with respect to overall focus and level of organizational detail captured, theoretical foundations, administration and completion methods, types of questions asked, and the extent to which psychometric property testing had been performed. The tools utilized within the Quality and Costs of Primary Care in Europe study and the Canadian Primary Health Care Practice-Based Surveys were the most recently developed tools. Furthermore, of the 30 tools reviewed, the Canadian Primary Health Care Practice-Based Surveys collected the most information on organizational attributes. Conclusions There is a need to collect primary care organizational attribute information at a national level to better understand factors affecting the quality of chronic disease prevention and management across a given country. The data collection tools identified in this review can be used to establish data collection strategies to collect this important information. PMID:24840066

Factors affecting cardiac rehabilitation referral by physician specialty.

PubMed

Grace, Sherry L; Grewal, Keerat; Stewart, Donna E

2008-01-01

Cardiac rehabilitation (CR) is widely underutilized because of multiple factors including physician referral practices. Previous research has shown CR referral varies by type of provider, with cardiologists more likely to refer than primary care physicians. The objective of this study was to compare factors affecting CR referral in primary care physicians versus cardiac specialists. A cross-sectional survey of a stratified random sample of 510 primary care physicians and cardiac specialists (cardiologists or cardiovascular surgeons) in Ontario identified through the Canadian Medical Directory Online was administered. One hundred four primary care physicians and 81 cardiac specialists responded to the 26-item investigator-generated survey examining medical, demographic, attitudinal, and health system factors affecting CR referral. Primary care physicians were more likely to endorse lack of familiarity with CR site locations (P < .001), lack of standardized referral forms (P < .001), inconvenience (P = .04), program quality (P = .004), and lack of discharge communication from CR (P = .001) as factors negatively impacting CR referral practices than cardiac specialists. Cardiac specialists were significantly more likely to perceive that their colleagues and department would regularly refer patients to CR than primary care physicians (P < .001). Where differences emerged, primary care physicians were more likely to perceive factors that would impede CR referral, some of which are modifiable. Marketing CR site locations, provision of standardized referral forms, and ensuring discharge summaries are communicated to primary care physicians may improve their willingness to refer to CR.

Do baby boomers use more healthcare services than other generations? Longitudinal trajectories of physician service use across five birth cohorts

PubMed Central

Canizares, Mayilee; Gignac, Monique; Hogg-Johnson, Sheilah; Glazier, Richard H; Badley, Elizabeth M

2016-01-01

Objective In light of concerns for meeting the provision of healthcare services given the large numbers of ageing baby boomers, we compared the trajectories of primary care and specialist services use across the lifecourse of 5 birth cohorts and examined factors associated with birth cohort differences. Design Longitudinal panel. Setting Canadian National Population Health Survey (1994–2011). Population Sample of 10 186 individuals aged 20–69 years in 1994–1995 and who were from 5 birth cohorts: Generation X (Gen X; born: 1965–1974), Younger Baby Boomers (born: 1955–1964), Older Baby Boomers (born: 1945–1954), World War II (born: 1935–1944) and pre-World War II (born: 1925–1934). Main outcomes Use of primary care and specialist services. Results Although the overall pattern suggested less use of physician services by each successive recent cohort, this blinded differences in primary and specialist care use by cohort. Multilevel analyses comparing cohorts showed that Gen Xers and younger boomers, particularly those with multimorbidity, were less likely to use primary care than earlier cohorts. In contrast, specialist use was higher in recent cohorts, with Gen Xers having the highest specialist use. These increases were explained by the increasing levels of multimorbidity. Education, income, having a regular source of care, sedentary lifestyle and obesity were significantly associated with physician services use, but only partially contributed to cohort differences. Conclusions The findings suggest a shift from primary care to specialist care among recent cohorts, particularly for those with multimorbidity. This is of concern given policies to promote primary care services to prevent and manage chronic conditions. There is a need for policies to address important generational differences in healthcare preferences and the balance between primary and specialty care to ensure integration and coordination of healthcare delivery. PMID:27687902

Primary care and health inequality: Difference-in-difference study comparing England and Ontario

PubMed Central

Cookson, Richard; Mondor, Luke; Kringos, Dionne S.; Klazinga, Niek S.

2017-01-01

Background It is not known whether equity-oriented primary care investment that seeks to scale up the delivery of effective care in disadvantaged communities can reduce health inequality within high-income settings that have pre-existing universal primary care systems. We provide some non-randomised controlled evidence by comparing health inequality trends between two similar jurisdictions–one of which implemented equity-oriented primary care investment in the mid-to-late 2000s as part of a cross-government strategy for reducing health inequality (England), and one which invested in primary care without any explicit equity objective (Ontario, Canada). Methods We analysed whole-population data on 32,482 neighbourhoods (with mean population size of approximately 1,500 people) in England, and 18,961 neighbourhoods (with mean population size of approximately 700 people) in Ontario. We examined trends in mortality amenable to healthcare by decile groups of neighbourhood deprivation within each jurisdiction. We used linear models to estimate absolute and relative gaps in amenable mortality between most and least deprived groups, considering the gradient between these extremes, and evaluated difference-in-difference comparisons between the two jurisdictions. Results Inequality trends were comparable in both jurisdictions from 2004–6 but diverged from 2007–11. Compared with Ontario, the absolute gap in amenable mortality in England fell between 2004–6 and 2007–11 by 19.8 per 100,000 population (95% CI: 4.8 to 34.9); and the relative gap in amenable mortality fell by 10 percentage points (95% CI: 1 to 19). The biggest divergence occurred in the most deprived decile group of neighbourhoods. Discussion In comparison to Ontario, England succeeded in reducing absolute socioeconomic gaps in mortality amenable to healthcare from 2007 to 2011, and preventing them from growing in relative terms. Equity-oriented primary care reform in England in the mid-to-late 2000s may have helped to reduce socioeconomic inequality in health, though other explanations for this divergence are possible and further research is needed on the specific causal mechanisms. PMID:29182652

Aligning population-based care management with chronic disease complexity.

PubMed

Hewner, Sharon; Seo, Jin Young; Gothard, Sandra E; Johnson, Barbara J

2014-01-01

Risk-stratified care management requires knowledge of the complexity of chronic disease and comorbidity, information that is often not readily available in the primary care setting. The purpose of this article was to describe a population-based approach to risk-stratified care management that could be applied in primary care. Three populations (Medicaid, Medicare, and privately insured) at a regional health plan were divided into risk-stratified cohorts based on chronic disease and complexity, and utilization was compared before and after the implementation of population-specific care management teams of nurses. Risk-stratified care management was associated with reductions in hospitalization rates in all three populations, but the opportunities to avoid admissions were different. Knowledge of population complexity is critical to the development of risk-stratified care management in primary care, and a complexity matrix can help nurses identify gaps in care and align interventions to cohort and population needs. Copyright © 2014 Elsevier Inc. All rights reserved.

The contribution of dietitians to the primary health care workforce.

PubMed

Howatson, Alexandra; Wall, Clare R; Turner-Benny, Petrina

2015-12-01

Dietetic intervention is effective in the management of nutrition-related conditions and their comorbidities. New Zealand has an increasing need for primary and preventive health care to reduce the burden of non-communicable disease. To review the recent evidence of effectiveness of dietetic intervention in primary health care on health and wider economic outcomes. Health benefits and cost benefits of employing dietitians to perform nutrition intervention in the primary health care setting are evaluated in the areas of obesity in conjunction with diabetes and cardiovascular disease, and malnutrition in older adults. An electronic literature search of four scientific databases, websites of major dietetic associations and high-impact nutrition and dietetic journals was conducted. Randomised controlled trials and non-randomised studies conducted from 2000 to 2014 were included. Dietetic intervention demonstrates statistically and clinically significant impacts on health outcomes in the areas of obesity, cardiovascular disease, diabetes, and malnutrition in older adults, when compared to usual care. Dietitians working in primary health care can also have significant economic benefits, potentially saving the health care system NZ$5.50-$99 for every NZ$1 spent on dietetic intervention. New Zealand must look to new models of health care provision that are not only patient-centred but are also cost-effective. This review demonstrates that dietitians in primary health care can improve patients' health and quality of life. Increasing the number of dietitians working in primary health care has the potential to make quality nutrition care accessible and affordable for more New Zealanders.

Suicide risk in primary care: identification and management in older adults.

PubMed

Raue, Patrick J; Ghesquiere, Angela R; Bruce, Martha L

2014-09-01

The National Strategy for Suicide Prevention (2012) has set a goal to reduce suicides by 20% within 5 years. Suicide rates are higher in older adults compared to most other age groups, and the majority of suicide completers have visited their primary care physician in the year before suicide. Primary care is an ideal setting to identify suicide risk and initiate mental health care. We review risk factors for late-life suicide; methods to assess for different levels of suicidality; and recent research developments regarding both effective assessment and management of suicide risk among older primary care patients. We highlight that broader scale screening of suicide risk may be considered in light of findings that suicidality can occur even in the absence of major risk factors like depression. We also highlight collaborative care models targeting suicide risk, and recent innovative interventions that aim to prevent the development of suicidal ideation and suicidal behavior.

Suicide Risk in Primary Care: Identification and Management in Older Adults

PubMed Central

Raue, Patrick J.; Ghesquiere, Angela R.; Bruce, Martha L.

2014-01-01

The National Strategy for Suicide Prevention (2012) has set a goal to reduce suicides by 20% within 5 years. Suicide rates are higher in older adults compared to most other age groups, and the majority of suicide completers have visited their primary care physician in the year before suicide. Primary care is an ideal setting to identify suicide risk and initiate mental health care. We review risk factors for late-life suicide; methods to assess for different levels of suicidality; and recent research developments regarding both effective assessment and management of suicide risk among older primary care patients. We highlight that broader scale screening of suicide risk may be considered in light of findings that suicidality can occur even in the absence of major risk factors like depression. We also highlight collaborative care models targeting suicide risk, and recent innovative interventions that aim to prevent the development of suicidal ideation and suicidal behavior. PMID:25030971

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.

A Computerized Decision Support System for Depression in Primary Care

PubMed Central

Kurian, Benji T.; Trivedi, Madhukar H.; Grannemann, Bruce D.; Claassen, Cynthia A.; Daly, Ella J.; Sunderajan, Prabha

2009-01-01

Objective: In 2004, results from The Texas Medication Algorithm Project (TMAP) showed better clinical outcomes for patients whose physicians adhered to a paper-and-pencil algorithm compared to patients who received standard clinical treatment for major depressive disorder (MDD). However, implementation of and fidelity to the treatment algorithm among various providers was observed to be inadequate. A computerized decision support system (CDSS) for the implementation of the TMAP algorithm for depression has since been developed to improve fidelity and adherence to the algorithm. Method: This was a 2-group, parallel design, clinical trial (one patient group receiving MDD treatment from physicians using the CDSS and the other patient group receiving usual care) conducted at 2 separate primary care clinics in Texas from March 2005 through June 2006. Fifty-five patients with MDD (DSM-IV criteria) with no significant difference in disease characteristics were enrolled, 32 of whom were treated by physicians using CDSS and 23 were treated by physicians using usual care. The study's objective was to evaluate the feasibility and efficacy of implementing a CDSS to assist physicians acutely treating patients with MDD compared to usual care in primary care. Primary efficacy outcomes for depression symptom severity were based on the 17-item Hamilton Depression Rating Scale (HDRS17) evaluated by an independent rater. Results: Patients treated by physicians employing CDSS had significantly greater symptom reduction, based on the HDRS17, than patients treated with usual care (P < .001). Conclusions: The CDSS algorithm, utilizing measurement-based care, was superior to usual care for patients with MDD in primary care settings. Larger randomized controlled trials are needed to confirm these findings. Trial Registration: clinicaltrials.gov Identifier: NCT00551083 PMID:19750065

A computerized decision support system for depression in primary care.

PubMed

Kurian, Benji T; Trivedi, Madhukar H; Grannemann, Bruce D; Claassen, Cynthia A; Daly, Ella J; Sunderajan, Prabha

2009-01-01

In 2004, results from The Texas Medication Algorithm Project (TMAP) showed better clinical outcomes for patients whose physicians adhered to a paper-and-pencil algorithm compared to patients who received standard clinical treatment for major depressive disorder (MDD). However, implementation of and fidelity to the treatment algorithm among various providers was observed to be inadequate. A computerized decision support system (CDSS) for the implementation of the TMAP algorithm for depression has since been developed to improve fidelity and adherence to the algorithm. This was a 2-group, parallel design, clinical trial (one patient group receiving MDD treatment from physicians using the CDSS and the other patient group receiving usual care) conducted at 2 separate primary care clinics in Texas from March 2005 through June 2006. Fifty-five patients with MDD (DSM-IV criteria) with no significant difference in disease characteristics were enrolled, 32 of whom were treated by physicians using CDSS and 23 were treated by physicians using usual care. The study's objective was to evaluate the feasibility and efficacy of implementing a CDSS to assist physicians acutely treating patients with MDD compared to usual care in primary care. Primary efficacy outcomes for depression symptom severity were based on the 17-item Hamilton Depression Rating Scale (HDRS(17)) evaluated by an independent rater. Patients treated by physicians employing CDSS had significantly greater symptom reduction, based on the HDRS(17), than patients treated with usual care (P < .001). The CDSS algorithm, utilizing measurement-based care, was superior to usual care for patients with MDD in primary care settings. Larger randomized controlled trials are needed to confirm these findings. clinicaltrials.gov Identifier: NCT00551083.

[Reducing stress levels and anxiety in primary-care physicians through training and practice of a mindfulness meditation technique].

PubMed

Franco Justo, Clemente

2010-11-01

To check the effectiveness of a mindfulness development meditation technique on stress and anxiety in a group of primary-care physicians. Quasi-experimental with pretest/posttest/follow-up measurements in a control group and an experimental group. SITE: University of Almeria. 38 primary-care physicians enrolled in a Teaching Aptitude Course (CAP). An experimental group and a control group were formed with 19 participants in each. The experimental group took a psycho-educational meditation program for training and practice in mindfulness. The Perceived Stress Scale (PSS), the Strain Questionnaire and the State-Trait Anxiety Questionnaire were used to measure stress and anxiety levels. A comparative statistical analysis was performed using the Mann-Whitney non-parametric U test, finding a significant reduction in all the primary-care physician stress and anxiety variables in the experimental group compared to the control group in pretest-posttest and follow-up tests. The results of this study support the effectiveness of mindfulness development meditation techniques in decreasing stress and anxiety in primary-care physicians. Nevertheless, the study shows various limitations that would have to be corrected in successive studies to bring more validity to the results. Copyright © 2009 Elsevier España, S.L. All rights reserved.

Retail clinic visits and receipt of primary care.

PubMed

Reid, Rachel O; Ashwood, J Scott; Friedberg, Mark W; Weber, Ellerie S; Setodji, Claude M; Mehrotra, Ateev

2013-04-01

An increasing number of patients are visiting retail clinics for simple acute conditions. Physicians worry that visits to retail clinics will interfere with primary care relationships. No prior study has evaluated the impact of retail clinics on receipt of primary care. To assess the association between retail clinic use and receipt of key primary care functions. We performed a retrospective cohort analysis using commercial insurance claims from 2007 to 2009. We identified patients who had a visit for a simple acute condition in 2008, the "index visit". We divided these 127,358 patients into two cohorts according to the location of that index visit: primary care provider (PCP) versus retail clinic. We evaluated three functions of primary care: (1) where patients first sought care for subsequent simple acute conditions; (2) continuity of care using the Bice-Boxerman index; and (3) preventive care and diabetes management. Using a difference-in-differences approach, we compared care received in the 365 days following the index visit to care received in the 365 days prior, using propensity score weights to account for selection bias. Visiting a retail clinic instead of a PCP for the index visit was associated with a 27.7 visits per 100 patients differential reduction (p < 0 .001) in subsequent PCP visits for new simple acute conditions. Visiting a retail clinic instead of a PCP was also associated with decreased subsequent continuity of care (10.9 percentage-point differential reduction in Bice-Boxerman index, p < 0 .001). There was no differential change between the cohorts in receipt of preventive care or diabetes management. Retail clinics may disrupt two aspects of primary care: whether patients go to a PCP first for new conditions and continuity of care. However, they do not negatively impact preventive care or diabetes management.

Spatial accessibility of primary health care in China: A case study in Sichuan Province.

PubMed

Wang, Xiuli; Yang, Huazhen; Duan, Zhanqi; Pan, Jay

2018-05-10

Access to primary health care is considered a fundamental right and an important facilitator of overall population health. Township health centers (THCs) and Community health centers (CHCs) serve as central hubs of China's primary health care system and have been emphasized during recent health care reforms. Accessibility of these hubs is poorly understood and a better understanding of the current situation is essential for proper decision making. This study assesses spatial access to health care provided by primary health care institutions (THCs/CHCs) in Sichuan Province as a microcosm in China. The Nearest-Neighbor method, Enhanced Two-Step Floating Catchment Area (E2SFCA) method, and Gini Coefficient are utilized to represent travel impedance, spatial accessibility, and disparity of primary health care resources (hospital beds, doctors, and health professionals). Accessibilities and Gini Coefficients are correlated with social development indexes (GDP, ethnicity, etc.) to identify influencing factors. Spatial access to primary health care is better in southeastern Sichuan compared to northwestern Sichuan in terms of shorter travel time, higher spatial accessibility, and lower inequity. Social development indexes all showed significant correlation with county averaged spatial accessibilities/Gini Coefficients, with population density ranking top. The disparity of access to primary health care is also apparent between ethnic minority and non-minority regions. To improve spatial access to primary health care and narrow the inequity, more township health centers staffed by qualified health professionals are recommended for northwestern Sichuan. Improved road networks will also help. Among areas with insufficient primary health care, the specific counties where demographics are dominated by older people and children due to widespread rural-urban migration of the workforce, and by ethnic minorities, should be especially emphasized in future planning. Copyright © 2018 Elsevier Ltd. All rights reserved.

Cost minimization analysis of low back pain claims data for chiropractic vs medicine in a managed care organization.

PubMed

Grieves, Brian; Menke, J Michael; Pursel, Kevin J

2009-01-01

A managed care organization (MCO) examined differences in allowed cost for managing low back pain by medical providers vs chiropractors in an integrated care environment. The purpose of this study is to provide a retrospective cost analysis of administrative data of chiropractic vs medical management of low back pain in a managed care setting. All patients with a low back pain-related diagnosis presenting for health care from January 2004 to June 2004 who were insured by an MCO in northeast Wisconsin were tracked. The cumulative health care costs incurred by this MCO during the 2-year period from January 2004 to December 2005 related to these back pain diagnoses were collected. Allowed costs of chiropractic treatment were 12% greater than medical primary care and 60% less per case than other types of medical care combined, on a per-case basis: median cost of medical primary care was $365.00, chiropractic care was $417.00, and medical nonprimary care was $669.00. This study of an MCO's low back pain allowed costs may be better redirected to primary care or chiropractic, given equivalent levels of case complexity. This study suggests chiropractic management as less expensive compared with medical management of back pain when care extends beyond primary care. Primary care management alone is virtually indistinguishable from chiropractic management in terms of costs.

The current state of cancer family history collection tools in primary care: a systematic review.

PubMed

Qureshi, Nadeem; Carroll, June C; Wilson, Brenda; Santaguida, Pasqualina; Allanson, Judith; Brouwers, Melissa; Raina, Parminder

2009-07-01

Systematic collection of family history is a prerequisite for identifying genetic risk. This study reviewed tools applicable to the primary care assessment of family history of breast, colorectal, ovarian, and prostate cancer. MEDLINE, EMBASE, CINAHL, and Cochrane Central were searched for publications. All primary study designs were included. Characteristics of the studies, the family history collection tools, and the setting were evaluated. Of 40 eligible studies, 18 relevant family history tools were identified, with 11 developed for use in primary care. Most collected information on more than one cancer and on affected relatives used self-administered questionnaires and paper-based formats. Eleven tools had been evaluated relative to current practice, demonstrating 46-78% improvement in data recording over family history recording in patient charts and 75-100% agreement with structured genetic interviews. Few tools have been developed specifically for primary care settings. The few that have been evaluated performed well. The very limited evidence, which depends in part on extrapolation from studies in settings other than primary care, suggests that systematic tools may add significant family health information compared with current primary care practice. The effect of their use on health outcomes has not been evaluated.

Effectiveness and Cost-effectiveness of Opportunistic Screening and Stepped-care Interventions for Older Alcohol Users in Primary Care.

PubMed

Coulton, Simon; Bland, Martin; Crosby, Helen; Dale, Veronica; Drummond, Colin; Godfrey, Christine; Kaner, Eileen; Sweetman, Jennifer; McGovern, Ruth; Newbury-Birch, Dorothy; Parrott, Steve; Tober, Gillian; Watson, Judith; Wu, Qi

2017-11-01

To compare the clinical effectiveness and cost-effectiveness of a stepped-care intervention versus a minimal intervention for the treatment of older hazardous alcohol users in primary care. Multi-centre, pragmatic RCT, set in Primary Care in UK. Patients aged ≥ 55 years scoring ≥ 8 on the Alcohol Use Disorders Identification Test were allocated either to 5-min of brief advice or to 'Stepped Care': an initial 20-min of behavioural change counselling, with Step 2 being three sessions of Motivational Enhancement Therapy and Step 3 referral to local alcohol services (progression between each Step being determined by outcomes 1 month after each Step). Outcome measures included average drinks per day, AUDIT-C, alcohol-related problems using the Drinking Problems Index, health-related quality of life using the Short Form 12, costs measured from a NHS/Personal Social Care perspective and estimated health gains in quality adjusted life-years measured assessed EQ-5D. Both groups reduced alcohol consumption at 12 months but the difference between groups was small and not significant. No significant differences were observed between the groups on secondary outcomes. In economic terms stepped care was less costly and more effective than the minimal intervention. Stepped care does not confer an advantage over a minimal intervention in terms of reduction in alcohol use for older hazardous alcohol users in primary care. However, stepped care has a greater probability of being more cost-effective. Current controlled trials ISRCTN52557360. A stepped care approach was compared with brief intervention for older at-risk drinkers attending primary care. While consumption reduced in both groups over 12 months there was no significant difference between the groups. An economic analysis indicated the stepped care which had a greater probability of being more cost-effective than brief intervention. © The Author 2017. Medical Council on Alcohol and Oxford University Press. All rights reserved.

EurOOHnet-the European research network for out-of-hours primary health care.

PubMed

Huibers, Linda; Philips, Hilde; Giesen, Paul; Remmen, Roy; Christensen, Morten Bondo; Bondevik, Gunnar Tschudi

2014-09-01

European countries face similar challenges in the provision of health care. Demographic factors like ageing, population growth, changing patient behaviour, and lack of work force lead to increasing demands, costs, and overcrowding of out-of-hours (OOH) care (i.e. primary care services, emergency departments (EDs), and ambulance services). These developments strain services and imply safety risks. In the last few decades, countries have been re-organizing their OOH primary health care services. AIM AND SCOPE OF THE NETWORK: We established a European research network for out-of-hours primary health care (EurOOHnet), which aims to transfer knowledge, share experiences, and conduct research. Combining research competencies and integrating results can generate a profound information flow to European researchers and decision makers in health policy, contributing towards feasible and high-quality OOH care. It also contributes to a more comparable performance level within European regions. CONDUCTED RESEARCH PROJECTS: The European research network aims to conduct mutual research projects. At present, three projects have been accomplished, among others concerning the diagnostic scope in OOH primary care services and guideline adherence for diagnosis and treatment of cystitis in OOH primary care. Future areas of research will be organizational models for OOH care; appropriate use of the OOH services; quality of telephone triage; quality of medical care; patient safety issues; use of auxiliary personnel; collaboration with EDs and ambulance care; and the role of GPs in OOH care.

Strengthening health human resources and improving clinical outcomes through an integrated guideline and educational outreach in resource-poor settings: a cluster-randomized trial.

PubMed

Schull, Michael J; Banda, Hastings; Kathyola, Damson; Fairall, Lara; Martiniuk, Alexandra; Burciul, Barry; Zwarenstein, Merrick; Sodhi, Sumeet; Thompson, Sandy; Joshua, Martias; Mondiwa, Martha; Bateman, Eric

2010-12-03

In low-income countries, only about a third of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) patients eligible for anti-retroviral treatment currently receive it. Providing decentralized treatment close to where patients live is crucial to a faster scale up, however, a key obstacle is limited health system capacity due to a shortage of trained health-care workers and challenges of integrating HIV/AIDS care with other primary care services (e.g. tuberculosis, malaria, respiratory conditions). This study will test an adapted primary care health care worker training and guideline intervention, Practical Approach to Lung Health and HIV/AIDS Malawi (PALM PLUS), on staff retention and satisfaction, and quality of patient care. A cluster-randomized trial design is being used to compare usual care with a standardized clinical guideline and training intervention, PALM PLUS. The intervention targets middle-cadre health care workers (nurses, clinical officers, medical assistants) in 30 rural primary care health centres in a single district in Malawi. PALM PLUS is an integrated, symptom-based and user-friendly guideline consistent with Malawian national treatment protocols. Training is standardized and based on an educational outreach approach. Trainers will be front-line peer healthcare workers trained to provide outreach training and support to their fellow front-line healthcare workers during focused (1-2 hours), intermittent, interactive sessions on-site in health centers. Primary outcomes are health care worker retention and satisfaction. Secondary outcomes are clinical outcomes measured at the health centre level for HIV/AIDS, tuberculosis, prevention-of-mother-to-child-transmission of HIV and other primary care conditions. Effect sizes and 95% confidence intervals for outcomes will be presented. Assessment of outcomes will occur at 1 year post- implementation. The PALM PLUS trial aims to address a key problem: strengthening middle-cadre health care workers to support the broader scale up of HIV/AIDS services and their integration into primary care. The trial will test whether the PALM PLUS intervention improves staff satisfaction and retention, as well as the quality of patient care, when compared to usual practice. Controlled Clinical Trials ISRCTN47805230.

Primary care careers among recent graduates of research-intensive private and public medical schools.

PubMed

Choi, Phillip A; Xu, Shuai; Ayanian, John Z

2013-06-01

Despite a growing need for primary care physicians in the United States, the proportion of medical school graduates pursuing primary care careers has declined over the past decade. To assess the association of medical school research funding with graduates matching in family medicine residencies and practicing primary care. Observational study of United States medical schools. One hundred twenty-one allopathic medical schools. The primary outcomes included the proportion of each school's graduates from 1999 to 2001 who were primary care physicians in 2008, and the proportion of each school's graduates who entered family medicine residencies during 2007 through 2009. The 25 medical schools with the highest levels of research funding from the National Institutes of Health in 2010 were designated as "research-intensive." Among research-intensive medical schools, the 16 private medical schools produced significantly fewer practicing primary care physicians (median 24.1% vs. 33.4%, p < 0.001) and fewer recent graduates matching in family medicine residencies (median 2.4% vs. 6.2%, p < 0.001) than the other 30 private schools. In contrast, the nine research-intensive public medical schools produced comparable proportions of graduates pursuing primary care careers (median 36.1% vs. 36.3%, p = 0.87) and matching in family medicine residencies (median 7.4% vs. 10.0%, p = 0.37) relative to the other 66 public medical schools. To meet the health care needs of the US population, research-intensive private medical schools should play a more active role in promoting primary care careers for their students and graduates.

Nephrology comanagement and the quality of antibiotic prescribing in primary care for patients with chronic kidney disease: a retrospective cross-sectional study.

PubMed

Zhu, Justin X G; Nash, Danielle M; McArthur, Eric; Farag, Alexandra; Garg, Amit X; Jain, Arsh K

2018-04-12

In primary care, patients with chronic kidney disease (CKD) are frequently prescribed excessive doses of antibiotics relative to their kidney function. We examined whether nephrology comanagement is associated with improved prescribing in primary care. In a retrospective propensity score-matched cross-sectional study, we studied the appropriateness of antibiotic prescriptions by primary care physicians to Ontarians ≥66 years of age with CKD Stages 4 and 5 (estimated glomerular filtration rate <30 mL/min/1.73 m2 not receiving dialysis) from 1 April 2003 to 31 March 2014. Comanagement was defined as having at least one outpatient visit with a nephrologist within the year prior to antibiotic prescription date. We compared the rate of appropriately dosed antibiotics in primary care between 3937 patients who were comanaged by a nephrologist and 3937 patients who were not. Only 1184 (30%) of 3937 noncomanaged patients had appropriately dosed antibiotic prescriptions prescribed by a primary care physician. Nephrology comanagement was associated with an increased likelihood that an appropriately dosed prescription was prescribed by a primary care physician; however, the magnitude of the effect was modest [1342/3937 (34%); odds ratio 1.20 (95% confidence interval 1.09-1.32); P < 0.001]. The majority of antibiotics prescribed by primary care physicians are inappropriately dosed in CKD patients, whether or not a nephrologist is comanaging the patient. Nephrologists have an opportunity to increase awareness of appropriate dosing of medications in primary care through the patients they comanage.

Cross-cultural adaptation of the US consumer form of the short Primary Care Assessment Tool (PCAT): the Korean consumer form of the short PCAT (KC PCAT) and the Korean standard form of the short PCAT (KS PCAT).

PubMed

Jeon, Ki-Yeob

2011-01-01

It is well known that countries with well-structured primary care have better health outcomes, better health equity and reduced healthcare costs. This study aimed to culturally modify and validate the US consumer form of the short Primary Care Assessment Tool (PCAT) in primary care in the Republic of Korea (hereafter referred to as Korea). The Korean consumer form of the short PCAT (KC PCAT) was cross-culturally modified from the original version using a standardised transcultural adaptation method. A pre-test version of the KC PCAT was formulated by replacement of four items and modification of a further four items from the 37 items of the original consumer form of the short PCAT at face value evaluation meetings. Pilot testing was done with a convenience sample of 15 responders at two different sites. Test-retest showed high reliability. To validate the KC PCAT, 606 clients participated in a survey carried out in Korea between February and May 2006. Internal consistency reliability, test-retest reliability and factor analysis were conducted in order to test validity. Psychometric testing was carried out on 37 items of the KC PCAT to make the KS PCAT which has 30 items and has seven principal domains: first contact utilisation, first contact accessibility, ongoing accountable care (ongoing care and coordinated rapport care), integrated care (patient-centred care with integration between primary and specialty care or between different specialties), comprehensive care, community-oriented care and culturally-oriented care. Component factors of the verified KS PCAT explained 58.28% of the total variance in the total item scores of primary care. The verified KS PCAT has been characterised by the seven classic domains of primary care with minor modifications. This may provide clues concerning differences in expectations for primary care in the Korean population as compared with that of the US. The KS PCAT is a reliable and valid tool for the evaluation of the quality of primary care in Korea. It will be used to identify any aspects of primary care linked to better or worse health outcomes, and to provide evidence-based evaluations of or recommendations for Korean healthcare policy. cross-cultural adaptation, Korean Standard Primary Care Assessment Tool, Primary Care Assessment Tool, quality of primary care.

Rural-to-Urban Migrants' Experiences with Primary Care under Different Types of Medical Institutions in Guangzhou, China

PubMed Central

Zeng, Jiazhi; Shi, Leiyu; Zou, Xia; Chen, Wen; Ling, Li

2015-01-01

Objectives China is facing the unprecedented challenge of rapidly increasing rural-to-urban migration. Migrants are in a vulnerable state when they attempt to access to primary care services. This study was designed to explore rural-to-urban migrants’ experiences in primary care, comparing their quality of primary care experiences under different types of medical institutions in Guangzhou, China. Methods The study employed a cross-sectional survey of 736 rural-to-urban migrants in Guangzhou, China in 2014. A validated Chinese version of Primary Care Assessment Tool—Adult Short Version (PCAT-AS), representing 10 primary care domains was used to collect information on migrants’ quality of primary care experiences. These domains include first contact (utilization), first contact (accessibility), ongoing care, coordination (referrals), coordination (information systems), comprehensiveness (services available), comprehensiveness (services provided), family-centeredness, community orientation and culturally competent. These measures were used to assess the quality of primary care performance as reported from patients’ perspective. Analysis of covariance was conducted for comparison on PCAT scores among migrants accessing primary care in tertiary hospitals, municipal hospitals, community health centers/community health stations, and township health centers/rural health stations. Multiple linear regression models were used to explore factors associated with PCAT total scores. Results After adjustments were made, migrants accessing primary care in tertiary hospitals (25.49) reported the highest PCAT total scores, followed by municipal hospitals (25.02), community health centers/community health stations (24.24), and township health centers/rural health stations (24.18). Tertiary hospital users reported significantly better performance in first contact (utilization), first contact (accessibility), coordination (information system), comprehensiveness (service available), and cultural competence. Community health center/community health station users reported significantly better experience in the community orientation domain. Township health center/rural health station users expressed significantly better experience in the ongoing care domain. There were no statistically significant differences across settings in the ongoing care, comprehensiveness (services provided), and family-centeredness domains. Multiple linear regression models showed that factors positively associated with higher PCAT total scores also included insurance covering parts of healthcare payment (P<0.001). Conclusions This study highlights the need for improvement in primary care provided by primary care institutions for rural-to-urban migrants. Relevant policies related to medical insurance should be implemented for providing affordable healthcare services for migrants accessing primary care. PMID:26474161

Can different primary care databases produce comparable estimates of burden of disease: results of a study exploring venous leg ulceration.

PubMed

Petherick, Emily S; Pickett, Kate E; Cullum, Nicky A

2015-08-01

Primary care databases from the UK have been widely used to produce evidence on the epidemiology and health service usage of a wide range of conditions. To date there have been few evaluations of the comparability of estimates between different sources of these data. To estimate the comparability of two widely used primary care databases, the Health Improvement Network Database (THIN) and the General Practice Research Database (GPRD) using venous leg ulceration as an exemplar condition. Cross prospective cohort comparison. GPRD and the THIN databases using data from 1998 to 2006. A data set was extracted from both databases containing all cases of persons aged 20 years or greater with a database diagnosis of venous leg ulceration recorded in the databases for the period 1998-2006. Annual rates of incidence and prevalence of venous leg ulceration were calculated within each database and standardized to the European standard population and compared using standardized rate ratios. Comparable estimates of venous leg ulcer incidence from the GPRD and THIN databases could be obtained using data from 2000 to 2006 and of prevalence using data from 2001 to 2006. Recent data collected by these two databases are more likely to produce comparable results of the burden venous leg ulceration. These results require confirmation in other disease areas to enable researchers to have confidence in the comparability of findings from these two widely used primary care research resources. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Primary care models for treating opioid use disorders: What actually works? A systematic review

PubMed Central

Klasa, Katarzyna; Bush, Christopher; Heisler, Michele; Chopra, Vineet; Bohnert, Amy

2017-01-01

Background Primary care-based models for Medication-Assisted Treatment (MAT) have been shown to reduce mortality for Opioid Use Disorder (OUD) and have equivalent efficacy to MAT in specialty substance treatment facilities. Objective The objective of this study is to systematically analyze current evidence-based, primary care OUD MAT interventions and identify program structures and processes associated with improved patient outcomes in order to guide future policy and implementation in primary care settings. Data sources PubMed, EMBASE, CINAHL, and PsychInfo. Methods We included randomized controlled or quasi experimental trials and observational studies evaluating OUD treatment in primary care settings treating adult patient populations and assessed structural domains using an established systems engineering framework. Results We included 35 interventions (10 RCTs and 25 quasi-experimental interventions) that all tested MAT, buprenorphine or methadone, in primary care settings across 8 countries. Most included interventions used joint multi-disciplinary (specialty addiction services combined with primary care) and coordinated care by physician and non-physician provider delivery models to provide MAT. Despite large variability in reported patient outcomes, processes, and tasks/tools used, similar key design factors arose among successful programs including integrated clinical teams with support staff who were often advanced practice clinicians (nurses and pharmacists) as clinical care managers, incorporating patient “agreements,” and using home inductions to make treatment more convenient for patients and providers. Conclusions The findings suggest that multidisciplinary and coordinated care delivery models are an effective strategy to implement OUD treatment and increase MAT access in primary care, but research directly comparing specific structures and processes of care models is still needed. PMID:29040331

Quality care provision for older people: an interview study with patients and primary healthcare professionals.

PubMed

van de Pol, Marjolein Helena Johanna; Fluit, Cornelia Rita Maria Gertruda; Lagro, Joep; Niessen, Danielle; Rikkert, Marcellinus Gerardus Maria Olde; Lagro-Janssen, Antoinette Leonarda Maria

2015-08-01

In recent years, primary health care for the ageing population has become increasingly complex. This study sought to explore the views and needs of healthcare professionals and older patients relating to primary care in order to identify focal areas for improving primary health care for older people. This research was structured as a mixed interview study with focus groups and individual interviews. Participants were made up of primary healthcare professionals and older patients. Patients were recruited from five elderly care homes in a small city in the southern part of the Netherlands. All interviews were transcribed verbatim and analysed by two individual researchers applying constant comparative analysis. Data collection proceeded until saturation was reached. Participants in the study agreed about the need for primary care for older patients, and showed sympathy with one another's perspectives. They did note, however, a number of obstacles hindering good healthcare provision. The major themes that arose were: 'autonomy and independence', 'organisational barriers', and 'professional expertise'. Participants generally noted that it is important to clarify differences in perspectives about good care between patients and healthcare professionals. Effective primary care intervention for older patients requires mutual understanding of the expectations and goals of all parties involved. There are a number of important requirements, especially accessible patient information in the form of care plans; specialist training for nurses and GPs on complex care and multimorbidity; and training on discussing autonomy, goal setting, and shared care. Further improvement in health care for older people and its evaluation research should focus on these requirements. © British Journal of General Practice 2015.

Improving Pain Care with Project ECHO in Community Health Centers.

PubMed

Anderson, Daren; Zlateva, Ianita; Davis, Bennet; Bifulco, Lauren; Giannotti, Tierney; Coman, Emil; Spegman, Douglas

2017-10-01

Pain is an extremely common complaint in primary care, and patient outcomes are often suboptimal. This project evaluated the impact of Project ECHO Pain videoconference case-based learning sessions on knowledge and quality of pain care in two Federally Qualified Health Centers. Quasi-experimental, pre-post intervention, with comparison group. Two large, multisite federally qualified health centers in Connecticut and Arizona. Intervention (N = 10) and comparison (N = 10) primary care providers. Primary care providers attended 48 weekly Project ECHO Pain sessions between January and December 2013, led by a multidisciplinary pain specialty team. Surveys and focus groups assessed providers' pain-related knowledge and self-efficacy. Electronic health record data were analyzed to evaluate opioid prescribing and specialty referrals. Compared with control, primary care providers in the intervention had a significantly greater increase in pain-related knowledge and self-efficacy. Providers who attended ECHO were more likely to use formal assessment tools and opioid agreements and refer to behavioral health and physical therapy compared with control providers. Opioid prescribing decreased significantly more among providers in the intervention compared with those in the control group. Pain is an extremely common and challenging problem, particularly among vulnerable patients such as those cared for at the more than 1,200 Federally Qualified Health Centers in the United States. In this study, attendance at weekly Project ECHO Pain sessions not only improved knowledge and self-efficacy, but also altered prescribing and referral patterns, suggesting that knowledge acquired during ECHO sessions translated into practice changes. © 2017 American Academy of Pain Medicine.

Association between women veterans' experiences with VA outpatient health care and designation as a women's health provider in primary care clinics.

PubMed

Bastian, Lori A; Trentalange, Mark; Murphy, Terrence E; Brandt, Cynthia; Bean-Mayberry, Bevanne; Maisel, Natalya C; Wright, Steven M; Gaetano, Vera S; Allore, Heather; Skanderson, Melissa; Reyes-Harvey, Evelyn; Yano, Elizabeth M; Rose, Danielle; Haskell, Sally

2014-01-01

Women veterans comprise a small percentage of Department of Veterans Affairs (VA) health care users. Prior research on women veterans' experiences with primary care has focused on VA site differences and not individual provider characteristics. In 2010, the VA established policy requiring the provision of comprehensive women's health care by designated women's health providers (DWHPs). Little is known about the quality of health care delivered by DWHPs and women veterans' experience with care from these providers. Secondary data were obtained from the VA Survey of Healthcare Experience of Patients (SHEP) using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient-centered medical home (PCMH) survey from March 2012 through February 2013, a survey designed to measure patient experience with care and the DWHPs Assessment of Workforce Capacity that discerns between DWHPs versus non-DWHPs. Of the 28,994 surveys mailed to women veterans, 24,789 were seen by primary care providers and 8,151 women responded to the survey (response rate, 32%). A total of 3,147 providers were evaluated by the SHEP-CAHPS-PCMH survey (40%; n = 1,267 were DWHPs). In a multivariable model, patients seen by DWHPs (relative risk, 1.02; 95% CI, 1.01-1.04) reported higher overall experiences with care compared with patients seen by non-DWHPs. The main finding is that women veterans' overall experiences with outpatient health care are slightly better for those receiving care from DWHPs compared with those receiving care from non-DWHPs. Our findings have important policy implications for how to continue to improve women veterans' experiences. Our work provides support to increase access to DWHPs at VA primary care clinics. Published by Elsevier Inc.

Contextual barriers to implementation in primary care: an ethnographic study of a programme to improve chronic kidney disease care

PubMed Central

Armstrong, Natalie; Herbert, Georgia; Brewster, Liz

2016-01-01

Background. Context is important in implementation—we know that what works in one setting may not work in the same way elsewhere. Primary care has been described as a unique context both in relation to the care delivered and efforts to carry out research and implementation of new evidence. Objective. To explore some of the distinctive features of the primary care environment that may influence implementation. Methods. We conducted an ethnographic study involving observations, interviews and documentary analysis of the ENABLE-CKD project, which involved general practices implementing a chronic kidney disease care bundle and offering self-management support tools to patients. Analysis was based on the constant comparative method. Results. Four elements of the primary care environment emerged as important influences on the extent to which implementation was successful. First, the nature of delivering care in this setting meant that prioritizing one condition over others was problematic. Second, the lack of alignment with financial and other incentives affected engagement. Third, the project team lacked mechanisms through which engagement could be mandated. Fourth, working relationships within practices impacted on engagement. Conclusions. Those seeking to implement interventions in primary care need to consider the particular context if they are to secure successful implementation. We suggest that there are particular kinds of interventions, which may be best suited to the primary care context. PMID:27297465

Contextual barriers to implementation in primary care: an ethnographic study of a programme to improve chronic kidney disease care.

PubMed

Armstrong, Natalie; Herbert, Georgia; Brewster, Liz

2016-08-01

Context is important in implementation-we know that what works in one setting may not work in the same way elsewhere. Primary care has been described as a unique context both in relation to the care delivered and efforts to carry out research and implementation of new evidence. To explore some of the distinctive features of the primary care environment that may influence implementation. We conducted an ethnographic study involving observations, interviews and documentary analysis of the ENABLE-CKD project, which involved general practices implementing a chronic kidney disease care bundle and offering self-management support tools to patients. Analysis was based on the constant comparative method. Four elements of the primary care environment emerged as important influences on the extent to which implementation was successful. First, the nature of delivering care in this setting meant that prioritizing one condition over others was problematic. Second, the lack of alignment with financial and other incentives affected engagement. Third, the project team lacked mechanisms through which engagement could be mandated. Fourth, working relationships within practices impacted on engagement. Those seeking to implement interventions in primary care need to consider the particular context if they are to secure successful implementation. We suggest that there are particular kinds of interventions, which may be best suited to the primary care context. © The Author 2016. Published by Oxford University Press.

Collaboration of midwives in primary care midwifery practices with other maternity care providers.

PubMed

Warmelink, J Catja; Wiegers, Therese A; de Cock, T Paul; Klomp, Trudy; Hutton, Eileen K

2017-12-01

Inter-professional collaboration is considered essential in effective maternity care. National projects are being undertaken to enhance inter-professional relationships and improve communication between all maternity care providers in order to improve the quality of maternity care in the Netherlands. However, little is known about primary care midwives' satisfaction with collaboration with other maternity care providers, such as general practitioners, maternity care assistance organisations (MCAO), maternity care assistants (MCA), obstetricians, clinical midwives and paediatricians. More insight is needed into the professional working relations of primary care midwives in the Netherlands before major changes are made OBJECTIVE: To assess how satisfied primary care midwives are with collaboration with other maternity care providers and to assess the relationship between their 'satisfaction with collaboration' and personal and work-related characteristics of the midwives, their attitudes towards their work and collaboration characteristics (accessibility). The aim of this study was to provide insight into the professional working relations of primary care midwives in the Netherlands. Our descriptive cross-sectional study is part of the DELIVER study. Ninety nine midwives completed a written questionnaire in May 2010. A Friedman ANOVA test assessed differences in satisfaction with collaboration with six groups of maternity care providers. Bivariate analyses were carried out to assess the relationship between satisfaction with collaboration and personal and work-related characteristics of the midwives, their attitudes towards their work and collaboration characteristics. Satisfaction experienced by primary care midwives when collaborating with the different maternity care providers varies within and between primary and secondary/tertiary care. Interactions with non-physicians (clinical midwives and MCA(O)) are ranked consistently higher on satisfaction compared with interactions with physicians (GPs, obstetricians and paediatricians). Midwives with more work experience were more satisfied with their collaboration with GPs. Midwives from the southern region of the Netherlands were more satisfied with collaboration with GPs and obstetricians. Compared to the urban areas, in the rural or mixed areas the midwives were more satisfied regarding their collaboration with MCA(O)s and clinical midwives. Midwives from non-Dutch origin were less satisfied with the collaboration with paediatricians. No relations were found between the overall mean satisfaction of collaboration and work-related and personal characteristics and attitude towards work. Inter-professionals relations in maternity care in the Netherlands can be enhanced, especially the primary care midwives' interactions with physicians and with maternity care providers in the northern and central part of the Netherlands, and in urban areas. Future exploratory or deductive research may provide additional insight in the collaborative practice in everyday work setting. Copyright © 2017 Elsevier Ltd. All rights reserved.

Travel burden and dentist bypass among dentally insured children.

PubMed

McKernan, Susan C; Pooley, Mark J; Momany, Elizabeth T; Kuthy, Raymond A

2016-06-01

Using administrative data from Iowa Medicaid and a large private dental insurer, we compared distance to the nearest primary care dentist for children ages 6-15 in 2012. Additionally, we examined rates of provider bypass in both populations as an indicator of spatial accessibility to dental care. We calculated measures of travel burden, including distance to the nearest primary care dentist and distance to current primary care dentist. Distance outcomes and rates of bypass, traveling beyond the nearest dentist for care, were compared by insurance type. We found that Medicaid-enrolled children lived farther from the nearest dentist and farther from their current dentist than privately insured children. However, rates of bypass were higher among the privately insured population. These results were consistent among urban and rural residents; additionally, both rural populations demonstrated greater travel distances than urban dwellers. Travel burden was greater among Medicaid-enrolled children. Lower rates of bypass, in conjunction with lower rates of dental utilization in this population, may indicate a distance threshold beyond which dental care becomes unattainable. © 2016 American Association of Public Health Dentistry.

Delivery System Integration and Health Care Spending and Quality for Medicare Beneficiaries

PubMed Central

McWilliams, J. Michael; Chernew, Michael E.; Zaslavsky, Alan M.; Hamed, Pasha; Landon, Bruce E.

2013-01-01

Background The Medicare accountable care organization (ACO) programs rely on delivery system integration and provider risk sharing to lower spending while improving quality of care. Methods Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5,000 assigned beneficiaries) and Pioneer (≥15,000) ACO programs and distinguished hospital-based from independent groups. We compared spending and quality of care between larger and smaller provider groups and examined how size-related differences varied by 2 factors considered central to ACO performance: group primary care orientation (measured by the primary care share of large groups’ specialty mix) and provider risk sharing (measured by county health maintenance organization penetration and its relationship to financial risk accepted by different group types for managed care patients). Spending and quality of care measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics. Results Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference: +$849), higher 30-day readmission rates (+1.3% percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (−$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care. Conclusions Spending was lower and quality of care better for Medicare beneficiaries served by larger independent physician groups with strong primary care orientations in environments where providers accepted greater risk. PMID:23780467

The effects of asking a fertility intention question in primary care settings: a systematic review protocol.

PubMed

Henning, Paul A; Burgess, Carolyne K; Jones, Heidi E; Norman, Wendy V

2017-01-19

Planning for pregnancy has been associated with reduced unwanted pregnancies and improved pregnancy outcomes. Despite the benefits of planned pregnancy, there are no guideline recommendations on routine counseling regarding pregnancy intention in primary care settings. The objective of the systematic review is to determine the effectiveness of incorporating questions of pregnancy intention into primary care. A systematic search of the literature will be conducted for any studies comparing questions of pregnancy intention in primary care settings with no intervention or a control intervention. Types of studies will include randomized controlled trials, non-randomized trials, and observation studies. Participants will include patients of reproductive age presenting to primary health care settings. Interventions will include any assessment of fertility intention and follow-up care compared with a control group or no intervention. Outcomes will include quantitative data with rates for contraceptive uptake, and any pregnancy related outcome. Databases (Ovid MEDLINE; Pubmed; CINAHL; EMBASE; CDR/DARE databases; Web of Science; ISRCTN registry; Clinicaltrials.gov; Cochrane Library) will be searched from the year 2000 to current. Screening of identified articles and data extraction will be conducted in duplicate by two independent reviewers. Methodological quality will be assessed using the Jadad scale. Methodological quality of observational and non-randomized trials will be assessed using the Newcastle-Ottawa scale. Discrepancies will be resolved by consensus or by consulting a third author. Meta-analyses will be performed if appropriate. Determining the effect of including questions of pregnancy intention into primary care can provide evidence for the development of clinical practice guidelines and inform primary care providers if this simple and low-cost intervention should be routinely employed. This review will also identify any gaps in the current literature on this topic and provide direction for future research in this area of study. Systematic Review Registration: PROSPERO CRD42015019726.

Primary care reform and service use by people with serious mental illness in Ontario.

PubMed

Steele, Leah S; Durbin, Anna; Lin, Elizabeth; Charles Victor, J; Klein-Geltink, Julie; Glazier, Richard H; Zagorski, Brandon; Kopp, Alexander

2014-01-01

To examine service use by adults with serious mental illness (SMI) rostered in new primary care models: enhanced fee-for-service (FFS), blended-capitation (CAP) and team-based capitation (TBC) models with and without mental health workers (MHW) in Ontario. This cross-sectional study used administrative health service databases to compare use of mental health and general health services among persons with SMI enrolled in new models (n = 125,233). Relative to persons rostered in enhanced FFS, those in CAP and TBC had fewer mental health primary care visits (adjusted rate ratios and 95% confidence limits: CAP: 0.77 [0.74, 0.81]; TBC with MHW: 0.72 [0.68, 0.76]; TBC with no MHW: 0.81 [0.72, 0.93]). Compared to patients in enhanced FFS, those in TBC models also had more mental health hospital admissions (TBC with MHW: 1.12 [1.05, 1.20]; TBC with no MHW: 1.22 [1.05, 1.41]). Patterns of use of general services were similar. Further attention to financial incentives in capitation that influence care of persons with SMI is necessary to determine if they are aligned with aims of primary care reform. Copyright © 2014 Longwoods Publishing.

Identification, summary and comparison of tools used to measure organizational attributes associated with chronic disease management within primary care settings.

PubMed

Lukewich, Julia; Corbin, Renée; VanDenKerkhof, Elizabeth G; Edge, Dana S; Williamson, Tyler; Tranmer, Joan E

2014-12-01

Given the increasing emphasis being placed on managing patients with chronic diseases within primary care, there is a need to better understand which primary care organizational attributes affect the quality of care that patients with chronic diseases receive. This study aimed to identify, summarize and compare data collection tools that describe and measure organizational attributes used within the primary care setting worldwide. Systematic search and review methodology consisting of a comprehensive and exhaustive search that is based on a broad question to identify the best available evidence was employed. A total of 30 organizational attribute data collection tools that have been used within the primary care setting were identified. The tools varied with respect to overall focus and level of organizational detail captured, theoretical foundations, administration and completion methods, types of questions asked, and the extent to which psychometric property testing had been performed. The tools utilized within the Quality and Costs of Primary Care in Europe study and the Canadian Primary Health Care Practice-Based Surveys were the most recently developed tools. Furthermore, of the 30 tools reviewed, the Canadian Primary Health Care Practice-Based Surveys collected the most information on organizational attributes. There is a need to collect primary care organizational attribute information at a national level to better understand factors affecting the quality of chronic disease prevention and management across a given country. The data collection tools identified in this review can be used to establish data collection strategies to collect this important information. © 2014 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.

Implementation of data management and effect on chronic disease coding in a primary care organisation: A parallel cohort observational study.

PubMed

Greiver, Michelle; Wintemute, Kimberly; Aliarzadeh, Babak; Martin, Ken; Khan, Shahriar; Jackson, Dave; Leggett, Jannet; Lambert-Lanning, Anita; Siu, Maggie

2016-10-12

Consistent and standardized coding for chronic conditions is associated with better care; however, coding may currently be limited in electronic medical records (EMRs) used in Canadian primary care.Objectives To implement data management activities in a community-based primary care organisation and to evaluate the effects on coding for chronic conditions. Fifty-nine family physicians in Toronto, Ontario, belonging to a single primary care organisation, participated in the study. The organisation implemented a central analytical data repository containing their EMR data extracted, cleaned, standardized and returned by the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), a large validated primary care EMR-based database. They used reporting software provided by CPCSSN to identify selected chronic conditions and standardized codes were then added back to the EMR. We studied four chronic conditions (diabetes, hypertension, chronic obstructive pulmonary disease and dementia). We compared changes in coding over six months for physicians in the organisation with changes for 315 primary care physicians participating in CPCSSN across Canada. Chronic disease coding within the organisation increased significantly more than in other primary care sites. The adjusted difference in the increase of coding was 7.7% (95% confidence interval 7.1%-8.2%, p < 0.01). The use of standard codes, consisting of the most common diagnostic codes for each condition in the CPCSSN database, increased by 8.9% more (95% CI 8.3%-9.5%, p < 0.01). Data management activities were associated with an increase in standardized coding for chronic conditions. Exploring requirements to scale and spread this approach in Canadian primary care organisations may be worthwhile.

The effect of implementing a care coordination program on team dynamics and the patient experience.

PubMed

Di Capua, Paul; Clarke, Robin; Tseng, Chi-Hong; Wilhalme, Holly; Sednew, Renee; McDonald, Kathryn M; Skootsky, Samuel A; Wenger, Neil

2017-08-01

Care coordination programs are frequently implemented in the redesign of primary care systems, focused on improving patient outcomes and reducing utilization. However, redesign can be disruptive, affect patient experiences, and undermine elements in the patient-centered medical home, such as team-based care. Case-controlled study with difference-in-differences (DID) and cross-sectional analyses. The phased implementation of a care coordination program permitted evaluation of a natural experiment to compare measures of patient experience and teamwork in practices with and without care coordinators. Patient experience scores were compared before and after the introduction of care coordinators, using DID analyses. Cross-sectional data were used to compare teamwork, based on the relational coordination survey, and physician-perceived barriers to coordinated care between clinics with and without care coordinators. We evaluated survey responses from 459 staff and physicians and 13,441 patients in 26 primary care practices. Practices with care coordinators did not have significantly different relational coordination scores compared with practices without care coordinators, and physicians in these practices did not report reduced barriers to coordinated care. After implementation of the program, patients in practices with care coordinators reported a more positive experience with staff over time (DID, 2.6 percentage points; P = .0009). A flexible program that incorporates care coordinators into the existing care team was minimally disruptive to existing team dynamics, and the embedded care coordinators were associated with a small increase in patient ratings that reflected a more positive experience with staff.

Primary care resident perceived preparedness to deliver cross-cultural care: an examination of training and specialty differences.

PubMed

Greer, Joseph A; Park, Elyse R; Green, Alexander R; Betancourt, Joseph R; Weissman, Joel S

2007-08-01

Previous research has shown that resident physicians report differences in training across primary care specialties, although limited data exist on education in delivering cross-cultural care. The goals of this study were to identify factors that relate to primary care residents' perceived preparedness to provide cross-cultural care and to explore the extent to which these perceptions vary across primary care specialties. Cross-sectional, national mail survey of resident physicians in their last year of training. Eleven hundred fifty primary care residents specializing in family medicine (27%), internal medicine (23%), pediatrics (26%), and obstetrics/gynecology (OB/GYN) (24%). Male residents as well as those who reported having graduated from U.S. medical schools, access to role models, and a greater cross-cultural case mix during residency felt more prepared to deliver cross-cultural care. Adjusting for these demographic and clinical factors, family practice residents were significantly more likely to feel prepared to deliver cross-cultural care compared to internal medicine, pediatric, and OB/GYN residents. Yet, when the quantity of instruction residents reported receiving to deliver cross-cultural care was added as a predictor, specialty differences became nonsignificant, suggesting that training opportunities better account for the variability in perceived preparedness than specialty. Across primary care specialties, residents reported different perceptions of preparedness to deliver cross-cultural care. However, this variation was more strongly related to training factors, such as the amount of instruction physicians received to deliver such care, rather than specialty affiliation. These findings underscore the importance of formal education to enhance residents' preparedness to provide cross-cultural care.

[The reform of primary health care: the economic, care and satisfaction results].

PubMed

Durán, J; Jodar, G; Pociello, V; Parellada, N; Martín, A; Pradas, J

1999-05-15

To compare the overall effect on the general public before and after the primary care reform, its economic outcome and professional satisfaction, following the model of the European Foundation for Quality Management. A descriptive analysis of results at reformed primary care centres compared with results at non-reformed centres in the same city. The study was conducted at Sant Boi de Llobregat, a town of 77,591 inhabitants in Baix Llobregat county (Barcelona). 32.7% of the population was covered by two reformed centres. The rest was covered by one single non-reformed primary care centre. Clinical audits and data on pharmaceutical prescription quality were used to find attendance. For economic results, the formula of attribution of cost/inhabitant and cost/inhabitant seen, including the costs of labour, structure, referral, further tests and pharmacy, were used. The satisfaction of the outside customer (user) was measured by a population survey. Internal customer satisfaction was measured by a survey of the professionals. Results were compared with those for 1997. The study showed that the reformed primary care sector's results, measured in terms of professional satisfaction, user-outside customer, attendance, economic results and social impact, were better than the non-reformed sector's. Inside and outside customers' satisfaction was higher in the reformed network. The cost per inhabitant in the reformed network was 31,874 pesetas, against 25,177 in the non-reformed network. The cost per inhabitant seen was 34,482 and 44,603, respectively. The reform creates efficient resource management and greater satisfaction of the general public and professionals, when an indicator sensitive to the real use of services is used.

Quantitative comparisons of urgent care service providers.

PubMed

Qin, Hong; Prybutok, Gayle L; Prybutok, Victor R; Wang, Bin

2015-01-01

The purpose of this paper is to develop, validate, and use a survey instrument to measure and compare the perceived quality of three types of US urgent care (UC) service providers: hospital emergency rooms, urgent care centres (UCC), and primary care physician offices. This study develops, validates, and uses a survey instrument to measure/compare differences in perceived service quality among three types of UC service providers. Six dimensions measured the components of service quality: tangibles, professionalism, interaction, accessibility, efficiency, and technical quality. Primary care physicians' offices scored higher for service quality and perceived value, followed by UCC. Hospital emergency rooms scored lower in both quality and perceived value. No significant difference was identified between UCC and primary care physicians across all the perspectives, except for interactions. The homogenous nature of the sample population (college students), and the fact that the respondents were recruited from a single university limits the generalizability of the findings. The patient's choice of a health care provider influences not only the continuity of the care that he or she receives, but compliance with a medical regime, and the evolution of the health care landscape. This work contributes to the understanding of how to provide cost effective and efficient UC services. This study developed and validated a survey instrument to measure/compare six dimensions of service quality for three types of UC service providers. The authors provide valuable data for UC service providers seeking to improve patient perceptions of service quality.

Does Lean healthcare improve patient satisfaction? A mixed-method investigation into primary care.

PubMed

Poksinska, Bozena Bonnie; Fialkowska-Filipek, Malgorzata; Engström, Jon

2017-02-01

Lean healthcare is claimed to contribute to improved patient satisfaction, but there is limited evidence to support this notion. This study investigates how primary-care centres working with Lean define and improve value from the patient's perspective, and how the application of Lean healthcare influences patient satisfaction. This paper contains two qualitative case studies and a quantitative study based on results from the Swedish National Patient Survey. Through the case studies, we investigated how primary-care organisations realised the principle of defining and improving value from the patient's perspective. In the quantitative study, we compared results from the patient satisfaction survey for 23 primary-care centres working with Lean with a control group of 23 care centres not working with Lean. We also analysed changes in patient satisfaction over time. Our case studies reveal that Lean healthcare implementations primarily target efficiency and little attention is paid to the patient's perspective. The quantitative study shows no significantly better results in patient satisfaction for primary-care centres working with Lean healthcare compared with those not working with Lean. Further, care centres working with Lean show no significant improvements in patient satisfaction over time. Lean healthcare implementations seem to have a limited impact on improving patient satisfaction. Care providers need to pay more attention to integrating the patient's perspective in the application of Lean healthcare. Value needs to be defined and value streams need to be improved based on both the knowledge and clinical expertise of care providers, and the preferences and needs of patients. 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/.

Who can provide diabetes self-management support in primary care? Findings from a randomized controlled trial.

PubMed

Siminerio, Linda; Ruppert, Kristine M; Gabbay, Robert A

2013-01-01

The purpose of this comparative effectiveness study is to compare diabetes self-management support (DSMS) approaches and determine who can be most effective in helping patients maintain/improve clinical outcomes, self-care behaviors, distress, and satisfaction following diabetes self-management education (DSME) delivered in primary care. After receiving DSME, 141 participants were randomized to receive DSMS delivered by a trained supporter: educator, peer, practice staff, or usual education during a 6-month follow-up period. DSMS groups were compared to determine which supporter helped participants to maintain/improve A1C, blood pressure, lipids, weight, self-care, and distress. DSMS satisfaction was also examined. There was a significant improvement in A1C, empowerment, aspects of self-care, and distress following DSME at 6 weeks. Those in the educator DSMS group best sustained improved A1C while those in the other DSMS groups maintained glycemic improvements but began to show trends toward worsening. No significant differences or clear trends were seen in other clinical, behavioral, or psychosocial outcomes. The Program Reinforcement Impacts Self-Management (PRISM) study demonstrates that following DSME, participants maintained improved glycemia, lipid, weight, and self-care behaviors and reductions in distress throughout the delivery of DSMS interventions regardless of DSMS supporter. All of the participants reported satisfaction with DSMS. These findings reaffirm the critical role of educators but suggest that others may serve as DSMS supporters. Results suggest that DSME delivered in primary care is effective and multiple DSMS agents are reasonable. As patient-centered self-management approaches are being explored in primary care, delivery of DSME and DSMS becomes paramount.

The impact of a disease management program (COACH) on the attainment of better cardiovascular risk control in dyslipidaemic patients at primary care centres (The DISSEMINATE Study): a randomised controlled trial

PubMed Central

2012-01-01

Background To evaluate the efficacy of Counselling and Advisory Care for Health (COACH) programme in managing dyslipidaemia among primary care practices in Malaysia. This open-label, parallel, randomised controlled trial compared the COACH programme delivered by primary care physicians alone (PCP arm) and primary care physicians assisted by nurse educators (PCP-NE arm). Methods This was a multi-centre, open label, randomised trial of a disease management programme (COACH) among dyslipidaemic patients in 21 Malaysia primary care practices. The participating centres enrolled 297 treatment naïve subjects who had the primary diagnosis of dyslipidaemia; 149 were randomised to the COACH programme delivered by primary care physicians assisted by nurse educators (PCP-NE) and 148 to care provided by primary care physicians (PCP) alone. The primary efficacy endpoint was the mean percentage change from baseline LDL-C at week 24 between the 2 study arms. Secondary endpoints included mean percentage change from baseline of lipid profile (TC, LDL-C, HDL-C, TG, TC: HDL ratio), Framingham Cardiovascular Health Risk Score and absolute risk change from baseline in blood pressure parameters at week 24. The study also assessed the sustainability of programme efficacy at week 36. Results Both study arms demonstrated improvement in LDL-C from baseline. The least squares (LS) mean change from baseline LDL-C were −30.09% and −27.54% for PCP-NE and PCP respectively. The difference in mean change between groups was 2.55% (p=0.288), with a greater change seen in the PCP-NE arm. Similar observations were made between the study groups in relation to total cholesterol change at week 24. Significant difference in percentage change from baseline of HDL-C were observed between the PCP-NE and PCP groups, 3.01%, 95% CI 0.12-5.90, p=0.041, at week 24. There was no significant difference in lipid outcomes between 2 study groups at week 36 (12 weeks after the programme had ended). Conclusion Patients who received coaching and advice from primary care physicians (with or without the assistance by nurse educators) showed improvement in LDL-cholesterol. Disease management services delivered by PCP-NE demonstrated a trend towards add-on improvements in cholesterol control compared to care delivered by physicians alone; however, the improvements were not maintained when the services were withdrawn. Trial registration National Medical Research Registration (NMRR) Number: NMRR-08-287-1442 Trial Registration Number (ClinicalTrials.gov Identifier): NCT00708370 PMID:23046818

The impact of a disease management program (COACH) on the attainment of better cardiovascular risk control in dyslipidaemic patients at primary care centres (The DISSEMINATE Study): a randomised controlled trial.

PubMed

Selvaraj, Francis Jude; Mohamed, Mafauzy; Omar, Khairani; Nanthan, Sudha; Kusiar, Zainab; Subramaniam, Selvaraj Y; Ali, Norsiah; Karanakaran, Kamalakaran; Ahmad, Fauziah; Low, Wilson H H

2012-10-10

To evaluate the efficacy of Counselling and Advisory Care for Health (COACH) programme in managing dyslipidaemia among primary care practices in Malaysia. This open-label, parallel, randomised controlled trial compared the COACH programme delivered by primary care physicians alone (PCP arm) and primary care physicians assisted by nurse educators (PCP-NE arm). This was a multi-centre, open label, randomised trial of a disease management programme (COACH) among dyslipidaemic patients in 21 Malaysia primary care practices. The participating centres enrolled 297 treatment naïve subjects who had the primary diagnosis of dyslipidaemia; 149 were randomised to the COACH programme delivered by primary care physicians assisted by nurse educators (PCP-NE) and 148 to care provided by primary care physicians (PCP) alone. The primary efficacy endpoint was the mean percentage change from baseline LDL-C at week 24 between the 2 study arms. Secondary endpoints included mean percentage change from baseline of lipid profile (TC, LDL-C, HDL-C, TG, TC: HDL ratio), Framingham Cardiovascular Health Risk Score and absolute risk change from baseline in blood pressure parameters at week 24. The study also assessed the sustainability of programme efficacy at week 36. Both study arms demonstrated improvement in LDL-C from baseline. The least squares (LS) mean change from baseline LDL-C were -30.09% and -27.54% for PCP-NE and PCP respectively. The difference in mean change between groups was 2.55% (p=0.288), with a greater change seen in the PCP-NE arm. Similar observations were made between the study groups in relation to total cholesterol change at week 24. Significant difference in percentage change from baseline of HDL-C were observed between the PCP-NE and PCP groups, 3.01%, 95% CI 0.12-5.90, p=0.041, at week 24. There was no significant difference in lipid outcomes between 2 study groups at week 36 (12 weeks after the programme had ended). Patients who received coaching and advice from primary care physicians (with or without the assistance by nurse educators) showed improvement in LDL-cholesterol. Disease management services delivered by PCP-NE demonstrated a trend towards add-on improvements in cholesterol control compared to care delivered by physicians alone; however, the improvements were not maintained when the services were withdrawn. National Medical Research Registration (NMRR) Number: NMRR-08-287-1442Trial Registration Number (ClinicalTrials.gov Identifier): NCT00708370.

Comparison of primary care models in the prevention of cardiovascular disease - a cross sectional study

PubMed Central

2011-01-01

Background Primary care providers play an important role in preventing and managing cardiovascular disease. This study compared the quality of preventive cardiovascular care delivery amongst different primary care models. Methods This is a secondary analysis of a larger randomized control trial, known as the Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation. Using baseline data collected through IDOCC, we conducted a cross-sectional study of 82 primary care practices from three delivery models in Eastern Ontario, Canada: 43 fee-for-service, 27 blended-capitation and 12 community health centres with salary-based physicians. Medical chart audits from 4,808 patients with or at high risk of developing cardiovascular disease were used to examine each practice's adherence to ten evidence-based processes of care for diabetes, chronic kidney disease, dyslipidemia, hypertension, weight management, and smoking cessation care. Generalized estimating equation models adjusting for age, sex, rurality, number of cardiovascular-related comorbidities, and year of data collection were used to compare guideline adherence amongst the three models. Results The percentage of patients with diabetes that received two hemoglobin A1c tests during the study year was significantly higher in community health centres (69%) than in fee-for-service (45%) practices (Adjusted Odds Ratio (AOR) = 2.4 [95% CI 1.4-4.2], p = 0.001). Blended capitation practices had a significantly higher percentage of patients who had their waistlines monitored than in fee-for-service practices (19% vs. 5%, AOR = 3.7 [1.8-7.8], p = 0.0006), and who were recommended a smoking cessation drug when compared to community health centres (33% vs. 16%, AOR = 2.4 [1.3-4.6], p = 0.007). Overall, quality of diabetes care was higher in community health centres, while smoking cessation care and weight management was higher in the blended-capitation models. Fee-for-service practices had the greatest gaps in care, most noticeably in diabetes care and weight management. Conclusions This study adds to the evidence suggesting that primary care delivery model impacts quality of care. These findings support current Ontario reforms to move away from the traditional fee-for-service practice. Trial Registration ClinicalTrials.gov: NCT00574808 PMID:22008366

Antibiotic prescribing practice and adherence to guidelines in primary care in the Cape Town Metro District, South Africa.

PubMed

Gasson, J; Blockman, M; Willems, B

2018-03-28

Knowledge of antibiotic prescribing practice in primary care in South Africa is limited. As 80% of human antibiotic use is in primary care, this knowledge is important in view of the global problem of antibiotic resistance. To assess antibiotic prescribing in primary care facilities in the Cape Town Metro District and compare it with current national guidelines, and to assess the reasons why prescriptions were not adherent to guidelines. A retrospective medical record review was performed in April/May 2016. Records of all patients seen over 2 days in each of eight representative primary care facilities in the Cape Town Metro District were reviewed. The treatment of any patient who raised a new complaint on either of those days was recorded. Prophylactic antibiotic courses, tuberculosis treatment and patients with a non-infection diagnosis were excluded. Treatment was compared with the Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare Level, 2014 edition. Of 654 records included, 68.7% indicated that an antibiotic had been prescribed. Overall guideline adherence was 45.1%. Adherence differed significantly between facilities and according to the physiological system being treated, whether the prescription was for an adult or paediatric patient, and the antibiotic prescribed. Healthcare professional type and patient gender had no significant effect on adherence. The main reasons for non-adherence were an undocumented diagnosis (30.5%), antibiotic not required (21.6%), incorrect dose (12.9%), incorrect drug (11.5%), and incorrect duration of therapy (9.5%). This study demonstrates poor adherence to guidelines. Irrational use of antibiotics is associated with increased antibiotic resistance. There is an urgent need to improve antibiotic prescribing practice in primary care in the Cape Town Metro District.

A randomised controlled trial of self‐help interventions in patients with a primary care diagnosis of irritable bowel syndrome

PubMed Central

Robinson, A; Lee, V; Kennedy, A; Middleton, L; Rogers, A; Thompson, D G; Reeves, D

2006-01-01

Introduction Functional abdominal symptoms are very common and account for nearly two million primary care consultations in Britain every year and produce significant morbidity. The aims of this study were to evaluate the impact of two self‐help interventions on consultation rates and symptom severity in patients with a primary care diagnosis of irritable bowel syndrome. Methods A total of 420 patients from 54 primary care centres were randomised either to receive self‐help information in the form of a guidebook or the guidebook plus a “self‐help” group meeting or to be in a control group receiving neither intervention. Data were collected using questionnaires and primary care records. Results At one year, patients in the guidebook group had a 60% reduction in primary care consultations (p<0.001) and a reduction in perceived symptom severity (p<0.001) compared with controls. Allocation to the self‐help group conferred no additional benefit. Actual symptom scores did not change significantly in any group. Costs per patient were reduced by £73 (confidence interval £43, £103) or 40% per year. Conclusion Introduction of a self‐help guidebook results in a reduction in primary care consultations, a perceived reduction in symptoms, and significant health service savings. This suggests that patients attending their primary care physician with functional abdominal symptoms should be offered self‐help information as part of their management. PMID:16099784

Differences in clinical characteristics between patients assessed for NHS specialist psychotherapy and primary care counselling.

PubMed

Chiesa, Marco; Fonagy, Peter; Bateman, Anthony W

2007-12-01

Although several studies have described patient populations in primary care counselling settings and NHS (National Health Service) specialist psychotherapy settings, there is a paucity of studies specifically comparing differences in clinical characteristics between the two groups of patients. The aim of this study is to ascertain if specialist psychotherapy referrals represent a more challenging client group than primary care counselling patients. We compare the socio-demographic features and severity of presentation in the symptomatic, interpersonal problems and global adjustment dimensions of a sample of patients (N=384) assessed by a primary care counselling service located in North London and a sample of patients (N=853) assessed in eight NHS psychotherapy centres located within urban settings in England. Both the groups completed the Brief Symptom Inventory, the Inventory of Interpersonal Problems and Clinical Outcomes in Routine Evaluation Outcome Measure. Patients referred for specialist psychotherapy services were more dysfunctional than those referred for primary care counselling. The linear function constructed to discriminate the groups showed that a combination of more psychotic symptoms, social inhibitions and higher risk of self-harm effectively identified those referred to psychotherapy services, while patients exhibiting greater levels of somatic and anxiety symptoms and non-assertiveness were more likely to be seen in primary care settings. However, similarities between the two samples were also marked, as shown by the overlap in the distribution of clinical outcomes in routine evaluation clinical scores in the two samples. The findings are discussed in terms of their implications for policy and service delivery of these two types of psychological therapy services.

Datasets collected in general practice: an international comparison using the example of obesity.

PubMed

Sturgiss, Elizabeth; van Boven, Kees

2018-06-04

International datasets from general practice enable the comparison of how conditions are managed within consultations in different primary healthcare settings. The Australian Bettering the Evaluation and Care of Health (BEACH) and TransHIS from the Netherlands collect in-consultation general practice data that have been used extensively to inform local policy and practice. Obesity is a global health issue with different countries applying varying approaches to management. The objective of the present paper is to compare the primary care management of obesity in Australia and the Netherlands using data collected from consultations. Despite the different prevalence in obesity in the two countries, the number of patients per 1000 patient-years seen with obesity is similar. Patients in Australia with obesity are referred to allied health practitioners more often than Dutch patients. Without quality general practice data, primary care researchers will not have data about the management of conditions within consultations. We use obesity to highlight the strengths of these general practice data sources and to compare their differences. What is known about the topic? Australia had one of the longest-running consecutive datasets about general practice activity in the world, but it has recently lost government funding. The Netherlands has a longitudinal general practice dataset of information collected within consultations since 1985. What does this paper add? We discuss the benefits of general practice-collected data in two countries. Using obesity as a case example, we compare management in general practice between Australia and the Netherlands. This type of analysis should start all international collaborations of primary care management of any health condition. Having a national general practice dataset allows international comparisons of the management of conditions with primary care. Without a current, quality general practice dataset, primary care researchers will not be able to partake in these kinds of comparison studies. What are the implications for practitioners? Australian primary care researchers and clinicians will be at a disadvantage in any international collaboration if they are unable to accurately describe current general practice management. The Netherlands has developed an impressive dataset that requires within-consultation data collection. These datasets allow for person-centred, symptom-specific, longitudinal understanding of general practice management. The possibilities for the quasi-experimental questions that can be answered with such a dataset are limitless. It is only with the ability to answer clinically driven questions that are relevant to primary care that the clinical care of patients can be measured, developed and improved.

Wait times to rheumatology care for patients with rheumatic diseases: a data linkage study of primary care electronic medical records and administrative data.

PubMed

Widdifield, Jessica; Bernatsky, Sasha; Thorne, J Carter; Bombardier, Claire; Jaakkimainen, R Liisa; Wing, Laura; Paterson, J Michael; Ivers, Noah; Butt, Debra; Lyddiatt, Anne; Hofstetter, Catherine; Ahluwalia, Vandana; Tu, Karen

2016-01-01

The Wait Time Alliance recently established wait time benchmarks for rheumatology consultations in Canada. Our aim was to quantify wait times to primary and rheumatology care for patients with rheumatic diseases. We identified patients from primary care practices in the Electronic Medical Record Administrative data Linked Database who had referrals to Ontario rheumatologists over the period 2000-2013. To assess the full care pathway, we identified dates of symptom onset, presentation in primary care and referral from electronic medical records. Dates of rheumatologist consultations were obtained by linking with physician service claims. We determined the duration of each phase of the care pathway (symptom onset to primary care encounter, primary care encounter to referral, and referral to rheumatologist consultation) and compared them with established benchmarks. Among 2430 referrals from 168 family physicians, 2015 patients (82.9%) were seen by 146 rheumatologists within 1 year of referral. Of the 2430 referrals, 2417 (99.5%) occurred between 2005 and 2013. The main reasons for referral were osteoarthritis (32.4%) and systemic inflammatory rheumatic diseases (30.6%). Wait times varied by diagnosis and geographic region. Overall, the median wait time from referral to rheumatologist consultation was 74 (interquartile range 27-101) days; it was 66 (interquartile range 18-84) days for systemic inflammatory rheumatic diseases. Wait time benchmarks were not achieved, even for the most urgent types of referral. For systemic inflammatory rheumatic diseases, most of the delays occurred before referral. Rheumatology wait times exceeded established benchmarks. Targeted efforts are needed to promote more timely access to both primary and rheumatology care. Routine linkage of electronic medical records with administrative data may help fill important gaps in knowledge about waits to primary and specialty care.

Differences in Experiences With Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities With Tailored and Nontailored Primary Care Teams.

PubMed

Jones, Audrey L; Hausmann, Leslie R M; Kertesz, Stefan; Suo, Ying; Cashy, John P; Mor, Maria K; Schaefer, James H; Gundlapalli, Adi V; Gordon, Adam J

2018-05-12

Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients. To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities). We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities. Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0). VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

Characteristics and Disparities among Primary Care Practices in the United States.

PubMed

Levine, David Michael; Linder, Jeffrey A; Landon, Bruce E

2018-04-01

Despite new incentives for US primary care, concerns abound that patient-centered practice capabilities are lagging. Describe the practice structure, patient-centered capabilities, and payment relationships of US primary care practices; identify disparities in practice capabilities. Analysis of the 2015 Medical Organizations Survey (MOS), part of the nationally representative Medical Expenditure Panel Survey (MEPS). Practice-reported information from primary care practices of MEPS respondents who reported receiving primary care and made at least one visit in 2015 to that practice. Surveyed primary care practices (n = 4318; 77% response rate) providing primary care to 7161 individuals, representing 101,159,263 Americans. Practice structure (ownership and personnel); practice capabilities (certification as a patient-centered medical home [PCMH], electronic health record [EHR] use, and x-ray capability); and payment orientation (accountable care organization [ACO] and capitation). Independently owned practices served 55% of patients, hospital-owned practices served 19%, and nonprofit/government/academic-owned served 20%. Solo practices served 25% of patients and practices with 2-10 physicians served 53% of patients. Forty-one percent of patients were served by practices certified as PCMHs. Practices with EHRs cared for 90% of patients and could exchange secure messages with 78% of patients. Practices with in-office x-ray capability cared for 34% of patients. Practices participating in ACOs and capitation served 44% and 46% of patients, respectively. Primary care patients in the South, compared to the rest of the country, had less access to nearly all practice capabilities, including patient care coordination (adjusted difference, 13% [95% CI, 8-18]) and secure EHR messaging (adjusted difference, 6% [95% CI, 1-10]). Uninsured patients were less likely to be served at a practice that used an EHR (adjusted difference, 9% [95% CI, 2-16]). Participants' primary care practices were mostly independently owned, nearly always used EHRs (albeit of varying capability), and frequently participated in innovative payment arrangements for a portion of their patients. Patient practices in the South had fewer capabilities than the rest of the country.

Remission in Depressed Geriatric Primary Care Patients: A Report From the PROSPECT Study

PubMed Central

Alexopoulos, George S.; Katz, Ira R.; Bruce, Martha L.; Heo, Moonseong; Have, Thomas Ten; Raue, Patrick; Bogner, Hillary R.; Schulberg, Herbert C.; Mulsant, Benoit H.; Reynolds, Charles F.

2009-01-01

Objective This study compared time to first remission for elderly depressed patients in primary care for practices that implemented a care management model versus those providing usual care. In addition, it sought to identify risk factors for nonremission that could guide treatment planning and referral to care managers or specialists. Method Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) data were analyzed. Participants were older patients (≥60 years) selected following screening of 9,072 randomly identified primary care patients. The present analysis examined patients with major depression and a 24-item Hamilton Depression Rating Scale score of 18 or greater who were followed for at least 4 months (N=215). Primary care practices were randomly assigned to offer the PROSPECT intervention or usual care. The intervention consisted of services of trained care managers, who offered algorithm-based recommendations to physicians and helped patients with treatment adherence over 18 months. Results First remission occurred earlier and was more common among patients receiving the intervention than among those receiving usual care. For all patients, limitations in physical and emotional functions predicted poor remission rate. Patients experiencing hopelessness were more likely to achieve remission if treated in intervention practices. Similarly, the intervention was more effective in patients with low baseline anxiety. Conclusions Longitudinal assessment of depression, hopelessness, anxiety, and physical and emotional functional limitations in depressed older primary care patients is critical. Patients with prominent symptoms or impairment in these areas may be candidates for care management or mental health care, since they are at risk for remaining depressed and disabled. PMID:15800144

Inequities in health care needs for children with medical complexity.

PubMed

Kuo, Dennis Z; Goudie, Anthony; Cohen, Eyal; Houtrow, Amy; Agrawal, Rishi; Carle, Adam C; Wells, Nora

2014-12-01

Children with special health care needs are believed to be susceptible to inequities in health and health care access. Within the group with special needs, there is a smaller group of children with medical complexity: children who require medical services beyond what is typically required by children with special health care needs. We describe health care inequities for the children with medical complexity compared to children with special health care needs but without medical complexity, based on a secondary analysis of data from the 2005-06 and 2009-10 National Survey of Children with Special Health Care Needs. The survey examines the prevalence, health care service use, and needs of children and youth with special care needs, as reported by their families. The inequities we examined were those based on race/ethnicity, primary language in the household, insurance type, and poverty status. We found that children with medical complexity were twice as likely to have at least one unmet need, compared to children without medical complexity. Among the children with medical complexity, unmet need was not associated with primary language, income level, or having Medicaid. We conclude that medical complexity itself can be a primary determinant of unmet needs. Project HOPE—The People-to-People Health Foundation, Inc.

Academic achievement and primary care specialty selection of volunteers at a student-run free clinic.

PubMed

Vaikunth, Sumeet S; Cesari, Whitney A; Norwood, Kimberlee V; Satterfield, Suzanne; Shreve, Robert G; Ryan, J Patrick; Lewis, James B

2014-01-01

Previous studies have reached conflicting conclusions about the associations between service and academic achievement and service and primary care specialty choice. This study examines the associations between service at a student-run clinic and academic achievement and primary care specialty choice. Retrospective review of medical student service and statistical analysis of grade point average (GPA), Step 1 and Step 2 Clinical Knowledge (CK) scores, and specialty choice were conducted, as approved by our Institutional Review Board. Volunteers, compared to nonvolunteers, had higher GPA (3.59 ± 0.33 vs. 3.40 ± 0.39, p < .001), Step 1 (229 ± 19 vs. 220 ± 21, p < .001), and Step 2 CK (240 ± 18 vs. 230 ± 21, p < .001) scores, but did not pursue primary care specialties at a significantly higher percentage (52% vs. 51%, χ² = .051, p = .82). Further exploration of the associations between service and academic achievement and primary care specialty choice is warranted.

The Thai-Australian Health Alliance: developing health management capacity and sustainability for primary health care services.

PubMed

Briggs, D S; Tejativaddhana, P; Cruickshank, M; Fraser, J; Campbell, S

2010-11-01

There have been recent calls for a renewed worldwide focus on primary health care. The Thai-Australian Health Alliance addresses this call by developing health care management capability in primary health care professionals in rural Thailand. This paper describes the history and current activities of the Thai-Australian Health Alliance and its approaches to developing health care management capacity for primary care services through international collaborations in research, education and training over a sustained time period. The Alliance's approach is described herein as a distributed network of practices with access to shared knowledge through collaboration. Its research and education approaches involve action research, multi-methods projects, and evaluative studies in the context of workshops and field studies. WHO principles underpin this approach, with countries sharing practical experiences and outcomes, encouraging leadership and management resource networks, creating clearing houses/knowledge centres, and harmonising and aligning partners with their country's health systems. Various evaluations of the Alliance's activities have demonstrated that a capacity building approach that aligns researchers, educators and health practitioners in comparative and reflective activities can be effective in transferring knowledge and skills among a collaboration's partners. Project participants, including primary health care practitioners, health policy makers and academics embraced the need to acquire management skills to sustain primary care units. Participants believe that the approaches described herein were crucial to developing the management skills needed of health care professionals for rural and remote primary health care. The implementation of this initiative was challenged by pre-existing low opinions of the importance of the management role in health care, but with time the Alliance's activities highlighted for all the importance of health care management. Acceptance of its activities and goals are evidenced by the establishment of a Centre of Leadership Expertise in Health Management and the endorsement of the Phitsanulok Declaration by more than 470 primary health care practitioners, academics and policy makers. Problems with the primary health care delivery system in rural Thailand continue, but the Alliance has successfully implemented a cross cultural strategic collaboration through a continuity of activities to augment practice management capacities in primary care practices.

Effectiveness of a Geriatric Care Model for frail older adults in primary care: Results from a stepped wedge cluster randomized trial.

PubMed

Hoogendijk, Emiel O; van der Horst, Henriëtte E; van de Ven, Peter M; Twisk, Jos W R; Deeg, Dorly J H; Frijters, Dinnus H M; van Leeuwen, Karen M; van Campen, Jos P C M; Nijpels, Giel; Jansen, Aaltje P D; van Hout, Hein P J

2016-03-01

Primary care-based comprehensive care programs have the potential to improve outcomes in frail older adults. We evaluated the impact of the Geriatric Care Model (GCM) on the quality of life of community-dwelling frail older adults. A 24-month stepped wedge cluster randomized controlled trial was conducted between May 2010 and March 2013 in 35 primary care practices in the Netherlands, and included 1147 frail older adults. The intervention consisted of a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Reassessment occurred every six months. Nurses worked together with primary care physicians and were supervised and trained by geriatric expert teams. Complex patients were reviewed in multidisciplinary consultations. The primary outcome was quality of life (SF-12). Secondary outcomes were health-related quality of life, functional limitations, self-rated health, psychological wellbeing, social functioning and hospitalizations. Intention-to-treat analyses based on multilevel modeling showed no significant differences between the intervention group and usual care regarding SF-12 and most secondary outcomes. Only for IADL limitations we found a small intervention effect in patients who received the intervention for 18months (B=-0.25, 95%CI=-0.43 to -0.06, p=0.007), but this effect was not statistically significant after correction for multiple comparisons. The GCM did not show beneficial effects on quality of life in frail older adults in primary care, compared to usual care. This study strengthens the idea that comprehensive care programs add very little to usual primary care for this population. The Netherlands National Trial Register NTR2160. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Research output on primary care in Australia, Canada, Germany, the Netherlands, the United Kingdom, and the United States: bibliometric analysis

PubMed Central

Glanville, Julie; Kendrick, Tony; McNally, Rosalind; Campbell, John

2011-01-01

Objective To compare the volume and quality of original research in primary care published by researchers from primary care in the United Kingdom against five countries with well established academic primary care. Design Bibliometric analysis. Setting United Kingdom, United States, Australia, Canada, Germany, and the Netherlands. Studies reviewed Research publications relevant to comprehensive primary care and authored by researchers from primary care, recorded in Medline and Embase, with publication dates 2001-7 inclusive. Main outcome measures Volume of published activity of generalist primary care researchers and the quality of the research output by those publishing the most using citation metrics: numbers of cited papers, proportion of cited papers, and mean citation scores. Results 82 169 papers published between 2001 and 2007 in the six countries were classified as research on primary care. In a 15% pragmatic random sample of these records, 40% of research on primary care from the United Kingdom and 46% from the Netherlands was authored by researchers employed in a primary care setting or employed in academic departments of primary care. The 141 researchers with the highest volume of publications reporting research findings published between 2001 and 2007 (inclusive) authored or part authored 8.3% of the total sample of papers. For authors with the highest proportion of publications cited at least five times, the best performers came from the United States (n=5), United Kingdom (n=4), and the Netherlands (n=2). In the top 10 of authors with the highest proportions of publications achieving 20 or more citations, six were from the United Kingdom and four from the United States. The mean Hirsch index (measure of a researcher’s productivity and impact of the published work) was 14 for the Netherlands, 13 for the United Kingdom, 12 for the United States, 7 for Canada, 4 for Australia, and 3 for Germany. Conclusion This international comparison of the volume and citation rates of papers by researchers from primary care consistently placed UK researchers among the best performers internationally. PMID:21385804

Motivational interviewing by peer outreach workers: a pilot randomized clinical trial to retain adolescents and young adults in HIV care.

PubMed

Naar-King, Sylvie; Outlaw, Angulique; Green-Jones, Monique; Wright, Kathryn; Parsons, Jeffrey T

2009-07-01

Youth living with HIV (YLH) are at particularly high risk for poor retention in HIV primary care. This study utilized Motivational Interviewing (MI) to improve youth retention in primary care and compared the fidelity and outcomes of peer outreach workers (POW) to masters level staff (MLS). Eighty-seven YLH were randomized to receive two MI sessions from POW or MLS. YLH were aged 16-29 and 92% were African American. Thirty-seven audiotaped sessions were coded with the Motivational Interviewing Treatment Integrity (MITI) coding system. Retention in care was assessed by review of medical records. POW had higher fidelity on two MITI scales, and did not differ from MLS on remaining three scales. While both groups improved the regularity of primary care appointments, the effect size for POW on retention in care and intervention dose was larger than that of MLS. The results suggest that POW can provide MI with quality comparable to MLS with adequate training and supervision. MI provided by POW to improve retention in health care services may increase the cost-effectiveness of evidence-based practices in urban settings.

Making strides towards better mental health care in Peru: Results from a primary care mental health training

PubMed Central

Borba, C. P.C.; Gelaye, B.; Zayas, L.; Ulloa, M.; Lavelle, J.; Mollica, R.F.; Henderson, D.C.

2015-01-01

Our program attempted to improve attitudes and confidence of Peruvian primary care physicians (PCPs) providing mental health care. The training program underwent an evaluation to determine impact of sustained confidence in performing medical and psychiatric procedures, and application of learned skills. Fifty-two Peruvian primary care practitioners were trained at the Harvard Program in Refugee Trauma (HPRT) over a two-week period. There was significant improvement in PCPs’ confidence levels of performing psychiatric procedures (counseling, prescribing medications, psychiatric diagnosis, assessing the risk for violence, and treating trauma victims) when comparing baseline and post-two-week to one year follow-up. When comparing post-two-week and one-year follow-up quantitative measures, confidences levels went slightly down. This may be an implication that the frequency of trainings and supervisions are needed more frequently. In contrast, qualitative responses from the one-year follow-up revealed increase in victims of violence clinical care, advocacy, awareness, education, training, policy changes, accessibility of care, and sustainment of diagnostic tools. This study supports the feasibility of training PCP's in a culturally effective manner with sustainability over time. PMID:27054141

Physicians' satisfaction with a collaborative disease management program for late-life depression in primary care.

PubMed

Levine, Stuart; Unützer, Jürgen; Yip, Judy Y; Hoffing, Marc; Leung, Moon; Fan, Ming-Yu; Lin, Elizabeth H B; Grypma, Lydia; Katon, Wayne; Harpole, Linda H; Langston, Christopher A

2005-01-01

This study describes physicians' satisfaction with care for patients with depression before and after the implementation of a primary care-based collaborative care program. Project Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) is a multisite, randomized controlled trial comparing a primary care-based collaborative disease management program for late-life depression with care as usual. A total of 450 primary care physicians at 18 participating clinics participated in a satisfaction survey before and 12 months after IMPACT initiation. The preintervention survey focused on physicians' satisfaction with current mental health resources and ability to provide depression care. The postintervention survey repeated these and added questions about physician's experience with the IMPACT collaborative care model. Before intervention, about half (54%) of the participating physicians were satisfied with resources to treat patients with depression. After intervention, more than 90% reported the intervention as helpful in treating patients with depression and 82% felt that the intervention improved patients' clinical outcomes. Participating physicians identified proactive patient follow-up and patient education as the most helpful components of the IMPACT model. Physicians perceived a substantial need for improving depression treatment in primary care. They were very satisfied with the IMPACT collaborative care model for treating depressed older adults and felt that similar care management models would also be helpful for treating other chronic medical illnesses.

Panel management, team culture, and worklife experience.

PubMed

Willard-Grace, Rachel; Dubé, Kate; Hessler, Danielle; O'Brien, Bridget; Earnest, Gillian; Gupta, Reena; Shunk, Rebecca; Grumbach, Kevin

2015-09-01

Burnout and professional dissatisfaction are threats to the primary care workforce. We investigated the relationship between panel management capability, team culture, cynicism, and perceived "do-ability" of primary care among primary care providers (PCPs) and staff in primary care practices. We surveyed 326 PCPs and 142 staff members in 10 county-administered, 6 university-run, and 3 Veterans Affairs primary care clinics in a large urban area in 2013. Predictor variables included capability for performing panel management and perception of team culture. Outcome variables included 2 work experience measures--the Maslach Burnout Inventory cynicism scale and a 1-item measure of the "do-ability" of primary care this year compared with last year. Generalized Estimation Equation (GEE) models were used to account for clustering at the clinic level. Greater panel management capability and higher team culture were associated with lower cynicism among PCPs and staff and higher reported "do-ability" of primary care among PCPs. Panel management capability and team culture interacted to predict the 2 work experience outcomes. Among PCPs and staff reporting high team culture, there was little association between panel management capability and the outcomes, which were uniformly positive. However, there was a strong relationship between greater panel management capability and improved work experience outcomes for PCPs and staff reporting low team culture. Team-based processes of care such as panel management may be an important strategy to protect against cynicism and dissatisfaction in primary care, particularly in settings that are still working to improve their team culture. (c) 2015 APA, all rights reserved).

Chronic care management for dependence on alcohol and other drugs: the AHEAD randomized trial.

PubMed

Saitz, Richard; Cheng, Debbie M; Winter, Michael; Kim, Theresa W; Meli, Seville M; Allensworth-Davies, Don; Lloyd-Travaglini, Christine A; Samet, Jeffrey H

2013-09-18

People with substance dependence have health consequences, high health care utilization, and frequent comorbidity but often receive poor-quality care. Chronic care management (CCM) has been proposed as an approach to improve care and outcomes. To determine whether CCM for alcohol and other drug dependence improves substance use outcomes compared with usual primary care. The AHEAD study, a randomized trial conducted among 563 people with alcohol and other drug dependence at a Boston, Massachusetts, hospital-based primary care practice. Participants were recruited from September 2006 to September 2008 from a freestanding residential detoxification unit and referrals from an urban teaching hospital and advertisements; 95% completed 12-month follow-up. Participants were randomized to receive CCM (n=282) or no CCM (n=281). Chronic care management included longitudinal care coordinated with a primary care clinician; motivational enhancement therapy; relapse prevention counseling; and on-site medical, addiction, and psychiatric treatment, social work assistance, and referrals (including mutual help). The no CCM (control) group received a primary care appointment and a list of treatment resources including a telephone number to arrange counseling. The primary outcome was self-reported abstinence from opioids, stimulants, or heavy drinking. Biomarkers were secondary outcomes. There was no significant difference in abstinence from opioids, stimulants, or heavy drinking between the CCM (44%) and control (42%) groups (adjusted odds ratio, 0.84; 95% CI, 0.65-1.10; P=.21). No significant differences were found for secondary outcomes of addiction severity, health-related quality of life, or drug problems. No subgroup effects were found except among those with alcohol dependence, in whom CCM was associated with fewer alcohol problems (mean score, 10 vs 13; incidence rate ratio, 0.85; 95% CI, 0.72-1.00; P=.048). Among persons with alcohol and other drug dependence, CCM compared with a primary care appointment but no CCM did not increase self-reported abstinence over 12 months. Whether more intensive or longer-duration CCM is effective requires further investigation. clinicaltrials.gov Identifier: NCT00278447.

Primary Care Research in the Patient-Centered Outcomes Research Institute's Portfolio.

PubMed

Selby, Joe V; Slutsky, Jean R

2016-04-01

In their article in this issue, Mazur and colleagues analyze the characteristics of early recipients of funding from the Patient-Centered Outcomes Research Institute (PCORI). Mazur and colleagues note correctly that PCORI has a unique purpose and mission and suggest that it should therefore have a distinct portfolio of researchers and departments when compared with other funders such as the National Institutes of Health (NIH). Responding on behalf of PCORI, the authors of this Commentary agree with the characterization of PCORI's mission as distinct from that of NIH and others. They agree too that data found on PCORI's Web site demonstrate that PCORI's portfolio of researchers and departments is more diverse and more heavily populated with clinician researchers, as would be expected. The authors take issue with Mazur and colleagues' suggestion that because half of clinical visits occur within primary care settings, half of PCORI's funded research should be based in primary care departments. PCORI's portfolio reflects what patients and others tell PCORI are the critical questions. Many of these do, in fact, occur with more complex conditions in specialty care. The authors question whether the research of primary care departments is too narrowly focused and whether it sufficiently considers study of these complex conditions. Research on more complex conditions including heart failure, coronary artery disease, and multiple comorbid conditions could be highly valuable when approached from the primary care perspective, where many of the comparative effectiveness questions first arise.

The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) project: an open-label pragmatic randomised control trial comparing the efficacy of differing therapeutic agents for primary care detoxification from either street heroin or methadone [ISRCTN07752728].

PubMed

Oldham, Nicola S; Wright, Nat M J; Adams, Clive E; Sheard, Laura; Tompkins, Charlotte N E

2004-04-29

Heroin is a synthetic opioid with an extensive illicit market leading to large numbers of people becoming addicted. Heroin users often present to community treatment services requesting detoxification and in the UK various agents are used to control symptoms of withdrawal. Dissatisfaction with methadone detoxification 8 has lead to the use of clonidine, lofexidine, buprenorphine and dihydrocodeine; however, there remains limited evaluative research. In Leeds, a city of 700,000 people in the North of England, dihydrocodeine is the detoxification agent of choice. Sublingual buprenorphine, however, is being introduced. The comparative value of these two drugs for helping people successfully and comfortably withdraw from heroin has never been compared in a randomised trial. Additionally, there is a paucity of research evaluating interventions among drug users in the primary care setting. This study seeks to address this by randomising drug users presenting in primary care to receive either dihydrocodeine or buprenorphine. The Leeds Evaluation of Efficacy of Detoxification Study (LEEDS) project is a pragmatic randomised trial which will compare the open use of buprenorphine with dihydrocodeine for illicit opiate detoxification, in the UK primary care setting. The LEEDS project will involve consenting adults and will be run in specialist general practice surgeries throughout Leeds. The primary outcome will be the results of a urine opiate screening at the end of the detoxification regimen. Adverse effects and limited data to three and six months will be acquired.

Moving effective treatment for posttraumatic stress disorder to primary care: A randomized controlled trial with active duty military.

PubMed

Cigrang, Jeffrey A; Rauch, Sheila A; Mintz, Jim; Brundige, Antoinette R; Mitchell, Jennifer A; Najera, Elizabeth; Litz, Brett T; Young-McCaughan, Stacey; Roache, John D; Hembree, Elizabeth A; Goodie, Jeffrey L; Sonnek, Scott M; Peterson, Alan L

2017-12-01

Many military service members with PTSD do not receive evidence-based specialty behavioral health treatment because of perceived barriers and stigma. Behavioral health providers in primary care can deliver brief, effective treatments expanding access and reducing barriers and stigma. The purpose of this randomized clinical trial was to determine if a brief cognitive-behavior therapy delivered in primary care using the Primary Care Behavioral Health model would be effective at reducing PTSD and co-occurring symptoms. A total of 67 service members (50 men, 17 women) were randomized to receive a brief, trauma-focused intervention developed for the primary care setting called Prolonged Exposure for Primary Care (PE-PC) or a delayed treatment minimal contact control condition. Inclusion criteria were significant PTSD symptoms following military deployment, medication stability, and interest in receiving treatment for PTSD symptoms in primary care. Exclusion criteria were moderate or greater risk of suicide, severe brain injury, or alcohol/substance use at a level that required immediate treatment. Assessments were completed at baseline, posttreatment/postminimal contact control, and at 8-week and 6-month posttreatment follow-up points. Primary measures were the PTSD Symptom Scale-Interview and the PTSD Checklist-Stressor-Specific. PE-PC resulted in larger reduction in PTSD severity and general distress than the minimal contact control. Delayed treatment evidenced medium to large effects comparable to the immediate intervention group. Treatment benefits persisted through the 6-month follow-up of the study. PE-PC delivered in integrated primary care is effective for the treatment of PTSD and co-occurring symptoms and may help reduce barriers and stigma found in specialty care settings. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Patient and clinician views on comparative effectiveness research and engagement in research.

PubMed

Forsythe, Laura P; Frank, Lori; Walker, Kara Odom; Anise, Ayodola; Wegener, Natalie; Weisman, Harlan; Hunt, Gail; Beal, Anne

2015-01-01

Describe and compare patient and primary care clinician attitudes about comparative effectiveness research (CER) and inclusion of patients and clinicians as partners in clinical research. Online survey of patients (n = 900) and primary care clinicians (n = 750) from opt-in survey panels. Nearly half (45%) of clinicians were not familiar with CER, but after reviewing a definition of CER, most (76%) agreed that it can improve patient care. Patients and clinicians indicated interest in engagement as research partners (66% and 55%, respectively). Lack of time was the most commonly endorsed barrier. Attitudes toward CER and engagement in clinical research were generally favorable. Identified facilitators and barriers point to strategies for enhancing patient and clinician engagement in research.

Impact of collaborative care on survival time for dogs with congestive heart failure and revenue for attending primary care veterinarians.

PubMed

Lefbom, Bonnie K; Peckens, Neal K

2016-07-01

OBJECTIVE To assess the effects of in-person collaborative care by primary care veterinarians (pcDVMs) and board-certified veterinary cardiologists (BCVCs) on survival time of dogs after onset of congestive heart failure (CHF) and on associated revenue for the attending pcDVMs. DESIGN Retrospective cohort study. ANIMALS 26 small-breed dogs treated for naturally occurring CHF secondary to myxomatous mitral valve disease at a multilocation primary care veterinary hospital between 2008 and 2013. PROCEDURES Electronic medical records were reviewed to identify dogs with confirmed CHF secondary to myxomatous mitral valve disease and collect information on patient care, survival time, and pcDVM revenue. Data were compared between dogs that received collaborative care from the pcDVM and a BCVC and dogs that received care from the pcDVM alone. RESULTS Dogs that received collaborative care had a longer median survival time (254 days) than did dogs that received care from the pcDVM alone (146 days). A significant positive correlation was identified between pcDVM revenue and survival time for dogs that received collaborative care (ie, the longer the dog survived, the greater the pcDVM revenue generated from caring for that patient). CONCLUSIONS AND CLINICAL RELEVANCE Findings suggested that collaborative care provided to small-breed dogs with CHF by a BCVC and pcDVM could result in survival benefits for affected dogs and increased revenue for pcDVMs, compared with care provided by a pcDVM alone.

Population management, systems-based practice, and planned chronic illness care: integrating disease management competencies into primary care to improve composite diabetes quality measures.

PubMed

Kimura, Joe; DaSilva, Karen; Marshall, Richard

2008-02-01

The increasing prevalence of chronic illnesses in the United States requires a fundamental redesign of the primary care delivery system's structure and processes in order to meet the changing needs and expectations of patients. Population management, systems-based practice, and planned chronic illness care are 3 potential processes that can be integrated into primary care and are compatible with the Chronic Care Model. In 2003, Harvard Vanguard Medical Associates, a multispecialty ambulatory physician group practice based in Boston, Massachusetts, began implementing all 3 processes across its primary care practices. From 2004 to 2006, the overall diabetes composite quality measures improved from 51% to 58% for screening (HgA1c x 2, low-density lipoprotein, blood pressure in 12 months) and from 13% to 17% for intermediate outcomes (HgA1c

Diabetes Mellitus Care Provided by Nurse Practitioners vs Primary Care Physicians.

PubMed

Kuo, Yong-Fang; Goodwin, James S; Chen, Nai-Wei; Lwin, Kyaw K; Baillargeon, Jacques; Raji, Mukaila A

2015-10-01

To compare processes and cost of care of older adults with diabetes mellitus cared for by nurse practitioners (NPs) with processes and cost of those cared for by primary care physicians (PCPs). Retrospective cohort study. Primary care in communities. Individuals with a diagnosis of diabetes mellitus in 2009 who received all their primary care from NPs or PCPs were selected from a national sample of Medicare beneficiaries (N = 64,354). Propensity score matching within each state was used to compare these two cohorts with regard to rate of eye examinations, low-density lipoprotein cholesterol (LDL-C) and glycosylated hemoglobin (HbA1C) testing, nephropathy monitoring, specialist consultation, and Medicare costs. The two groups were also compared regarding medication adherence and use of statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (for individuals with a diagnosis of hypertension), and potentially inappropriate medications (PIMs). Nurse practitioners and PCPs had similar rates of LDL-C testing (odds ratio (OR) = 1.01, 95% confidence interval (CI) = 0.94-1.09) and nephropathy monitoring (OR = 1.05, 95% CI = 0.98-1.03), but NPs had lower rates of eye examinations (OR = 0.89, 95% CI = 0.84-0.93) and HbA1C testing (OR = 0.88, 95% CI = 0.79-0.98). NPs were more likely to have consulted cardiologists (OR = 1.29, 95% CI = 1.21-1.37), endocrinologists (OR = 1.64, 95% CI = 1.48-1.82), and nephrologists (OR = 1.90, 95% CI = 1.67-2.17) and more likely to have prescribed PIMs (OR = 1.07, 95% CI = 1.01-1.12). There was no statistically significant difference in adjusted Medicare spending between the two groups (P = .56). Nurse practitioners were similar to PCPs or slightly lower in their rates of diabetes mellitus guideline-concordant care. NPs used specialist consultations more often but had similar overall costs of care to PCPs. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.

Patients' and health professionals' views on primary care for people with serious mental illness: focus group study

PubMed Central

Lester, Helen; Tritter, Jonathan Q; Sorohan, Helen

2005-01-01

Objective To explore the experience of providing and receiving primary care from the perspectives of primary care health professionals and patients with serious mental illness respectively. Design Qualitative study consisting of six patient groups, six health professional groups, and six combined focus groups. Setting Six primary care trusts in the West Midlands. Participants Forty five patients with serious mental illness, 39 general practitioners (GPs), and eight practice nurses. Results Most health professionals felt that the care of people with serious mental illness was too specialised for primary care. However, most patients viewed primary care as the cornerstone of their health care and preferred to consult their own GP, who listened and was willing to learn, rather than be referred to a different GP with specific mental health knowledge. Swift access was important to patients, with barriers created by the effects of the illness and the noisy or crowded waiting area. Some patients described how they exaggerated symptoms (“acted up”) to negotiate an urgent appointment, a strategy that was also employed by some GPs to facilitate admission to secondary care. Most participants felt that structured reviews of care had value. However, whereas health professionals perceived serious mental illness as a lifelong condition, patients emphasised the importance of optimism in treatment and hope for recovery. Conclusions Primary care is of central importance to people with serious mental illness. The challenge for health professionals and patients is to create a system in which patients can see a health professional when they want to without needing to exaggerate their symptoms. The importance that patients attach to optimism in treatment, continuity of care, and listening skills compared with specific mental health knowledge should encourage health professionals in primary care to play a greater role in the care of patients with serious mental illness. PMID:15843427

Collaborative care for depression in European countries: a systematic review and meta-analysis.

PubMed

Sighinolfi, Cecilia; Nespeca, Claudia; Menchetti, Marco; Levantesi, Paolo; Belvederi Murri, Martino; Berardi, Domenico

2014-10-01

This is a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of collaborative care compared to Primary Care Physician's (PCP's) usual care in the treatment of depression, focusing on European countries. A systematic review of English and non-English articles, from inception to March 2014, was performed using database PubMed, British Nursing Index and Archive, Ovid Medline (R), PsychINFO, Books@Ovid, PsycARTICLES Full Text, EMBASE Classic+Embase, DARE (Database of Abstract of Reviews of Effectiveness) and the Cochrane Library electronic database. Search term included depression, collaborative care, physician family and allied health professional. RCTs comparing collaborative care to usual care for depression in primary care were included. Titles and abstracts were independently examined by two reviewers, who extracted from the included trials information on participants' characteristics, type of intervention, features of collaborative care and type of outcome measure. The 17 papers included, regarding 15 RCTs, involved 3240 participants. Primary analyses showed that collaborative care models were associated with greater improvement in depression outcomes in the short term, within 3 months (standardized mean difference (SMD) -0.19, 95% CI=-0.33; -0.05; p=0.006), medium term, between 4 and 11 months (SMD -0.24, 95% CI=-0.39; -0.09; p=0.001) and medium-long term, from 12 months and over (SMD -0.21, 95% CI=-0.37; -0.04; p=0.01), compared to usual care. The present review, specifically focusing on European countries, shows that collaborative care is more effective than treatment as usual in improving depression outcomes. Copyright © 2014 Elsevier Inc. All rights reserved.

Quality care provision for older people: an interview study with patients and primary healthcare professionals

PubMed Central

van de Pol, Marjolein Helena Johanna; Fluit, Cornelia Rita Maria Gertruda; Lagro, Joep; Niessen, Danielle; Rikkert, Marcellinus Gerardus Maria Olde; Lagro-Janssen, Antoinette Leonarda Maria

2015-01-01

Background In recent years, primary health care for the ageing population has become increasingly complex. Aim This study sought to explore the views and needs of healthcare professionals and older patients relating to primary care in order to identify focal areas for improving primary health care for older people. Design and setting This research was structured as a mixed interview study with focus groups and individual interviews. Participants were made up of primary healthcare professionals and older patients. Patients were recruited from five elderly care homes in a small city in the southern part of the Netherlands. Method All interviews were transcribed verbatim and analysed by two individual researchers applying constant comparative analysis. Data collection proceeded until saturation was reached. Results Participants in the study agreed about the need for primary care for older patients, and showed sympathy with one another’s perspectives. They did note, however, a number of obstacles hindering good healthcare provision. The major themes that arose were: ‘autonomy and independence’, ‘organisational barriers’, and ‘professional expertise’. Participants generally noted that it is important to clarify differences in perspectives about good care between patients and healthcare professionals. Conclusion Effective primary care intervention for older patients requires mutual understanding of the expectations and goals of all parties involved. There are a number of important requirements, especially accessible patient information in the form of care plans; specialist training for nurses and GPs on complex care and multimorbidity; and training on discussing autonomy, goal setting, and shared care. Further improvement in health care for older people and its evaluation research should focus on these requirements. PMID:26212845

Comparison of gastro-oesophageal reflux disease and heartburn diagnoses in UK primary care.

PubMed

Ruigómez, Ana; García Rodríguez, Luis Alberto; Wallander, Mari-Ann; Johansson, Saga; Dent, John

2006-09-01

It is unclear how gastro-oesophageal reflux disease (GORD) is diagnosed in primary care. The aim of this study is to compare patients given a diagnosis of GORD with those diagnosed with heartburn. Data from the UK General Practice Research Database were extracted for patients newly diagnosed with heartburn (n = 1841) or GORD (n = 5318) in 1996. Patient characteristics, morbidity, healthcare use and prescribed treatments were compared using unconditional logistic regression analysis. GORD was diagnosed more frequently than heartburn (3.2 vs. 1.1 per 1000 patient-years). A diagnosis of GORD was less likely among females (odds ratio (OR): 0.8; confidence interval (CI): 0.7-0.9), smokers (OR: 0.8; CI: 0.7-0.9) and patients who consulted their physician frequently (OR: 0.8; CI: 0.7-0.9). There was a wide distribution in the ratio of GORD-to-heartburn diagnoses between primary care practices (mean 2.9; range 0-infinity). GORD patients were more likely to receive proton pump inhibitors (OR: 2.9; CI: 2.6-3.4), but 24% of GORD patients and 40% of heartburn patients received no acid-suppressive treatment in the month after diagnosis. Several factors influenced the diagnosis of gastro-oesophageal reflux symptoms by primary care physicians. Further research is needed to aid the diagnosis of GORD in primary care.

Advanced Practice Pharmacists: a retrospective evaluation of the efficacy and cost of ClinicaL Pharmacist PractitionErs managing ambulatory Medicare patients in North Carolina (APPLE-NC).

PubMed

Kislan, Michèle M; Bernstein, Adam T; Fearrington, Loretta R; Ives, Timothy J

2016-10-21

Clinical Pharmacist Practitioners are advanced practicing pharmacists in North Carolina that provide disease-specific management. The purpose of this retrospective cohort study was to compare the efficacy and charges from referrals to a Clinical Pharmacist Practitioner by the primary care provider, to those managed by a primary care provider alone. Patients were separated into cohorts depending if they had at least two appointments with a Clinical Pharmacist Practitioner from November 2008 to November 2011. A primary care provider saw all patients at least twice during the study period. Cohorts were then matched by age, gender, and disease states. Medicare billed data was evaluated from outpatient visits related to hypertension, diabetes mellitus, and peripheral neuropathy, as well as emergency department visits and inpatient admissions. Cost of medications was estimated using 2009 AWP data corresponding to medication histories within the electronic medical record. Efficacy was defined as ability to reach disease state goal determined using national guidelines and reduction in pain score. Efficacy was analyzed by difference-in-differences test and all other numerical data tested by paired t-tests. The Clinical Pharmacist Practitioners cohort experienced more outpatient visits (1338 vs. 858, p < 0.001), fewer emergency department visits (115 vs. 190, p < 0.05), and similar inpatient admissions (88 vs. 117, p > 0.05) than the primary care providers cohort, respectively. The Clinical Pharmacist Practitioners cohort showed changes in charges of +22.6 % for outpatient visits, -45.5 % emergency department visits, and -13.2 % inpatient admissions relative to the primary care provider cohort. There was no difference in average daily medication cost (Clinical Pharmacist Practitioners $38.52 vs. primary care providers $38.23, p = 0.97) or achievement of disease state goals. APPLE-NC demonstrated that through referrals, Clinical Pharmacist Practitioners provide services comparable in charges and efficacy to primary care providers. Consequently, the current increased need for primary care practitioners can be met in part by increasing the utilization of advanced practice pharmacists for chronic disease management. This does not apply for this retrospective cohort study.

Behavioural activation by mental health nurses for late-life depression in primary care: a randomized controlled trial.

PubMed

Janssen, Noortje; Huibers, Marcus J H; Lucassen, Peter; Voshaar, Richard Oude; van Marwijk, Harm; Bosmans, Judith; Pijnappels, Mirjam; Spijker, Jan; Hendriks, Gert-Jan

2017-06-26

Depressive symptoms are common in older adults. The effectiveness of pharmacological treatments and the availability of psychological treatments in primary care are limited. A behavioural approach to depression treatment might be beneficial to many older adults but such care is still largely unavailable. Behavioural Activation (BA) protocols are less complicated and more easy to train than other psychological therapies, making them very suitable for delivery by less specialised therapists. The recent introduction of the mental health nurse in primary care centres in the Netherlands has created major opportunities for improving the accessibility of psychological treatments for late-life depression in primary care. BA may thus address the needs of older patients while improving treatment outcome and lowering costs.The primary objective of this study is to compare the effectiveness and cost-effectiveness of BA in comparison with treatment as usual (TAU) for late-life depression in Dutch primary care. A secondary goal is to explore several potential mechanisms of change, as well as predictors and moderators of treatment outcome of BA for late-life depression. Cluster-randomised controlled multicentre trial with two parallel groups: a) behavioural activation, and b) treatment as usual, conducted in primary care centres with a follow-up of 52 weeks. The main inclusion criterion is a PHQ-9 score > 9. Patients are excluded from the trial in case of severe mental illness that requires specialized treatment, high suicide risk, drug and/or alcohol abuse, prior psychotherapy, change in dosage or type of prescribed antidepressants in the previous 12 weeks, or moderate to severe cognitive impairment. The intervention consists of 8 weekly 30-min BA sessions delivered by a trained mental health nurse. We expect BA to be an effective and cost-effective treatment for late-life depression compared to TAU. BA delivered by mental health nurses could increase the availability and accessibility of non-pharmacological treatments for late-life depression in primary care. This study is retrospectively registered in the Dutch Clinical Trial Register NTR6013 on August 25th 2016.

Choice of primary health care source in an urbanized low-income community in Singapore: a mixed-methods study.

PubMed

Wee, Liang En; Lim, Li Yan; Shen, Tong; Lee, Elis Yuexian; Chia, Yet Hong; Tan, Andrew Yen Siong; Koh, Gerald Choon-Huat

2014-02-01

Cost and misperceptions may discourage lower income Singaporeans from utilizing primary care. We investigated sources of primary care in a low-income Singaporean community in a mixed-methods study. Residents of a low-income public rental flat neighbourhood were asked for sociodemographic details and preferred source of primary care relative to their higher income neighbours. In the qualitative component, interviewers elicited, from patients and health care providers, barriers/enablers to seeking care from Western-trained doctors. Interviewees were selected via purposive sampling. Transcripts were analyzed thematically, and iterative analysis was carried out using established qualitative method. Participation was 89.8% (359/400). Only 11.1% (40/359) preferred to approach Western-trained doctors, 29.5% (106/359) preferred alternative medicine, 6.7% (24/359) approached family/friends and 52.6% (189/359) preferred self-reliance. Comparing against higher income neighbours, rental flat residents were more likely to turn to alternative medicine and family members but less likely to turn to Western-trained doctors (P < 0.001). For the qualitative component, a total of 20 patients and 9 providers were interviewed before data saturation was reached. Patient and provider comments fell into the following content areas: primary care characteristics, knowledge, costs, priorities, attitudes and information sources. Self-reliance was perceived as acceptable for 'small' illnesses but not for 'big' ones, communal spirit was cited as a reason for consulting family/friends and social distance from primary care practitioners was highlighted as a reason for not consulting Western-trained doctors. Western-trained physicians are not the first choice of lower income Singaporeans for seeking primary care. Knowledge, primary care characteristics and costs were identified as potential barriers/enablers.

Pediatric asthma hospitalizations among urban minority children and the continuity of primary care.

PubMed

Utidjian, Levon H; Fiks, Alexander G; Localio, A Russell; Song, Lihai; Ramos, Mark J; Keren, Ron; Bell, Louis M; Grundmeier, Robert W

2017-12-01

To examine the effect of ambulatory health care processes on asthma hospitalizations. A retrospective cohort study using electronic health records was completed. Patients aged 2-18 years receiving health care from 1 of 5 urban practices between Jan 1, 2004 and Dec 31, 2008 with asthma documented on their problem list were included. Independent variables were modifiable health care processes in the primary care setting: (1) use of asthma controller medications; (2) regular assessment of asthma symptoms; (3) use of spirometry; (4) provision of individualized asthma care plans; (5) timely influenza vaccination; (6) access to primary healthcare; and (7) use of pay for performance physician incentives. Occurrence of one or more asthma hospitalizations was the primary outcome of interest. We used a log linear model (Poisson regression) to model the association between the factors of interest and number of asthma hospitalizations. 5,712 children with asthma were available for analysis. 96% of the children were African American. The overall hospitalization rate was 64 per 1,000 children per year. None of the commonly used asthma-specific indicators of high quality care were associated with fewer asthma hospitalizations. Children with documented asthma who experienced a lack of primary health care (no more than one outpatient visit at their primary care location in the 2 years preceding hospitalization) were at higher risk of hospitalization compared to those children with a greater number of visits (incidence rate ratio 1.39; 95% CI 1.09-1.78). In children with asthma, more frequent primary care visits are associated with reduced asthma hospitalizations.

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.

Patients' experiences in different models of community health centers in southern China.

PubMed

Wang, Harry H X; Wong, Samuel Y S; Wong, Martin C S; Wei, Xiao Lin; Wang, Jia Ji; Li, Donald K T; Tang, Jin Ling; Gao, Gemma Y; Griffiths, Sian M

2013-01-01

Current health care reforms in China have an overall goal of strengthening primary care through the establishment and expansion of primary care networks based on community health centers (CHCs). Implementation in urban areas has led to the emergence of different models of ownership and management. The objective of this study was to evaluate the primary care experiences of patients in the Pearl River Delta as measured by the Primary Care Assessment Tool (PCAT) and the relationships with ownership and management in the 3 different models we describe. This cross-sectional study was conducted on-site at CHCs in 3 cities within the Pearl River Delta, China, using a multistage cluster sampling method. A validated Mandarin Chinese version of the PCAT-Adult Edition (short version) was adopted to collect information from adult patients regarding their experiences with primary care sources. PCAT scores for individual primary care attributes and total primary care assessment scores were assessed with respect to sociodemographic characteristics, health characteristics, and health care service utilization across 3 primary care models. One thousand four hundred forty (1,440) primary care patients responded to the survey, for an overall response rate of 86.1%. Respondents gave government-owned and -managed CHCs the highest overall PCAT scores when compared with CHCs either managed by hospitals (95.18 vs 90.81; P = .005) or owned by private and social entities (95.18 vs 90.69; P =.007) as a result of better first-contact care (better first-contact utilization) and coordination of care (better service coordination and information system). Factors that were positively and significantly associated with higher overall assessment scores included the presence of a chronic condition (P <.001), having medical insurance (P = .006), and a self-reported good health status (P <.001). This study suggests that government-owned and -managed CHCs may be able to provide better first-contact care in terms of utilization and coordination of care, and may be better at solving the problem of underutilization of the CHCs as the first-contact point of care, one key problem facing the reforms in China.

Mental health in the Dutch population and in general practice: 1987–2001

PubMed Central

Verhaak, Peter FM; Hoeymans, Nancy; Garssen, Anna A; Westert, Gert P

2005-01-01

Background In the last 15 years, both the demand for and supply of specialised mental health care increased considerably in the Netherlands. Increased demand may reflect a change in psychological morbidity, but may also be a consequence of increased supply. Specialised health care in the Netherlands is accessible only through referral by a GP, and so it is important to consider the role of primary care in the diagnosis of mental health problems. Aim The aim of this study is to achieve a better understanding of the development of mental health status in the Dutch population and the consequent help-seeking behaviour in primary care. Method Using two comparable morbidity studies carried out in the Dutch population and in primary care, we compared data from 1987 and 2001 to assess the following: possible differences in mental health between 1987 and 2001; possible differences in prevalence of mental disorder as diagnosed by GPs in 1987 and 2001; possible differences in the sociodemographic determinants of mental health and mental disorder in primary care between 1987 and 2001. Results Our results show an increase in mental and social problems in the population between 1987 and 2001. However, GPs diagnosed fewer patients as having a mental disorder in 2001 than they did in 1987. The risk of mental disorders or social problems in several sociodemographic groups remained largely the same, as did the chance of receiving a psychological or social diagnosis. Conclusion We conclude that, while mental disorder in the population is increasing, the role of primary care has changed. Although GPs diagnose a lower percentage of mental problems as such, they refer an increasingly larger proportion of these to secondary care. PMID:16212852

The effect of primary midwife-led care on women's experience of childbirth: results from the COSMOS randomised controlled trial.

PubMed

McLachlan, H L; Forster, D A; Davey, M-A; Farrell, T; Flood, M; Shafiei, T; Waldenström, U

2016-02-01

To determine the effect of primary midwife-led care ('caseload midwifery') on women's experiences of childbirth. Randomised controlled trial. Tertiary care women's hospital in Melbourne, Australia. A total of 2314 low-risk pregnant women. Women randomised to caseload care received antenatal, intrapartum and postpartum care from a primary midwife, with some care provided by a 'back-up' midwife. Women in standard care received midwifery-led care with varying levels of continuity, junior obstetric care or community-based medical care. The primary outcome of the study was caesarean section. This paper presents a secondary outcome, women's experience of childbirth. Women's views and experiences were sought using seven-point rating scales via postal questionnaires 2 months after the birth. A total of 2314 women were randomised between September 2007 and June 2010; 1156 to caseload and 1158 to standard care. Response rates to the follow-up questionnaire were 88 and 74%, respectively. Women in the caseload group were more positive about their overall birth experience than women in the standard care group (adjusted odds ratio 1.50, 95% CI 1.22-1.84). They also felt more in control during labour, were more proud of themselves, less anxious, and more likely to have a positive experience of pain. Compared with standard maternity care, caseload midwifery may improve women's experiences of childbirth. Primary midwife-led care ('caseload midwifery') improves women's experiences of childbirth. © 2015 Royal College of Obstetricians and Gynaecologists.

Providers' Access of Imaging Versus Only Reports: A System Log File Analysis.

PubMed

Jung, Hye-Young; Gichoya, Judy Wawira; Vest, Joshua R

2017-02-01

An increasing number of technologies allow providers to access the results of imaging studies. This study examined differences in access of radiology images compared with text-only reports through a health information exchange system by health care professionals. The study sample included 157,256 historical sessions from a health information exchange system that enabled 1,670 physicians and non-physicians to access text-based reports and imaging over the period 2013 to 2014. The primary outcome was an indicator of access of an imaging study instead of access of a text-only report. Multilevel mixed-effects regression models were used to estimate the association between provider and session characteristics and access of images compared with text-only reports. Compared with primary care physicians, specialists had an 18% higher probability of accessing actual images instead of text-only reports (β = 0.18; P < .001). Compared with primary care practice settings, the probability of accessing images was 4% higher for specialty care practices (P < .05) and 8% lower for emergency departments (P < .05). Radiologists, orthopedists, and neurologists accounted for 79% of all the sessions with actual images accessed. Orthopedists, radiologists, surgeons, and pulmonary disease specialists accessed imaging more often than text-based reports only. Consideration for differences in the need to access images compared with text-only reports based on the type of provider and setting of care are needed to maximize the benefits of image sharing for patient care. Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Adult community health-promoting interventions in primary health care: A systematic review.

PubMed

March, Sebastià; Torres, Elena; Ramos, María; Ripoll, Joana; García, Atanasio; Bulilete, Oana; Medina, David; Vidal, Clara; Cabeza, Elena; Llull, Micaela; Zabaleta-del-Olmo, Edurne; Aranda, José Manuel; Sastre, Silvia; Llobera, Joan

2015-07-01

To examine evidence on the effectiveness of health-promoting community interventions carried out in primary health care. Systematic review of originals and systematic reviews of health-promoting community interventions with the participation of primary health care. A working definition of community activities was used in the inclusion criteria. Databases searched up to 2013: PUBMED, EMBASE, CINHAL, Web of SCIENCE, IBECS, IME, and PSICODOC. No restrictions on year of publication or design. Articles were reviewed by separate researchers to identify risks of bias. Fifty-one articles published between 1966 and 2013 were included: 11 systematic reviews and 40 originals that described 39 community interventions. There is evidence on the effectiveness of community interventions in reducing cardiovascular risk factors, encouraging physical exercise, preventing falls and improving self-care among chronic patients compared with usual individual care. The effectiveness of some interventions increases when the community is involved in their development. Most assessments show positive results despite design limitations. The community approach may be more effective than the individual in usual preventive interventions in primary care. There is a lack of evidence on many community interventions in primary care and further research is needed. Copyright © 2015 Elsevier Inc. All rights reserved.

Effectiveness of collaborative stepped care for anxiety disorders in primary care: a pragmatic cluster randomised controlled trial.

PubMed

Muntingh, Anna; van der Feltz-Cornelis, Christina; van Marwijk, Harm; Spinhoven, Philip; Assendelft, Willem; de Waal, Margot; Adèr, Herman; van Balkom, Anton

2014-01-01

Collaborative stepped care (CSC) may be an appropriate model to provide evidence-based treatment for anxiety disorders in primary care. In a cluster randomised controlled trial, the effectiveness of CSC compared to care as usual (CAU) for adults with panic disorder (PD) or generalised anxiety disorder (GAD) in primary care was evaluated. Thirty-one psychiatric nurses who provided their services to 43 primary care practices in the Netherlands were randomised to deliver CSC (16 psychiatric nurses, 23 practices) or CAU (15 psychiatric nurses, 20 practices). CSC was provided by the psychiatric nurses (care managers) in collaboration with the general practitioner and a consultant psychiatrist. The intervention consisted of 3 steps, namely guided self-help, cognitive behavioural therapy and antidepressants. Anxiety symptoms were measured with the Beck Anxiety Inventory (BAI) at baseline and after 3, 6, 9 and 12 months. We recruited 180 patients with a DSM-IV diagnosis of PD or GAD, of whom 114 received CSC and 66 received usual primary care. On the BAI, CSC was superior to CAU [difference in gain scores from baseline to 3 months: -5.11, 95% confidence interval (CI) -8.28 to -1.94; 6 months: -4.65, 95% CI -7.93 to -1.38; 9 months: -5.67, 95% CI -8.97 to -2.36; 12 months: -6.84, 95% CI -10.13 to -3.55]. CSC, with guided self-help as a first step, was more effective than CAU for primary care patients with PD or GAD.

Primary Care Resident Perceived Preparedness to Deliver Cross-cultural Care: An Examination of Training and Specialty Differences

PubMed Central

Park, Elyse R.; Green, Alexander R.; Betancourt, Joseph R.; Weissman, Joel S.

2007-01-01

Objective Previous research has shown that resident physicians report differences in training across primary care specialties, although limited data exist on education in delivering cross-cultural care. The goals of this study were to identify factors that relate to primary care residents’ perceived preparedness to provide cross-cultural care and to explore the extent to which these perceptions vary across primary care specialties. Design Cross-sectional, national mail survey of resident physicians in their last year of training. Participants Eleven hundred fifty primary care residents specializing in family medicine (27%), internal medicine (23%), pediatrics (26%), and obstetrics/gynecology (OB/GYN) (24%). Results Male residents as well as those who reported having graduated from U.S. medical schools, access to role models, and a greater cross-cultural case mix during residency felt more prepared to deliver cross-cultural care. Adjusting for these demographic and clinical factors, family practice residents were significantly more likely to feel prepared to deliver cross-cultural care compared to internal medicine, pediatric, and OB/GYN residents. Yet, when the quantity of instruction residents reported receiving to deliver cross-cultural care was added as a predictor, specialty differences became nonsignificant, suggesting that training opportunities better account for the variability in perceived preparedness than specialty. Conclusions Across primary care specialties, residents reported different perceptions of preparedness to deliver cross-cultural care. However, this variation was more strongly related to training factors, such as the amount of instruction physicians received to deliver such care, rather than specialty affiliation. These findings underscore the importance of formal education to enhance residents’ preparedness to provide cross-cultural care. PMID:17516107

Patients living with disabilities: The need for high-quality primary care.

PubMed

Lofters, Aisha; Guilcher, Sara; Maulkhan, Niraj; Milligan, James; Lee, Joseph

2016-08-01

To compare the potential risk factors for lower-quality primary care, the potential markers of unmet needs in primary care, and the willingness to participate in future research among primary care patients with versus without physical disabilities. A waiting room survey using a convenience sample. A family health team (FHT) in Kitchener-Waterloo, Ont, with a designated Mobility Clinic. A total of 40 patients seen at the FHT Mobility Clinic and 80 patients from the general patient population of the same FHT. Socioeconomic status and social capital, number of self-reported emergency department visits and hospitalizations in the preceding year, and willingness of the patients in the 2 groups to participate in future research studies. Patients from the Mobility Clinic were more than twice as likely to be receiving benefits or social assistance (75.0% vs 32.1%, P < .001), were twice as likely to report an annual household income of less than $40000 (58.6% vs 29.2%, P = .006), and were more likely to report their health status to be fair or poor (42.5% vs 16.2%, P = .002). Half of Mobility Clinic patients had visited the emergency department at least once in the preceding year, compared with 29.7% in the general patient population (P = .027). When asked if they would be willing to provide their health card number in the future so that it could be linked to health care data for research, 82.5% of Mobility Clinic patients agreed versus 55.0% of those in the general patient population (P = .004). In this study, patients with disabilities were at a social disadvantage compared with their peers without disabilities and were more likely to use the emergency department, suggesting that they had unmet health needs. Future research should continue to explore this patient population and to investigate if an interprofessional primary health care team approach focused on patients with disabilities can help to increase quality of care. Copyright© the College of Family Physicians of Canada.

A quality improvement project aimed at adapting primary care to ensure the delivery of evidence-based psychotherapy for adult anxiety.

PubMed

Williams, Mark D; Sawchuk, Craig N; Shippee, Nathan D; Somers, Kristin J; Berg, Summer L; Mitchell, Jay D; Mattson, Angela B; Katzelnick, David J

2018-01-01

Primary care patients frequently present with anxiety with prevalence ratios up to 30%. Brief cognitive-behavioural therapy (CBT) has been shown in meta-analytic studies to have a strong effect size in the treatment of anxiety. However, in surveys of anxious primary care patients, nearly 80% indicated that they had not received CBT. In 2010, a model of CBT (Coordinated Anxiety Learning and Management (CALM)) adapted to primary care for adult anxiety was published based on results of a randomised controlled trial. This project aimed to integrate an adaptation of CALM into one primary care practice, using results from the published research as a benchmark with the secondary intent to spread a successful model to other practices. A quality improvement approach was used to translate the CALM model of CBT for anxiety into one primary care clinic. Plan-Do-Study-Act steps are highlighted as important steps towards our goal of comparing our outcomes with benchmarks from original research. Patients with anxiety as measured by a score of 10 or higher on the Generalized Anxiety Disorder 7 item scale (GAD-7) were offered CBT as delivered by licensed social workers with support by a PhD psychologist. Outcomes were tracked and entered into an electronic registry, which became a critical tool upon which to adapt and improve our delivery of psychotherapy to our patient population. Challenges and adaptations to the model are discussed. Our 6-month response rates on the GAD-7 were 51%, which was comparable with that of the original research (57%). Quality improvement methods were critical in discovering which adaptations were needed before spread. Among these, embedding a process of measurement and data entry and ongoing feedback to patients and therapists using this data are critical step towards sustaining and improving the delivery of CBT in primary care.

Comparison of two European paediatric emergency departments: does primary care organisation influence emergency attendance?

PubMed

Poropat, F; Heinz, P; Barbi, E; Ventura, A

2017-03-08

To compare paediatric Emergency Department (ED) attendances and admission outcomes in two European hospitals with different paediatric primary care set-up. This is a retrospective prevalence study comparing all paediatric ED attendances during calendar years 2013 in two EDs with similar catchment area: one in Italy (Trieste) where paediatric primary care is provided by office paediatricians, the other, in the UK (Cambridge), where paediatric primary care is provided by general practitioners. Data on reason for presentation, discharge diagnosis and admission rate were collected and sub-group analysis for specific age groups (<1 year, 1-4 years, 5-15 years) was performed. Over 12 months, 20.331 children (0-15 years old) were seen in Cambridge and 18.646 in Trieste, with a very similar age distribution in both centres, except for the youngest age group: the percentage of infants seen in comparison with the total number of children attending ED was 1/3 higher in England than in Italy (15.4% vs 11.4%). The reasons for attendance were similar: under 1 year of age, the chief complaints were fever, breathing difficulties and gastrointestinal problems while in the older age groups trauma represented the commonest reason. Among discharge diagnoses, no differences were found between the two hospitals, except for faltering growth and "well child", more frequently diagnosed in English children under 5 years. The proportion of admissions was three times higher in Cambridge (14.1% vs 4.8%) with most children being admitted for infectious diseases. ED attendances in infants are more common in a primary care setting provided by general practicioner and, moreover, admission rates in all age groups are 1/3 reduced by primary care based paediatricians. Due to the methodological limits of this study, it isn't possible to evaluate whether these results depend only on paediatric primary care set-up or be determined by other confounding factors. New studies are needed to confirm this preliminary evidence.

Treating Depression in Staff-Model Versus Network-Model Managed Care Organizations

PubMed Central

Meredith, Lisa S; Rubenstein, Lisa V; Rost, Kathryn; Ford, Daniel E; Gordon, Nancy; Nutting, Paul; Camp, Patti; Wells, Kenneth B

1999-01-01

OBJECTIVE To compare primary care providers’ depression-related knowledge, attitudes, and practices and to understand how these reports vary for providers in staff or group-model managed care organizations (MCOs) compared with network-model MCOs including independent practice associations and preferred provider organizations. DESIGN Survey of primary care providers’ depression-related practices in 1996. SETTING AND PARTICIPANTS We surveyed 410 providers, from 80 outpatient clinics, in 11 MCOs participating in four studies designed to improve the quality of depression care in primary care. MEASUREMENTS AND MAIN RESULTS We measured knowledge based on depression guidelines, attitudes (beliefs about burden, skill, and barriers) related to depression, and reported behavior. Providers in both types of MCO are equally knowledgeable about treating depression (better knowledge of pharmacologic than psychotherapeutic treatments) and perceive equivalent skills in treating depression. However, compared with network-model providers, staff/group-model providers have stronger beliefs that treating depression is burdensome to their practice. While more staff/group-model providers reported time limitations as a barrier to optimal depression treatment, more network-model providers reported limited access to mental health specialty referral as a barrier. Accordingly, these staff/group-model providers are more likely to treat patients with major depression through referral (51% vs 38%) or to assess but not treat (17% vs 7%), and network-model providers are more likely to prescribe antidepressants (57% vs 6%) as first-line treatment. CONCLUSIONS Whereas the providers from staff/group-model MCOs had greater access to and relied more on referral, the providers from network-model organizations were more likely to treat depression themselves. Given varying attitudes and behaviors, improving primary care for the treatment of depression will require unique strategies beyond enhancing technical knowledge for the two types of MCOs. PMID:9893090

Primary health care utilization by immigrants as compared to the native population: a multilevel analysis of a large clinical database in Catalonia.

PubMed

Muñoz, Miguel-Angel; Pastor, Esther; Pujol, Joan; Del Val, José Luis; Cordomí, Silvia; Hermosilla, Eduardo

2012-06-01

Immigration is a relevant public health issue and there is a great deal of controversy surrounding its impact on health services utilization. To determine differences between immigrants and non-immigrants in the utilization of primary health care services in Catalonia, Spain. Population based, cross-sectional, multicentre study. We used the information from 16 primary health care centres in an area near Barcelona, Spain. We conducted a multilevel analysis for the year 2008 to compare primary health care services utilization between all immigrants aged 15 or more and a sample of non-immigrants, paired by age and sex. Overall, immigrants living in Spain used health services more than non-immigrants (Incidence Risk Ratio (IRR) 1.16 (95% Confidence Interval (CI): 1.15-1.16) and (IRR 1, 26, 95% CI: 1.25-1.28) for consultations with GPs and referrals to specialized care, respectively. People coming from the Maghreb and the rest of Africa requested the most consultations involving a GP and nurses (IRR 1.34, 95% CI: 1.33-1.36 and IRR 1.06, 95% CI: 1.03-1.44, respectively). They were more frequently referred to specialized care (IRR 1.44, 95% CI: 1.41-1.46) when compared to Spaniards. Immigrants from Asia had the lowest numbers of consultations with a GP and referrals (IRR 0.76, 95% CI: 0.66-0.88 and IRR 0.76, 95% CI: 0.61-0.95, respectively. On average, immigrants living in Catalonia used the health services more than non-immigrants. Immigrants from the Maghreb and other African countries showed the highest and those from Asia the lowest, number of consultations and referrals to specialized care.

Physicians' perceptions of capacity building for managing chronic disease in seniors using integrated interprofessional care models.

PubMed

Lee, Linda; Heckman, George; McKelvie, Robert; Jong, Philip; D'Elia, Teresa; Hillier, Loretta M

2015-03-01

To explore the barriers to and facilitators of adapting and expanding a primary care memory clinic model to integrate care of additional complex chronic geriatric conditions (heart failure, falls, chronic obstructive pulmonary disease, and frailty) into care processes with the goal of improving outcomes for seniors. Mixed-methods study using quantitative (questionnaires) and qualitative (interviews) methods. Ontario. Family physicians currently working in primary care memory clinic teams and supporting geriatric specialists. Family physicians currently working in memory clinic teams (n = 29) and supporting geriatric specialists(n = 9) were recruited as survey participants. Interviews were conducted with memory clinic lead physicians (n = 16).Statistical analysis was done to assess differences between family physician ratings and geriatric specialist ratings related to the capacity for managing complex chronic geriatric conditions, the role of interprofessional collaboration within primary care, and funding and staffing to support geriatric care. Results from both study methods were compared to identify common findings. Results indicate overall support for expanding the memory clinic model to integrate care for other complex conditions. However, the current primary care structure is challenged to support optimal management of patients with multiple comorbidities, particularly as related to limited funding and staffing resources. Structured training, interprofessional teams, and an active role of geriatric specialists within primary care were identified as important facilitators. The memory clinic model, as applied to other complex chronic geriatric conditions, has the potential to build capacity for high-quality primary care, improve health outcomes,promote efficient use of health care resources, and reduce healthcare costs.

Effectiveness and cost effectiveness of counselling in primary care.

PubMed

Bower, P; Rowland, N

2006-07-19

The prevalence of mental health and psychosocial problems in primary care is high. This review examines the clinical and cost-effectiveness of psychological therapies provided in primary care by counsellors. To assess the effectiveness and cost effectiveness of counselling in primary care by reviewing cost and outcome data in randomised controlled trials for patients with psychological and psychosocial problems considered suitable for counselling. To update the review, the following electronic databases were searched on 25-10-2005: MEDLINE, EMBASE, PsycLIT, CINAHL, the Cochrane Controlled Trials register and the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers. All controlled trials comparing counselling in primary care with other treatments for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of June 2005 were included in the review. Data were extracted using a standardised data extraction sheet. Trials were rated for quality using CCDAN criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. Eight trials were included in the review. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar. Counselling is associated with modest improvement in short-term outcome compared to usual care, but provides no additional advantages in the long-term. Patients are satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs.

The roles and training of primary care doctors: China, India, Brazil and South Africa.

PubMed

Mash, Robert; Almeida, Magda; Wong, William C W; Kumar, Raman; von Pressentin, Klaus B

2015-12-04

China, India, Brazil and South Africa contain 40% of the global population and are key emerging economies. All these countries have a policy commitment to universal health coverage with an emphasis on primary health care. The primary care doctor is a key part of the health workforce, and this article, which is based on two workshops at the 2014 Towards Unity For Health Conference in Fortaleza, Brazil, compares and reflects on the roles and training of primary care doctors in these four countries. Key themes to emerge were the need for the primary care doctor to function in support of a primary care team that provides community-orientated and first-contact care. This necessitates task-shifting and an openness to adapt one's role in line with the needs of the team and community. Beyond clinical competence, the primary care doctor may need to be a change agent, critical thinker, capability builder, collaborator and community advocate. Postgraduate training is important as well as up-skilling the existing workforce. There is a tension between training doctors to be community-orientated versus filling the procedural skills gaps at the facility level. In training, there is a need to plan postgraduate education at scale and reform the system to provide suitable incentives for doctors to choose this as a career path. Exposure should start at the undergraduate level. Learning outcomes should be socially accountable to the needs of the country and local communities, and graduates should be person-centred comprehensive generalists.

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.

Are Michigan State University medical school (MSU-CHM) alumni more likely to practice in the region of their graduate medical education primary care program compared to non-MSU-CHM alumni?

PubMed

Switzer, Richard; VandeZande, Luke; Davis, Alan T; Koehler, Tracy J

2018-05-24

Over the past 10 years, three new MD schools have been created in the state of Michigan, while the Michigan State University College of Human Medicine (MSU-CHM) has increased their class size to 850 students. The aim of this study was to determine if MSU-CHM alumni who graduate from an MSU-affiliated primary care residency from a single graduate medical education (GME) training program in Michigan are more likely to go on to practice in close proximity to the location of their training program immediately after graduation compared to non MSU-CHM alumni. Changes over time in the proportion of primary care graduates who received fellowship training immediately following residency were also compared between these groups. A review of historical data was performed for all 2000-2016 primary care (Family Medicine, FM; Internal Medicine, IM; Internal Medicine-Pediatrics, IMP; Pediatrics, Peds) program graduates sponsored by Grand Rapids Medical Education Partners (GRMEP). Study variables included primary care program, gender, age at graduation, fellowship training, practice location immediately after graduation and undergraduate medical education location. Summary statistics were calculated for the data. Comparisons were made using the chi-square test or Fisher's Exact test when appropriate. Significance was assessed at p < 0.05. There were 478 primary care program graduates who went into practice immediately following graduation, 102 of whom also graduated from MSU-CHM. Just over half of the graduates were female and the average age at graduation was 32 years. There were 152 FM, 150 IM, 50 IMP and 126 Peds graduates. Those that graduated from both MSU-CHM and GRMEP were more likely to practice in Michigan immediately after residency training (79.4% vs 52.0%; p < 0.001), as well as within 100 miles of GRMEP (71.6% vs 46.4%; p < 0.001). There were 8% of MSU-CHM primary care graduates who went on to fellowship training from 2000 to 2009, increasing to 34% from 2010 to 2016 (p < 0.001). Medical school graduates of MSU-CHM who receive GME training in primary care are more likely to practice medicine within close proximity to their training site than non MSU-CHM graduates. However, plans for fellowship after training may add one caveat to this finding.

Short report: factors that affect specialty choice and career plans of Wisconsin's medical students.

PubMed

Knox, Kjersti E; Getzin, Anne; Bergum, Alison; McBride, Patrick; Rieselbach, Richard; Friedsam, Donna

2008-12-01

To identify factors that influence specialty choice among Wisconsin medical students and provide insight into approaches to encourage more students to pursue careers in primary care. The importance of several factors in medical student career choice was surveyed using a Web survey convenience sample of all Wisconsin medical students. Students intending to pursue a career in primary care and in other specialties were compared. Respondents, regardless of specialty choice or gender, identified a similar group of factors as highly influential, and similar group of factors as non-influential in their decision-making. However, significantly more primary care students than other specialty students considered interest in underserved populations, relationships with patients, scope of practice, and role models important in their career choice. Significantly more primary care students than other specialty students responded that salary and competitiveness were "not at all" important. A greater number of other specialty students than primary care students stated that interest in scope of practice, role models, and training years were "not at all" important. Debt-related factors were reported as "not at all" important by nearly one-third of respondents. Although primary care and other specialty students report making their career plans based on the impact of similar factors, significant differences between primary care and other specialty students were reported in key areas. These results validate many previously reported factors, and indicate that salary and years of training may have been overemphasized in understanding student career choice. The results of this survey may be useful for Wisconsin medical schools in order to sustain, support, and foster student interest in primary care.

Patient costs in anticoagulation management: a comparison of primary and secondary care.

PubMed Central

Parry, D; Bryan, S; Gee, K; Murray, E; Fitzmaurice, D

2001-01-01

BACKGROUND: The demand for anticoagulation management is increasing. This has led to care being provided in non-hospital settings. While clinical studies have similarly demonstrated good clinical care in these settings, it is still unclear as to which alternative is the most efficient. AIM: To determine the costs borne by patients when attending an anticoagulation management clinic in either primary or secondary care and to use this information to consider the cost-effectiveness of anticoagulation management in primary and secondary care, both from the National Health Service and patient perspectives. DESIGN OF STUDY: Observational study comparing two cohorts of patients currently attending anticoagulation management clinics. SETTING: Four primary care clinics in Birmingham and one in Warwickshire, and the haematology clinics at the University of Birmingham Hospitals Trust and the City Hospital NHS Trust. METHOD: The survey of patients attending the clinics was used to ascertain patient costs. This information was then used in conjunction with the findings of a recent randomised controlled trial to establish cost-effectiveness. RESULTS: Patient costs were lower in primary care than in secondary care settings; the mean (standard deviation) costs per visit were Pound Sterling6.78 (Pound Sterling5.04) versus Pound Sterling14.58 (Pound Sterling9.08). While a previous cost-effectiveness analysis from a health sector perspective alone found a higher cost for primary care, the adoption of the societal perspective lead to a marked change in the result: a similar total cost per patient in both sectors. CONCLUSION: There are significantly higher costs borne by patients attending secondary care anticoagulation management clinics than similar patients attending primary care clinics. This study also demonstrates that the perspective adopted in an economic evaluation can influence the final result. PMID:11766869

Renin angiotensin-aldosterone system (RAAS) blockers usage among type II diabetes mellitus patients-A Retrospective Study.

PubMed

Ng, Yen Ping; Balasubramanian, Ganesh Pandian; Heng, Yi Ping; Kalaiselvan, Meera; Teh, Yu Wen; Cheong, Kin Man; Hadi, Muhammad Faiz Bin Abdul; Othman, Rosmaliza Bt

2018-05-01

Recent data showed an alarming rise of new dialysis cases secondary to diabetic nephropathy despite the growing usage of RAAS blockers. Primary objective of this study is to explore the prevalence of RAAS blockers usage among type II diabetic patients, secondary objectives are to compare the prescribing pattern of RAAS blocker between primary and tertiary care center and to explore if the dose of RAAS blocker prescribed was at optimal dose as suggested by trials. This is a retrospective study conducted at one public tertiary referral hospital and one public health clinic in Sungai Petani, Kedah, Malaysia. RAAS blockers in T2DM patients was found to be 65%. In primary care, 14.3% of the RAAS blockers prescribed was ARB. Tertiary care had higher utilization of ARB, which was 42.9%. In primary care setting, the most commonly used ACEI were perindopril (92.4%) followed by enalapril (7.6%), meanwhile perindopril was the only ACEI being prescribed in tertiary care. The most prescribed ARB was irbesartan (63.6%) and telmisartan (54.2%) respectively in primary and tertiary care. Overall, 64.9% of RAAS blockers prescribed by both levels of care were found to be achieving the target dose as recommended in landmark trials. Crude odd ratio of prescribing RAAS blocker in primary care versus tertiary care was reported as 2.70 (95% CI: 1.49 to 4.91). RAAS blockers usage among T2DM patients was higher in primary care versus tertiary care settings. Majority of the patients did not receive optimal dose of RAAS blockers. Copyright © 2017 Diabetes India. Published by Elsevier Ltd. All rights reserved.

A review of recent literature - nurse case managers in diabetes care: equivalent or better outcomes compared to primary care providers.

PubMed

Watts, Sharon A; Lucatorto, Michelle

2014-07-01

Primary care has changed remarkably with chronic disease burden growth. Nurse case managers assist with this chronic disease by providing if not significantly better care, than equivalent care to that provided by usual primary care providers. Chronic disease management requires patient-centered skills and tools, such as registries, panel management, review of home data, communicating with patients outside of face-to-face care, and coordinating multiple services. Evidence reviewed in this article demonstrates that registered nurse care managers (RNCM) perform many actions required for diabetes chronic disease management including initiation and titration of medications with similar or improved physiologic and patient satisfaction outcomes over usual care providers. Selection and training of the nurse case managers is of utmost importance for implementation of a successful chronic disease management program. Evidence based guidelines, algorithms, protocols, and adequate ongoing education and mentoring are generally cited as necessary support tools for the nurse case managers.

Clinical characteristics of persistent frequent attenders in primary care: case-control study.

PubMed

Patel, Shireen; Kai, Joe; Atha, Christopher; Avery, Anthony; Guo, Boliang; James, Marilyn; Malins, Samuel; Sampson, Christopher; Stubley, Michelle; Morriss, Richard

2015-12-01

Most frequent attendance in primary care is temporary, but persistent frequent attendance is expensive and may be suitable for psychological intervention. To plan appropriate intervention and service delivery, there is a need for research involving standardized psychiatric interviews with assessment of physical health and health status. To compare the mental and physical health characteristics and health status of persistent frequent attenders (FAs) in primary care, currently and over the preceding 2 years, with normal attenders (NAs) matched by age, gender and general practice. Case-control study of 71 FAs (30 or more GP or practice nurse consultations in 2 years) and 71 NAs, drawn from five primary care practices, employing standardized psychiatric interview, quality of life, health anxiety and primary care electronic record review over the preceding 2 years. Compared to NAs, FAs were more likely to report a lower quality of life (P < 0.001), be unmarried (P = 0.03) and have no educational qualifications (P = 0.009) but did not differ in employment status. FAs experienced greater health anxiety (P < 0.001), morbid obesity (P = 0.02), pain (P < 0.001) and long-term pathological and ill-defined physical conditions (P < 0.001). FAs had more depression including dysthymia, anxiety and somatoform disorders (all P < 0.001). Persistent frequent attendance in primary care was associated with poor quality of life and high clinical complexity characterized by diverse and often persistent physical and mental multimorbidity. A brokerage model with GPs working in close liaison with skilled psychological therapists is required to manage such persistent complexity. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Economic evaluation of a primary care trial to reduce weight gain in overweight/obese children: the LEAP trial.

PubMed

Wake, Melissa; Gold, Lisa; McCallum, Zoë; Gerner, Bibi; Waters, Elizabeth

2008-01-01

A common policy response to the childhood obesity epidemic is to recommend that primary care physicians screen for and offer counseling to the overweight/obese. As the literature suggests, this approach may be ineffective; it is important to document the opportunity costs incurred by brief primary care obesity interventions that ultimately may not alter body mass index (BMI) trajectory. Live, Eat and Play (LEAP) was a randomized controlled trial of a brief secondary prevention intervention delivered by family physicians in 2002-2003 that targeted overweight/mildly obese children aged 5 to 9 years. Primary care utilization was prospectively audited via medical records, and parents reported family resource use by written questionnaire. Outcome measures were BMI (primary) and parent-reported physical activity and dietary habits (secondary) in intervention compared with control children. The cost of LEAP per intervention family was AU $4094 greater than for control families, mainly due to increased family resources devoted to child physical activity. Total health sector costs were AU $873 per intervention family and AU $64 per control, a difference of AU $809 (P < .001). At 15 months, intervention children did not differ significantly in adjusted BMI or daily physical activity scores compared with the control group, but dietary habits had improved. This brief intervention resulted in higher costs to families and the health care sector, which could have been devoted to other uses that do create benefits to health and/or family well-being. This has implications for countries such as the United States, the United Kingdom, and Australia, whose current guidelines recommend routine surveillance and counseling for high child BMI in the primary care sector.

Cost Analysis of a Digital Health Care Model in Sweden.

PubMed

Ekman, Björn

2017-09-22

Digital technologies in health care are expected to increase in scope and to affect ever more parts of the health care system. It is important to enhance the knowledge of whether new digital methods and innovations provide value for money compared with traditional models of care. The objective of the study was to evaluate whether a digital health care model for primary care is a less costly alternative compared with traditional in-office primary care in Sweden. Cost data for the two care models were collected and analyzed to obtain a measure in local currency per care contact. The comparison showed that the total economic cost of a digital consultation is 1960 Swedish krona (SEK) (SEK100 = US$11.29; February 2017) compared with SEK3348 for a traditional consultation at a health care clinic. Cost differences arose on both the provider side and on the user side. The digital health care model may be a less costly alternative to the traditional health care model. Depending on the rate of digital substitution, gross economic cost savings of between SEK1 billion and SEK10 billion per year could be realized if more digital consultations were made. Further studies are needed to validate the findings, assess the types of care most suitable for digital care, and also to obtain various quality-adjusted outcome measures.

Unravelling referral paths relating to the dental care of children: a study in Liverpool.

PubMed

Harris, Rebecca V; Pender, Susan M; Merry, Alison; Leo, Anthony

2008-04-01

To describe primary care referral networks relating to children's dental care and the main influences on referral decisions taken by dentists working in a primary care setting. A postal questionnaire to all 130 general dental practitioners (GDPs) in contract with Primary Care Trusts (PCTs), and 24 Community Dental Service (CDS) dentists in Liverpool. Characteristics of patient groups and factors influencing the choice of referral pathway of children referred from primary dental care. There were good responses rates (110 [85%] GDPs and 22 [92%] CDS dentists). The two main reasons why GDPs referred children to hospitals were (a) for treatment under general anaesthetic (GA) or relative analgesia (RA) and (b) for restorative care of dentally anxious children. GDPs also referred anxious children requiring simple restorative care and/or RA to the CDS. Only eight GDPs (7%) cited a lack of experience as a reason for referral of dentally anxious children for simple restorative care, compared to 53 (48%) who cited a lack of RA facilities, and 25 (23%) who cited financial considerations. GDPs refer children to both hospital services and the CDS, and identify a lack of RA facilities and economic pressures as key reasons for referral.

Design, Recruitment and Start Up of a Primary Care Weight Loss Trial Targeting African American and Hispanic Adults

PubMed Central

Kumanyika, Shiriki; Fassbender, Jennifer; Phipps, Etienne; Tan-Torres, Susan; Localio, Russell; Morales, Knashawn H.; Sarwer, David B.; Harralson, Tina; Allison, Kelly; Wesby, Lisa; Kessler, Ronni; Tsai, Adam Gilden; Wadden, Thomas A.

2011-01-01

Primary care offices are critical access points for obesity treatment, but evidence for approaches that can be implemented within these settings is limited. The Think Health! (¡Vive Saludable!) Study was designed to assess the feasibility and effectiveness of a behavioral weight loss program, adapted from the Diabetes Prevention Program, for implementation in routine primary care. Recruitment of clinical sites targeted primary care practices serving African American and Hispanic adults. The randomized design compares (a) a moderate-intensity treatment consisting of primary care provider counseling plus additional counseling by an auxiliary staff member (i.e., lifestyle coach), with (b) a low-intensity, control treatment involving primary care provider counseling only. Treatment and follow up duration are 1 to 2 years. The primary outcome is weight change from baseline at 1 and 2 years post-randomization. Between November 2006 and January 2008, 14 primary care providers (13 physicians; 1 physician assistant) were recruited at five clinical sites. Patients were recruited between October 2007 and November 2008. A total of 412 patients were pre-screened, of whom 284 (68.9%) had baseline assessments and 261 were randomized, with the following characteristics: 65% African American; 16% Hispanic American; 84% female; mean (SD) age of 47.2 (11.7) years; mean (SD) BMI of 37.2(6.4) kg/m2; 43.7% with high blood pressure; and 18.4% with diabetes. This study will provide insights into the potential utility of moderate-intensity lifestyle counseling delivered by motivated primary care clinicians and their staff. The study will have particular relevance to African Americans and women. PMID:21062645

Barriers to Integrating Mental Health Services in Community-Based Primary Care Settings in Mexico City: A Qualitative Analysis.

PubMed

Martinez, William; Galván, Jorge; Saavedra, Nayelhi; Berenzon, Shoshana

2017-05-01

Despite the high prevalence of mental disorders in Mexico, minimal mental health services are available and there are large gaps in mental health treatment. Community-based primary care settings are often the first contact between patients and the health system and thus could serve as important settings for assessing and treating mental disorders. However, no formal assessment has been undertaken regarding the feasibility of implementing these services in Mexico. Before tools are developed to undertake such an assessment, a more nuanced understanding of the microprocesses affecting mental health service delivery must be acquired. A qualitative study used semistructured interviews to gather information from 25 staff in 19 community-based primary care clinics in Mexico City. Semistructured interviews were analyzed by using the meaning categorization method. In a second phase of coding, emerging themes were compared with an established typology of barriers to health care access. Primary care staff reported a number of significant barriers to implementing mental health services in primary care clinics, an already fragile and underfunded system. Barriers included the following broad thematic categories: service issues, language and cultural issues, care recipient characteristics, and issues with lack of knowledge. Results indicate that the implementation of mental health services in primary care clinics in Mexico will be difficult. However, the information in this study can help inform the integration of mental health into community-based primary care in Mexico through the development of adequate evaluative tools to assess the feasibility and progress of integrating these services.

Too Little? Too Much? Primary care physicians' views on US health care: a brief report.

PubMed

Sirovich, Brenda E; Woloshin, Steven; Schwartz, Lisa M

2011-09-26

Some believe that a substantial amount of US health care is unnecessary, suggesting that it would be possible to control costs without rationing effective services. The views of primary care physicians-the frontline of health care delivery-are not known. Between June and December 2009, we conducted a nationally representative mail survey of US primary care physicians (general internal medicine and family practice) randomly selected from the American Medical Association Physician Masterfile (response rate, 70%; n=627). Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little. The most important factors physicians identified as leading them to practice more aggressively were malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%). Physicians also believe that financial incentives encourage aggressive practice: 62% said diagnostic testing would be reduced if it did not generate revenue for medical subspecialists (39% for primary care physicians). Almost all physicians (95%) believe that physicians vary in what they would do for identical patients; 76% are interested in learning how aggressive or conservative their own practice style is compared with that of other physicians in their community. Many US primary care physicians believe that their own patients are receiving too much medical care. Malpractice reform, realignment of financial incentives, and more time with patients could remove pressure on physicians to do more than they feel is needed. Physicians are interested in feedback on their practice style, suggesting they may be receptive to change. clinicaltrials.gov Identifier: NCT00853918.

Too Little? Too Much? Primary Care Physicians’ Views on US Health Care

PubMed Central

Sirovich, Brenda E.; Woloshin, Steven; Schwartz, Lisa M.

2011-01-01

Background Some believe that a substantial amount of US health care is unnecessary, suggesting that it would be possible to control costs without rationing effective services. The views of primary care physicians—the frontline of health care delivery—are not known. Methods Between June and December 2009, we conducted a nationally representative mail survey of US primary care physicians (general internal medicine and family practice) randomly selected from the American Medical Association Physician Masterfile (response rate, 70%; n=627). Results Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little. The most important factors physicians identified as leading them to practice more aggressively were malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%). Physicians also believe that financial incentives encourage aggressive practice: 62% said diagnostic testing would be reduced if it did not generate revenue for medical subspecialists (39% for primary care physicians). Almost all physicians (95%) believe that physicians vary in what they would do for identical patients; 76% are interested in learning how aggressive or conservative their own practice style is compared with that of other physicians in their community. Conclusions Many US primary care physicians believe that their own patients are receiving too much medical care. Malpractice reform, realignment of financial incentives, and more time with patients could remove pressure on physicians to do more than they feel is needed. Physicians are interested in feedback on their practice style, suggesting they may be receptive to change. PMID:21949169

Advancing team-based primary health care: a comparative analysis of policies in western Canada.

PubMed

Suter, Esther; Mallinson, Sara; Misfeldt, Renee; Boakye, Omenaa; Nasmith, Louise; Wong, Sabrina T

2017-07-17

We analyzed and compared primary health care (PHC) policies in British Columbia, Alberta and Saskatchewan to understand how they inform the design and implementation of team-based primary health care service delivery. The goal was to develop policy imperatives that can advance team-based PHC in Canada. We conducted comparative case studies (n = 3). The policy analysis included: Context review: We reviewed relevant information (2007 to 2014) from databases and websites. Policy review and comparative analysis: We compared and contrasted publically available PHC policies. Key informant interviews: Key informants (n = 30) validated narratives prepared from the comparative analysis by offering contextual information on potential policy imperatives. Advisory group and roundtable: An expert advisory group guided this work and a key stakeholder roundtable event guided prioritization of policy imperatives. The concept of team-based PHC varies widely across and within the three provinces. We noted policy gaps related to team configuration, leadership, scope of practice, role clarity and financing of team-based care; few policies speak explicitly to monitoring and evaluation of team-based PHC. We prioritized four policy imperatives: (1) alignment of goals and policies at different system levels; (2) investment of resources for system change; (3) compensation models for all members of the team; and (4) accountability through collaborative practice metrics. Policies supporting team-based PHC have been slow to emerge, lacking a systematic and coordinated approach. Greater alignment with specific consideration of financing, reimbursement, implementation mechanisms and performance monitoring could accelerate systemic transformation by removing some well-known barriers to team-based care.

Career plans of primary care midwives in the Netherlands and their intentions to leave the current job.

PubMed

Warmelink, J Catja; Wiegers, Therese A; de Cock, T Paul; Spelten, Evelien R; Hutton, Eileen K

2015-05-10

In labour market policy and planning, it is important to understand the motivations of people to continue in their current job or to seek other employment. Over the last decade, besides the increasingly medical approach to pregnancy and childbirth and decreasing home births, there were additional dramatic changes and pressures on primary care midwives and midwifery care. Therefore, it is important to re-evaluate the career plans of primary care midwives and their intentions to leave their current job. All 108 primary care midwives of 20 selected midwifery care practices in the Netherlands were invited to fill out a written questionnaire with questions regarding career plans and intentions to leave. Bivariate analyses were carried out to compare career plans and work-related and personal characteristics and attitudes towards work among the group of midwives who indicated that they intended to leave their current job (ITL group) and those who indicated they had no intention to leave (NITL group). Significant predictors of ITL were included in the multiple binary logistic regression with 'intention to leave' as the dependent variable. In 2010, 32.7% of the 98 participating primary care midwives surveyed had considered an intention to leave their current type of job in the past year. Fewer ITL midwives wanted to be a self-employed practitioner with the full range of primary care tasks and work full-time. Significant predictors of the primary care midwives' intention to leave included a lower overall score on the job satisfaction scale (OR = 0.18; 95% CI = 0.06-0.58; p = 0.004) and being between 30 and 45 years old (OR = 2.69; 95% CI = 1.04-7.0; p = 0.041). Our study shows that, despite significant changes in the reproductive, maternal and newborn health service delivery that impact on independent midwifery practice, the majority of primary care midwives intended to stay in primary care. The absence of job satisfaction, and being in the age group between 30 and 45 years old, is associated with primary care midwives' intention to leave their current job. Ongoing monitoring will be important in the future.

Physicians’ perceptions of capacity building for managing chronic disease in seniors using integrated interprofessional care models

PubMed Central

Lee, Linda; Heckman, George; McKelvie, Robert; Jong, Philip; D’Elia, Teresa; Hillier, Loretta M.

2015-01-01

Abstract Objective To explore the barriers to and facilitators of adapting and expanding a primary care memory clinic model to integrate care of additional complex chronic geriatric conditions (heart failure, falls, chronic obstructive pulmonary disease, and frailty) into care processes with the goal of improving outcomes for seniors. Design Mixed-methods study using quantitative (questionnaires) and qualitative (interviews) methods. Setting Ontario. Participants Family physicians currently working in primary care memory clinic teams and supporting geriatric specialists. Methods Family physicians currently working in memory clinic teams (n = 29) and supporting geriatric specialists (n = 9) were recruited as survey participants. Interviews were conducted with memory clinic lead physicians (n = 16). Statistical analysis was done to assess differences between family physician ratings and geriatric specialist ratings related to the capacity for managing complex chronic geriatric conditions, the role of interprofessional collaboration within primary care, and funding and staffing to support geriatric care. Results from both study methods were compared to identify common findings. Main findings Results indicate overall support for expanding the memory clinic model to integrate care for other complex conditions. However, the current primary care structure is challenged to support optimal management of patients with multiple comorbidities, particularly as related to limited funding and staffing resources. Structured training, interprofessional teams, and an active role of geriatric specialists within primary care were identified as important facilitators. Conclusion The memory clinic model, as applied to other complex chronic geriatric conditions, has the potential to build capacity for high-quality primary care, improve health outcomes, promote efficient use of health care resources, and reduce health care costs. PMID:25932482

Acupuncture and Counselling for Depression in Primary Care: A Randomised Controlled Trial

PubMed Central

MacPherson, Hugh; Richmond, Stewart; Bland, Martin; Brealey, Stephen; Gabe, Rhian; Hopton, Ann; Keding, Ada; Lansdown, Harriet; Perren, Sara; Sculpher, Mark; Spackman, Eldon; Torgerson, David; Watt, Ian

2013-01-01

Background Depression is a significant cause of morbidity. Many patients have communicated an interest in non-pharmacological therapies to their general practitioners. Systematic reviews of acupuncture and counselling for depression in primary care have identified limited evidence. The aim of this study was to evaluate acupuncture versus usual care and counselling versus usual care for patients who continue to experience depression in primary care. Methods and Findings In a randomised controlled trial, 755 patients with depression (Beck Depression Inventory BDI-II score ≥20) were recruited from 27 primary care practices in the North of England. Patients were randomised to one of three arms using a ratio of 2∶2∶1 to acupuncture (302), counselling (302), and usual care alone (151). The primary outcome was the difference in mean Patient Health Questionnaire (PHQ-9) scores at 3 months with secondary analyses over 12 months follow-up. Analysis was by intention-to-treat. PHQ-9 data were available for 614 patients at 3 months and 572 patients at 12 months. Patients attended a mean of ten sessions for acupuncture and nine sessions for counselling. Compared to usual care, there was a statistically significant reduction in mean PHQ-9 depression scores at 3 months for acupuncture (−2.46, 95% CI −3.72 to −1.21) and counselling (−1.73, 95% CI −3.00 to −0.45), and over 12 months for acupuncture (−1.55, 95% CI −2.41 to −0.70) and counselling (−1.50, 95% CI −2.43 to −0.58). Differences between acupuncture and counselling were not significant. In terms of limitations, the trial was not designed to separate out specific from non-specific effects. No serious treatment-related adverse events were reported. Conclusions In this randomised controlled trial of acupuncture and counselling for patients presenting with depression, after having consulted their general practitioner in primary care, both interventions were associated with significantly reduced depression at 3 months when compared to usual care alone. Trial Registration Controlled-Trials.com ISRCTN63787732 Please see later in the article for the Editors' Summary PMID:24086114

Patient and provider interventions for managing osteoarthritis in primary care: protocols for two randomized controlled trials

PubMed Central

2012-01-01

Background Osteoarthritis (OA) of the hip and knee are among the most common chronic conditions, resulting in substantial pain and functional limitations. Adequate management of OA requires a combination of medical and behavioral strategies. However, some recommended therapies are under-utilized in clinical settings, and the majority of patients with hip and knee OA are overweight and physically inactive. Consequently, interventions at the provider-level and patient-level both have potential for improving outcomes. This manuscript describes two ongoing randomized clinical trials being conducted in two different health care systems, examining patient-based and provider-based interventions for managing hip and knee OA in primary care. Methods / Design One study is being conducted within the Department of Veterans Affairs (VA) health care system and will compare a Combined Patient and Provider intervention relative to usual care among n = 300 patients (10 from each of 30 primary care providers). Another study is being conducted within the Duke Primary Care Research Consortium and will compare Patient Only, Provider Only, and Combined (Patient + Provider) interventions relative to usual care among n = 560 patients across 10 clinics. Participants in these studies have clinical and / or radiographic evidence of hip or knee osteoarthritis, are overweight, and do not meet current physical activity guidelines. The 12-month, telephone-based patient intervention focuses on physical activity, weight management, and cognitive behavioral pain management. The provider intervention involves provision of patient-specific recommendations for care (e.g., referral to physical therapy, knee brace, joint injection), based on evidence-based guidelines. Outcomes are collected at baseline, 6-months, and 12-months. The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (self-reported pain, stiffness, and function), and secondary outcomes are the Short Physical Performance Test Protocol (objective physical function) and the Patient Health Questionnaire-8 (depressive symptoms). Cost effectiveness of the interventions will also be assessed. Discussion Results of these two studies will further our understanding of the most effective strategies for improving hip and knee OA outcomes in primary care settings. Trial registration NCT01130740 (VA); NCT 01435109 (NIH) PMID:22530979

Job Satisfaction Differences between Primary Health Care and Treatment Sectors: An Experience from Iran

PubMed Central

Bagheri, Shokoufe; Janati, Ali; Kousha, Ahmad; Sadeghi-Bazargani, Homayoun; Asghari-Jafarabadi, Mohammad; Farahbakhsh, Mostafa

2013-01-01

Background: The aim of this study was to compare the levels of job satisfaction and its predictors among primary health care and treatment sectors' staff in East Azerbaijan Province, Iran. Methods: This comparative study was conducted in East Azerbaijan Province,Iran in 2011. A questionnaire survey was performed on 420 staff from health care and treatment sectors using multi-stage proportional cluster sampling method. Job satisfaction was measured in five aspects namely: structural and managerial; individual; social; work-itself; environmental and welfare job satisfaction factors.The job satisfaction measurement score was normalized to fall into a range of zero to 100. Statistical analyses were performed using Friedman and independent sample t-tests. Results: Overall satisfaction in health and treatment sectors was moderate with a mean score above 50. Hospital General Practitioners reported significantly higher job satisfaction score (mean ± SD=57.34 ± 17.02) compared to health care center General Practitioners (mean ± SD= 31.74±14.99). The highest satisfaction scores belonged to individual factors both in health care sector staff (64.83±18.50) and treatment sector staff (63.55±17.44). The lowest job satisfaction was observed with environmental and welfare factors (38.47±19.86 and 36.83±19.86, respectively). Conclusion: The job satisfaction significantly differs between primary health care and treatment sectors. Based on the results, environmental and welfare factors may be targeted to improve the job satisfaction in public health care system. PMID:24688957

Team composition and chronic disease management within primary healthcare practices in eastern Ontario: an application of the Measuring Organizational Attributes of Primary Health Care Survey.

PubMed

Lukewich, Julia; Edge, Dana S; VanDenKerkhof, Elizabeth; Williamson, Tyler; Tranmer, Joan

2018-04-15

Various organizational-level attributes are being implemented in primary healthcare to improve healthcare delivery. There is a need to describe the distribution and nature of these attributes and explore differences across practices.AimThe aim of this study was to better understand organizational attributes of primary care teams, focusing specifically on team composition, nursing roles, and strategies that support chronic disease management. We employed a cross-sectional survey design. Team composition, nursing roles, availability of health services, and chronic disease management activities were described using the 'Measuring Organizational Attributes of Primary Health Care Survey.'FindingsA total of 76% (n=26 out of 34) of practice locations completed the survey, including family health teams (FHT; n=21) and community health centers (CHC; n=4). Nurse practitioners (NPs) and registered nurses (RNs) were the most common non-physician providers, and CHCs had a greater proportion of non-physician providers than FHTs. There was overlap in roles performed by NPs and RNs, and registered practical nurses engaged in fewer roles compared with NPs and RNs. A greater proportion of FHTs had systematic chronic disease management services for hypertension, depression and Alzheimer's disease compared with CHC practices. The 'Measuring Organizational Attributes of Primary Health Care Survey' was a useful tool to highlight variability in organizational attributes across PHC practices. Nurses are prominent within PHC practices, engaging in a wide range of roles related to chronic disease management, suggesting a need to better understand their contributions to patient care to optimize their roles.

Alerts in electronic medical records to promote a colorectal cancer screening programme: a cluster randomised controlled trial in primary care.

PubMed

Guiriguet, Carolina; Muñoz-Ortiz, Laura; Burón, Andrea; Rivero, Irene; Grau, Jaume; Vela-Vallespín, Carmen; Vilarrubí, Mercedes; Torres, Miquel; Hernández, Cristina; Méndez-Boo, Leonardo; Toràn, Pere; Caballeria, Llorenç; Macià, Francesc; Castells, Antoni

2016-07-01

Participation rates in colorectal cancer screening are below recommended European targets. To evaluate the effectiveness of an alert in primary care electronic medical records (EMRs) to increase individuals' participation in an organised, population-based colorectal cancer screening programme when compared with usual care. Cluster randomised controlled trial in primary care centres of Barcelona, Spain. Participants were males and females aged 50-69 years, who were invited to the first round of a screening programme based on the faecal immunochemical test (FIT) (n = 41 042), and their primary care professional. The randomisation unit was the physician cluster (n = 130) and patients were blinded to the study group. The control group followed usual care as per the colorectal cancer screening programme. In the intervention group, as well as usual care, an alert to health professionals (cluster level) to promote screening was introduced in the individual's primary care EMR for 1 year. The main outcome was colorectal cancer screening participation at individual participant level. In total, 67 physicians and 21 619 patients (intervention group) and 63 physicians and 19 423 patients (control group) were randomised. In the intention-to-treat analysis screening participation was 44.1% and 42.2% respectively (odds ratio 1.08, 95% confidence interval [CI] = 0.97 to 1.20, P = 0.146). However, in the per-protocol analysis screening uptake in the intervention group showed a statistically significant increase, after adjusting for potential confounders (OR, 1.11; 95% CI = 1.02 to 1.22; P = 0.018). The use of an alert in an individual's primary care EMR is associated with a statistically significant increased uptake of an organised, FIT-based colorectal cancer screening programme in patients attending primary care centres. © British Journal of General Practice 2016.

Primary care physician assistant and advance practice nurses roles: Patient healthcare utilization, unmet need, and satisfaction.

PubMed

Everett, Christine M; Morgan, Perri; Jackson, George L

2016-12-01

Team-based care involving physician assistants (PAs) and advance practice nurses (APNs) is one strategy for improving access and quality of care. PA/APNs perform a variety of roles on primary care teams. However, limited research describes the relationship between PA/APN role and patient outcomes. We examined multiple outcomes associated with primary care PA/APN roles. In this cross-sectional survey analysis, we studied adult respondents to the 2010 Health Tracking Household Survey. Outcomes included primary care and emergency department visits, hospitalizations, unmet need, and satisfaction. PA/APN role was categorized as physician only (no PA/APN visits; reference), usual provider (PA/APN provide majority of primary care visits) or supplemental provider (physician as usual provider, PA/APN provide a subset of visits). Multivariable logistic and multinomial logistic regressions were performed. Compared to people with physician only care, patients with PA/APNs as usual providers [5-9 visits RRR=2.4 (CI 1.8-3.4), 10+ visits RRR=3.0 (CI 2.0-4.5): reference 2-4 visits] and supplemental providers had increased risk of having 5 or more primary care visits [5-9 visits RRR=1.3 (CI 1.0-1.6)]. Patients reporting PA/APN as supplemental providers had increased risk of emergency department utilization [2+ visits: RRR 1.8 (CI 1.3, 2.5)], and lower satisfaction [very dissatisfied: RRR 1.8 (CI 1.03-3.0)]. No differences were seen for hospitalizations or unmet need. Healthcare utilization patterns and satisfaction varied between adults with PA/APN in different roles, but reported unmet need did not. These findings suggest a wide range of outcomes should be considered when identifying the best PA/APN role on primary care teams. Copyright © 2016 Elsevier Inc. All rights reserved.

Descriptive Analysis of a Novel Health Care Approach: Reverse Colocation—Primary Care in a Community Mental Health “Home”

PubMed Central

Sirna, Megan; Mangurian, Christina; Dilley, James W.; Shumway, Martha

2013-01-01

Objective: Persons with serious mental illness have increased rates of chronic medical conditions, have limited access to primary care, and incur significant health care expenditures. Few studies have explored providing medical care for these patients in the ambulatory mental health setting. This study describes a real-world population of mental health patients receiving primary care services in a community mental health clinic to better understand how limited primary care resources are being utilized. Method:Chart review was performed on patients receiving colocated primary care (colocation group, N = 143) and randomly chosen patients receiving mental health care only (mental-health group, N = 156) from January 2006 through June 2011. Demographic and mental and physical health variables were assessed. Results: Compared to the mental-health group, the colocation patients had more psychiatric hospitalizations (mean = 1.07 vs 0.23, P < .01), were more likely to be homeless (P < .01), and were more likely to require intensive case management (P < .01). Interestingly, the colocation group was not more medically ill than the mental-health group on key metabolic measures, including mean body mass index (colocation = 27.8 vs mental-health = 28.7, P = .392), low-density liprotein (colocation = 110.0 vs mental-health = 104.4, P = .480), and glucose (colocation = 94.1 vs mental-health = 109.2, P = .059). The most common medical disorders in the colocation group were related to metabolic syndrome. Conclusions: Colocated primary care services were allocated on the basis of severity of psychiatric impairment rather than severity of medical illness. This program serves as a model for other systems to employ for integrated primary and behavioral health services for patients with serious mental illness. PMID:24511447

Impact of the implementation of an online network support tool among clinicians of primary health care and specialists: ECOPIH Project.

PubMed

Lacasta Tintorer, David; Flayeh Beneyto, Souhel; Alzaga Reig, Xavier; Mundet Tuduri, Xavier; De la Fuente, Josep Anton; Manresa, Josep Maria; Torán Monserrat, Pere; Saigí Rubió, Francesc

2013-10-03

There has been created an online communication tool with the objective to improve the communication among different levels of care, between Primary Care clinicians and Specialists. This tool is web 2.0 based technology (ECOPIH project). It allows to review clinical cases and to share knowledge. Our study will evaluate its impact in terms of reduction on the number of referrals to three specialties two years after the use of this tool. Open, multicenter, controlled, non random intervention study over 24 months. Study population includes 131 Primary Care Physicians assigned to nine health centers. The study will compare the clinicians that use the ECOPIH with the ones that do not use the tool. Also, professionals that start to use the tool during the period time of the study will be included.The number of annual referrals during the first and second year will be analyzed and retrospectively compared with the previous year to the implementation of the tool. Moreover, it will be assessed the level of satisfaction of the professionals with the tool and to what extend the tool responds to their needs. The implementation of ECOPIH in the field of Primary Health Care can decrease the number of referrals from primary care to specialist care.It is expected that the reduction will be more noticeable in the group of professionals that use more intensively the tool. Furthermore, we believe that it can be also observed with the professionals that read the contributions of the others.We anticipate high degree of customer satisfaction as it is a very helpful resource never used before in our environment.

Impact of the implementation of an online network support tool among clinicians of Primary Health Care and Specialists: ECOPIH Project

PubMed Central

2013-01-01

Background There has been created an online communication tool with the objective to improve the communication among different levels of care, between Primary Care clinicians and Specialists. This tool is web 2.0 based technology (ECOPIH project). It allows to review clinical cases and to share knowledge. Our study will evaluate its impact in terms of reduction on the number of referrals to three specialties two years after the use of this tool. Methods/Design Open, multicenter, controlled, non random intervention study over 24 months. Study population includes 131 Primary Care Physicians assigned to nine health centers. The study will compare the clinicians that use the ECOPIH with the ones that do not use the tool. Also, professionals that start to use the tool during the period time of the study will be included. The number of annual referrals during the first and second year will be analyzed and retrospectively compared with the previous year to the implementation of the tool. Moreover, it will be assessed the level of satisfaction of the professionals with the tool and to what extend the tool responds to their needs. Discussion The implementation of ECOPIH in the field of Primary Health Care can decrease the number of referrals from primary care to specialist care. It is expected that the reduction will be more noticeable in the group of professionals that use more intensively the tool. Furthermore, we believe that it can be also observed with the professionals that read the contributions of the others. We anticipate high degree of customer satisfaction as it is a very helpful resource never used before in our environment. PMID:24088387

Beyond the Examination Room

PubMed Central

O'Malley, Ann S; Forrest, Christopher B

2002-01-01

OBJECTIVE To assess whether primary care performance of low-income women's primary care delivery sites is associated with the strength of their relationships with their physicians. DESIGN Random-digit-dial and targeted household telephone survey of a population-based sample. SETTING Washington, D.C. census tracts with ≥30% of households below 200% of federal poverty threshold. PARTICIPANTS Women over age 40 (N = 1,205), 82% of whom were African American. MEASUREMENTS AND MAIN RESULTS The response rate was 85%. Primary care performance was assessed using women's ratings of their systems' accessibility (organizational, geographic, and financial), continuity, comprehensiveness, and coordination. Respondents' ratings of trust in their physicians, communication with their physicians, and compassion shown by their physicians were used to operationalize the patient-physician relationship. Controlling for population and insurance characteristics, 4 primary care features were positively associated with women's trust in and communication with their physicians: continuity with a single clinician, organizational accessibility of the practice, comprehensive care, and coordination of specialty care services. Better organizational access, but not geographic or financial access, was associated with greater levels of trust, compassion, and communication (odds ratios [ORs], 3.2, 7.4, and 6.9, respectively; P≤ .01). Women who rated highest their doctor's ability to take care of all of their health care needs (highest level of comprehensiveness) had 11 times the odds of trusting their physician (P≤ .01) and 6 times the odds of finding their physicians compassionate and communicative (P≤ .01), compared to those with the lowest level of comprehensiveness. CONCLUSIONS Primary care delivery sites organized to be more accessible, to link patients with the same clinician for their visits, to provide for all of a woman's health care needs, and to coordinate specialty care services are associated with stronger relationships between low-income women and their physicians. Primary care systems that fail to emphasize these features of primary care may jeopardize the clinician-patient relationship and indirectly the quality of care and health outcomes. PMID:11903777

Impact of an electronic health record alert in primary care on increasing hepatitis c screening and curative treatment for baby boomers.

PubMed

Konerman, Monica A; Thomson, Mary; Gray, Kristen; Moore, Meghan; Choxi, Hetal; Seif, Elizabeth; Lok, Anna S F

2017-12-01

Despite effective treatment for chronic hepatitis C, deficiencies in diagnosis and access to care preclude disease elimination. Screening of baby boomers remains low. The aims of this study were to assess the impact of an electronic health record-based prompt on hepatitis C virus (HCV) screening rates in baby boomers in primary care and access to specialty care and treatment among those newly diagnosed. We implemented an electronic health record-based "best practice advisory" (BPA) that prompted primary care providers to perform HCV screening for patients seen in primary care clinic (1) born between 1945 and 1965, (2) who lacked a prior diagnosis of HCV infection, and (3) who lacked prior documented anti-HCV testing. The BPA had associated educational materials, order set, and streamlined access to specialty care for newly diagnosed patients. Pre-BPA and post-BPA screening rates were compared, and care of newly diagnosed patients was analyzed. In the 3 years prior to BPA implementation, 52,660 baby boomers were seen in primary care clinics and 28% were screened. HCV screening increased from 7.6% for patients with a primary care provider visit in the 6 months prior to BPA to 72% over the 1 year post-BPA. Of 53 newly diagnosed patients, all were referred for specialty care, 11 had advanced fibrosis or cirrhosis, 20 started treatment, and 9 achieved sustained virologic response thus far. Implementation of an electronic health record-based prompt increased HCV screening rates among baby boomers in primary care by 5-fold due to efficiency in determining needs for HCV screening and workflow design. Streamlined access to specialty care enabled patients with previously undiagnosed advanced disease to be cured. This intervention can be easily integrated into electronic health record systems to increase HCV diagnosis and linkage to care. (Hepatology 2017;66:1805-1813). © 2017 by the American Association for the Study of Liver Diseases.

Differences in unmet healthcare needs between public and private primary care providers: A population-based study.

PubMed

Lindström, Christine; Rosvall, Maria; Lindström, Martin

2018-06-01

To investigate if any differences in unmet healthcare needs between persons registered at public and private primary care providers exist in Skåne (southernmost Sweden). The 2012 public health survey in Skåne was conducted with a postal questionnaire and included 28,029 respondents aged between 18 and 80 years. The study was cross-sectional. If the responder in the last three months had perceived oneself to be in need of medical care by a physician but did not seek it, this was used as a measure of unmet healthcare needs. Differences in unmet healthcare needs in relation to the primary care provider were investigated while adjusting for socioeconomic status and self-rated health in a logistic regression. Differences in unmet healthcare needs were small and non-significant when comparing public and private healthcare providers. Non-manual workers were to a somewhat higher extent using private providers while manual workers showed a reverse pattern. Unmet healthcare needs had decreased slightly since 2008, but so had the response rate. With the current primary care system, no significant differences in unmet healthcare needs seem to exist when comparing public and private providers. It is likely that the providers are similar in their organizational setup, accessibility and doctor-patient continuity. Still more studies need to be done, preferably in a way so that uncertainty about what type of primary care provider the respondent is listed at can be avoided and perhaps using a longer time interval for unmet needs so that more subjects could be included.

A systematic review of the effect of different models of after-hours primary medical care services on clinical outcome, medical workload, and patient and GP satisfaction.

PubMed

Leibowitz, Ruth; Day, Susan; Dunt, David

2003-06-01

The organization of after-hours primary medical care services is changing in many countries. Increasing demand, economic considerations and changes in doctors' attitudes are fueling these changes. Information for policy makers in this field is needed. However, a comprehensive review of the international literature that compares the effects of one model of after-hours care with another is lacking. The aim of this study was to carry out a systematic review of the international literature to determine what evidence exists about the effect of different models of out-of-hours primary medical care service on outcome. Original studies and systematic reviews written since 1976 on the subject of 'after-hours primary medical care services' were identified. Databases searched were Medline/Premedline, CINAHL, HealthSTAR, Current Contents, Cochrane Reviews, DARE, EBM Reviews and EconLit. For each paper where the optimal design would have been an interventional study, the 'level' of evidence was assessed as described in the National Health and Medical Research Council Handbook. 'Comparative' studies (levels I, II, III and IV pre-/post-test studies) were included in this review. Six main models of after-hours primary care services (not mutually exclusive) were identified: practice-based services, deputizing services, emergency departments, co-operatives, primary care centres, and telephone triage and advice services. Outcomes were divided into the following categories: clinical outcomes, medical workload, and patient and GP satisfaction. The results indicate that the introduction of a telephone triage and advice service for after-hours primary medical care may reduce the immediate medical workload. Deputizing services increase immediate medical workload because of the low use of telephone advice and the high home visiting rate. Co-operatives, which use telephone triage and primary care centres and have a low home visiting rate, reduce immediate medical workload. There is little evidence on the effect of different service models on subsequent medical workload apart from the finding that GPs working in emergency departments may reduce the subsequent medical workload. There was very little evidence about the advantages of one service model compared with another in relation to clinical outcome. Studies consistently showed patient dissatisfaction with telephone consultations. The rapid growth in telephone triage and advice services appears to have the advantage of reducing immediate medical workload through the substitution of telephone consultations for in-person consultations, and this has the potential to reduce costs. However, this has to be balanced with the finding of reduced patient satisfaction when in-person consultations are replaced by telephone consultations. These findings should be borne in mind by policy makers deciding on the shape of future services.

Patient characteristics associated with hospitalisations for ambulatory care sensitive conditions in Victoria, Australia

PubMed Central

2012-01-01

Background Ambulatory Care Sensitive Conditions (ACSCs) are those for which hospitalisation is thought to be avoidable with the application of preventive care and early disease management, usually delivered in a primary care setting. ACSCs are used extensively as indicators of accessibility and effectiveness of primary health care. We examined the association between patient characteristics and hospitalisation for ACSCs in the adult and paediatric population in Victoria, Australia, 2003/04. Methods Hospital admissions data were merged with two area-level socioeconomic indexes: Index of Socio-Economic Disadvantage (IRSED) and Accessibility/Remoteness Index of Australia (ARIA). Univariate and multiple logistic regressions were performed for both adult (age 18+ years) and paediatric (age <18 years) groups, reporting odds ratios (OR) and 95% confidence intervals (CI) for a number of predictors of ACSCs admissions compared to non-ACSCs admissions. Results Predictors were much more strongly associated with ACSCs admissions compared to non-ACSCs admissions in the adult group than for the paediatric group with the exception of rurality. Significant adjusted ORs in the adult group were 1.06, 1.15, 1.13, 1.06 and 1.11 for sex, rurality, age, IRSED and ARIA variables, and 1.34, 1.04 and 1.09 in the paediatric group for rurality, IRSED and ARIA, respectively. Conclusions Disadvantaged paediatric and adult population experience more need of hospital care for ACSCs. Access barriers to primary care are plausible causes for the observed disparities. Understanding the characteristics of individuals experiencing access barriers to primary care will be useful for developing targeted interventions meeting the unique ambulatory needs of the population. PMID:23259969

Context for Understanding the National Demonstration Project and the Patient-Centered Medical Home

PubMed Central

Stange, Kurt C.; Miller, William L.; Nutting, Paul A.; Crabtree, Benjamin F.; Stewart, Elizabeth E.; Jaén, Carlos Roberto

2010-01-01

This article introduces a journal supplement evaluating the country’s first national demonstration of the patient-centered medical home (PCMH) concept. The PCMH is touted by some as a linchpin for renewing the foundering US health care system and its primary care foundation. The National Demonstration Project (NDP) tested a new model of care and compared facilitated and self-directed implementation approaches in a group-randomized clinical trial. The NDP asked what a national sample of 36 highly motivated family practices could accomplish in moving toward the PCMH ideal during 2 years within the current US health care payment and organizational system. Our independent evaluation used a multimethod approach that integrated qualitative methods to tell the NDP story from multiple perspectives and quantitative methods to assess and compare aspects that could be measured. The 7 scientific reports presented in this supplement explain the process, outcomes, lessons, and implications of the NDP. This introductory article provides context for making sense of the NDP. Important context includes the evolution of the PCMH concept and movement, the roots of the NDP and how it developed, and both what is valuable and what is problematic about family medicine and primary care. Together, the articles in this supplement show how primary care practices and the concept of the PCMH can continue to evolve. The evaluation depicts some of the early effects of this evolution on patients and practices, and shows how the process of practice development can be understood and how lessons from the NDP can inform ongoing and future efforts to transform primary care and health care systems. PMID:20530391

The management of new primary care organizations: an international perspective.

PubMed

Meads, Geoffrey; Wild, Andrea; Griffiths, Frances; Iwami, Michiyo; Moore, Phillipa

2006-08-01

Management practice arising from parallel policies for modernizing health systems is examined across a purposive sample of 16 countries. In each, novel organizational developments in primary care are a defining feature of the proposed future direction. Semistructured interviews with national leaders in primary care policy development and local service implementation indicate that management strategies, which effectively address the organized resistance of medical professions to modernizing policies, have these four consistent characteristics: extended community and patient participation models; national frameworks for interprofessional education and representation; mechanisms for multiple funding and accountabilities; and the diversification of non-governmental organizations and their roles. The research, based on a two-year fieldwork programme, indicates that at the meso-level of management planning and practice, there is a considerable potential for exchange and transferable learning between previously unconnected countries. The effectiveness of management strategies abroad, for example, in contexts where for the first time alternative but comparable new primary care organizations are exercising responsibilities for local resource utilization, may be understood through the application of stakeholder analyses, such as those employed to promote parity of relationships in NHS primary care trusts.

Partnering Urban Academic Medical Centers And Rural Primary Care Clinicians To Provide Complex Chronic Disease Care

PubMed Central

Arora, Sanjeev; Kalishman, Summers; Dion, Denise; Som, Dara; Thornton, Karla; Bankhurst, Arthur; Boyle, Jeanne; Harkins, Michelle; Moseley, Kathleen; Murata, Glen; Komaramy, Miriam; Katzman, Joanna; Colleran, Kathleen; Deming, Paulina; Yutzy, Sean

2013-01-01

Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need for various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have delivered more than 10,000 specialty care consultations for hepatitis C and other chronic diseases. PMID:21596757

Prevalence of Painful Diabetic Neuropathy Using the Self-Completed Leeds Assessment of Neuropathic Symptoms and Signs Questionnaire in a Population with Diabetes.

PubMed

Aslam, Amir; Singh, Jaipaul; Rajbhandari, Satyan

2015-08-01

This study assessed the feasibility of diagnosing painful diabetic neuropathy (PDN) using a postal self-completed Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire, and it compared the prevalence of PDN in patients with diabetes attending primary and secondary care. This was an observational study in northwest England, United Kingdom (n=204). S-LANSS were used by post to diagnose PDN. Consent for participation and access of blood results were obtained from the subjects with diabetes. Ethical approval was granted to do the work. In this study the prevalence of PDN was 30.3%, comprising 33.1% of patients with type 2 diabetes compared to 14.1% patients with type 1 diabetes. The overall prevalence of PDN was 33% (n=43) in the secondary care group and 25.6% (n=19) in the primary care group; the rates were not statistically significant. There were no gender differences between the primary and secondary care populations. There was a significant association of obesity, smoking and height in males with PDN compared to the non-PDN group (p<0.05). There was a significant trend toward increasing prevalence of PDN with duration of diabetes, increasing glycated hemoglobin and increasing body mass index (p<0.05). The overall prevalence of PDN in this study was 30.3%. The results demonstrated the use of self-administered S-LANSS was easy and can be used for epidemiologic surveys of PDN. The results are comparable to and similar to other published series, in both primary and secondary care settings. Copyright © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

Evaluation of a community transition to professional practice program for graduate registered nurses in Australia.

PubMed

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

2018-03-26

Australia has an increasing demand for a sustainable primary health care registered nursing workforce. Targeting graduate registered nurses who typically begin their nursing career in acute-care hospital settings is a potential workforce development strategy. We evaluated a graduate registered nurse Community Transition to Professional Practice Program which was designed specifically to develop and foster skills required for primary health care. The aims of this study were to evaluate graduates' intention to remain in the primary health care nursing workforce, and graduate competency, confidence and experiences of program support; these were compared with graduates undertaking the conventional acute-care transition program. Preceptor ratings of graduate competence were also measured. All of the 25 graduates (n = 12 community, n = 13 acute-care) who completed the questionnaire at 6 and 12 months intended to remain in nursing, and 55% (n = 6) of graduates in the Community Transition Program intended to remain in the primary health care nursing workforce. There were no differences in graduate experiences, including level of competence, or preceptors' perceptions of graduate competence, between acute-care and Community Transition Programs. The Community Transition to Professional Practice program represents a substantial step towards developing the primary health care health workforce by facilitating graduate nurse employment in this area. Copyright © 2018 Elsevier Ltd. All rights reserved.

Community health centers and primary care access and quality for chronically-ill patients - a case-comparison study of urban Guangdong Province, China.

PubMed

Shi, Leiyu; Lee, De-Chih; Liang, Hailun; Zhang, Luwen; Makinen, Marty; Blanchet, Nathan; Kidane, Ruth; Lindelow, Magnus; Wang, Hong; Wu, Shaolong

2015-11-30

Reform of the health care system in urban areas of China has prompted concerns about the utilization of Community Health Centers (CHC). This study examined which of the dominant primary care delivery models, i.e., the public CHC model, the 'gate-keeper' CHC model, or the hospital-owned CHC models, was most effective in enhancing access to and quality of care for patients with chronic illness. The case-comparison design was used to study nine health care organizations in Guangzhou, Dongguan, and Shenzhen cities within Guangdong province, China. 560 patients aged 50 or over with hypertension or diabetes who visited either CHCs or hospitals in these three cities were surveyed by using face-to-face interviews. Bivariate analyses were performed to compare quality and value of care indicators among subjects from the three cities. Multivariate analyses were used to assess the association between type of primary care delivery and quality as well as value of chronic care after controlling for patients' demographic and health status characteristics. Patients from all three cities chose their current health care providers primarily out of concern for quality of care (both provider expertise and adequate medical equipment), patient-centered care, and insurance plan requirement. Compared with patients from Guangzhou, those from Dongguan performed significantly better on most quality and value of care indicators. Most of these indicators remained significantly better even after controlling for patients' demographic and health status characteristics. The Shenzhen model (hospital-owned and -managed CHC) was generally effective in enhancing accessibility and continuity. However, coordination suffered due to seemingly duplicating primary care outpatients at the hospital setting. Significant associations between types of health care facilities and quality of care were also observed such that patients from CHCs were more likely to be satisfied with traveling time and follow-up care by their providers. The study suggested that the Dongguan model (based on insurance mandate and using family practice physicians as 'gate-keepers') seemed to work best in terms of improving access and quality for patients with chronic conditions. The study suggested adequately funded and well-organized primary care system can play a gatekeeping role and has the potential to provide a reasonable level of care to patients.

Managing resources in NHS dentistry: the views of decision-makers in primary care organisations.

PubMed

Holmes, R D; Donaldson, C; Exley, C; Steele, J G

2008-09-27

To investigate priority setting and decision-making in primary care organisations and to determine how resources are managed in order to meet the oral health needs of local populations. This is a qualitative study. The purposive sample comprised twelve dental public health consultants and six senior finance representatives from contrasting care systems across the United Kingdom. Participants completed a written information sheet followed by a recorded semi-structured telephone interview. Conversations were professionally transcribed verbatim and analysed independently by two investigators using the constant comparative method. The emergent themes focused upon: the role of participants in decision-making; professional relationships; managing change; information needs; and identifying and managing priorities. There was wide interpretation with respect to participants' roles and perceived information needs for decision-making and commissioning. A unifying factor was the importance placed by participants upon trust and the influence of individuals on the success of relationships forged between primary care organisations and general dental practitioners. To facilitate decision-making in primary care organisations, commissioners and managers could engage further with practitioners and incorporate them into commissioning and resource allocation processes. Greater clarity is required regarding the role of dental public health consultants within primary care organisations and commissioning decisions.

Impact of a complex chronic care patient case conference on quality and utilization.

PubMed

Weppner, William G; Davis, Kyle; Tivis, Rick; Willis, Janet; Fisher, Amber; King, India; Smith, C Scott

2018-05-23

There is need for effective venues to allow teams to coordinate care for high-risk or high-need patients. In addition, health systems need to assess the impact of such approaches on outcomes related to chronic health conditions and patient utilization. We evaluate the clinical impact of a novel case conference involving colocated trainees and supervisors in an interprofessional academic primary care clinic. The study utilized a prospective cohort with control group. Intervention patients (N = 104) were matched with controls (N = 104) from the same provider's panel using propensity scores based on age, gender, risk predictors, and prior utilization patterns. Clinical outcomes and subsequent utilization patterns were compared prior to and up to 6 months following the conference. In terms of utilization, intervention patients demonstrated increased visits with primary care team members (p = .0002) compared with controls, without a corresponding increase in the number of primary care providers' visits. There was a trend towards decreased urgent care and emergency visits (p = .07) and a significant decrease in the rate of hospitalizations (p = .04). Patients with poorly-controlled hypertension saw significant decreases in mean systolic blood pressure from 167 to 146 mm Hg. However, there were no differences between the intervention and control groups. Intervention patients with diabetes demonstrated a nonsignificant trend towards decreased hemoglobin A1c from 9.8 to 9.4, when compared with controls. Interprofessional case conferences have potential to improve care coordination and may be associated with improved disease management, decreased unplanned care, and overall reduced hospitalizations.

Advising people to take more exercise is ineffective: a randomized controlled trial of physical activity promotion in primary care.

PubMed

Hillsdon, Melvyn; Thorogood, Margaret; White, Ian; Foster, Charlie

2002-08-01

Over the last 10 years 'exercise referral schemes' have been popular even though the evidence for effectiveness of any one-to-one intervention in primary care is deficient. We report the results of a primary care based one-to-one intervention that compared the effect of two communication styles with a no-intervention control group on self-reported physical activity at 12 months. In all, 1658 middle-aged men and women were randomly assigned to 30 minutes of brief negotiation or direct advice in primary care or a no-intervention control group. The main outcome was self-reported physical activity at 12 months. Secondary outcome measures included change in blood pressure and body mass index. Intention-to-treat analysis revealed no significant differences in physical activity between groups. Brief negotiation group participants who completed the study increased their physical activity significantly more than controls. There was no change in body mass index in any group. The brief negotiation group produced a greater reduction in diastolic blood pressure than direct advice. If patients whose health may benefit from increased physical activity seek advice in primary care, 20-30 minutes of brief negotiation to increase physical activity is probably more effective than similar attempts to persuade or coerce. However, blanket physical activity promotion in primary care is not effective. The most effective way of increasing physical activity in primary care has yet to be determined.

How do Policy and Institutional Settings Shape Opportunities for Community-Based Primary Health Care? A Comparison of Ontario, Québec and New Zealand

PubMed Central

Miller, Fiona; Breton, Mylaine; Couturier, Yves; Morton-Chang, Frances; Ashton, Toni; Sheridan, Nicolette; Peckham, Alexandra; Williams, A Paul; Kenealy, Tim; Wodchis, Walter

2017-01-01

Community-based primary health care describes a model of service provision that is oriented to the population health needs and wants of service users and communities, and has particular relevance to supporting the growing proportion of the population with multiple chronic conditions. Internationally, aspirations for community-based primary health care have stimulated local initiatives and influenced the design of policy solutions. However, the ways in which these ideas and influences find their way into policy and practice is strongly mediated by policy settings and institutional legacies of particular jurisdictions. This paper seeks to compare the key institutional and policy features of Ontario, Québec and New Zealand that shape the ‘space available’ for models of community-based primary health care to take root and develop. Our analysis suggests that two key conditions are the integration of relevant health and social sector organisations, and the range of policy levers that are available and used by governments. New Zealand has the most favourable conditions, and Ontario the least favourable. All jurisdictions, however, share a crucial barrier, namely the ‘barbed-wire fence’ that separates funding of medical and ‘non-medical’ primary care services, and the clear interests primary care doctors have in maintaining this fence. Moves in the direction of system-wide community-based primary health care require a gradual dismantling of this fence. PMID:28970754

Factors Influencing Medical School Graduates Toward a Career in Psychiatry: Analysis from the 2011-2013 Association of American Medical Colleges Graduation Questionnaire.

PubMed

Wilbanks, Lindsey; Spollen, John; Messias, Erick

2016-04-01

Various factors influence choice of medical specialty. Previous research grouped specialties into controllable lifestyle, primary care, and surgical. This study compared factors influencing individuals to choose psychiatry versus other specialties. Data came from the 2011-2013 Association of American Medical Colleges Graduation Questionnaire. The authors grouped responses, ranging from no influence to minor, moderate, and strong influence, into psychiatry and controllable lifestyle, primary care, and surgical specialties and analyzed the data using one-way analysis of variance. The analyses included 29,227 students, of which 1329 (4.5%) elected psychiatry; 10,998 (37.6%), controllable lifestyle specialties; 12,320 (42.2%), primary care specialties; and 4580 (15.7%), surgical specialties. Students choosing psychiatry reported less influence of competitiveness, student debt, and salary expectations than those choosing controllable lifestyle and surgical specialties (p < 0.0001) and more influence of work/life balance than those choosing primary care and surgical specialties (p < 0.0001). They reported less influence of family expectations than those choosing controllable lifestyle specialties (p < 0.0001). They reported more influence of fit with personality than controllable lifestyle, primary care, and surgical specialties (p < 0.004). Students entering psychiatry do not fit the traditional categories of controllable lifestyle, primary care, and surgical profiles, but fall between controllable lifestyle and primary care specialties. Recruitment efforts may need to address this different pattern of influences.

[Care for immigrant patients: facts and professionals' perception in 6 primary health care zones in Navarre].

PubMed

Fuertes Goñi, Maria Carmen; Elizalde, L; De Andrés, M R; García Castellano, P; Urmeneta, S; Uribe, J M; Bustince, P

2010-01-01

To describe utilisation of health care services and motives for consultation in Primary Care in the native and the immigrant population, and compare this with the perception of primary care professionals. Data was collected on health care activity during the year 2006 for all people registered (N=86,966) in the 6 basic health care zones with the highest proportion of immigrants (14.4%) and on the following variables: country of origin, age, sex, year of inscription in the public health service. The health card and OMI-AP programme databases were used. A qualitative methodology of focus groups and in-depth interviews was employed. Seventy-two point four percent of immigrants requested care from the primary care professionals in 2006, of whom 50% proceeded from Ecuador and 70% were between 25 and 44 years old. Eighty-two percent of the natives made consultations and required more referrals to specialised care than the immigrants of the same age group. The most frequent consultation with natives and with immigrants was "acute respiratory infections" (7 to 23% according to age group). The second most frequent with immigrants was "administrative problems". The consultations with immigrants were not related to preventive aspects such as smoking and there were more consultations (p>0.001) for gynaeco-obstetric episodes (10.7%) and those related to work (19%) or psychosomatic problems (8.5%). The perception of the primary care professionals was that the immigrants carry out more consultations than the natives and generate a certain "disorder" in the clinic. Immigrants use healthcare services less than the native population. Nonetheless, this fact is not perceived in this way by the primary care professionals. Fewer preventive activities are carried out with immigrants, who suffer from more labour and psychosomatic problems.

The Cost-Effectiveness of Integrating HIV Counseling and Testing into Primary Health Care in the Ukraine.

PubMed

Johns, Benjamin; Doroshenko, Olena; Tarantino, Lisa; Cowley, Peter

2017-03-01

We estimate the number of HIV cases diagnosed, costs, and cost per HIV case detected associated with integrating HIV counseling and testing (HCT) into primary health care facilities in Ukraine. The study uses a difference-in-difference design with four districts implementing the intervention compared to 20 districts where HCT were offered only at specialized HIV clinics. There was a 2.01 (95 % CI: 1.12-3.61) times increase in the number of HIV cases detected per capita in intervention districts compared to other districts. The incremental cost of the intervention was $21,017 and the incremental cost per HIV case detected was $369. The average cost per HIV case detected before the intervention was $558. Engaging primary health care facilities to provide HCT is likely desirable from an efficiency point-of-view. However, the affordability of the intervention needs to be assessed because expansion will require additional investment.

Pilot study of pharmacist-assisted delivery of pharmacogenetic testing in a primary care setting.

PubMed

Haga, Susanne B; LaPointe, Nancy M Allen; Cho, Alex; Reed, Shelby D; Mills, Rachel; Moaddeb, Jivan; Ginsburg, Geoffrey S

2014-09-01

To describe the rationale and design of a pilot program to implement and evaluate pharmacogenetic (PGx) testing in a primary care setting. Several factors have impeded the uptake of PGx testing, including lack of provider knowledge and challenges with operationalizing PGx testing in a clinical practice setting. We plan to compare two strategies for the implementation of PGx testing: a pharmacist-initiated testing arm compared with a physician-initiated PGx testing arm. Providers in both groups will be required to attend an introduction to PGx seminar. Anticipated results: We anticipate that providers in the pharmacist-initiated group will be more likely to order PGx testing than providers in the physician-initiated group. Overall, we aim to generate data that will inform an effective delivery model for PGx testing and to facilitate a seamless integration of PGx testing in primary care practices.

Randomised controlled feasibility trial of a web-based weight management intervention with nurse support for obese patients in primary care

PubMed Central

2014-01-01

Background There is a need for cost-effective weight management interventions that primary care can deliver to reduce the morbidity caused by obesity. Automated web-based interventions might provide a solution, but evidence suggests that they may be ineffective without additional human support. The main aim of this study was to carry out a feasibility trial of a web-based weight management intervention in primary care, comparing different levels of nurse support, to determine the optimal combination of web-based and personal support to be tested in a full trial. Methods This was an individually randomised four arm parallel non-blinded trial, recruiting obese patients in primary care. Following online registration, patients were randomly allocated by the automated intervention to either usual care, the web-based intervention only, or the web-based intervention with either basic nurse support (3 sessions in 3 months) or regular nurse support (7 sessions in 6 months). The main outcome measure (intended as the primary outcome for the main trial) was weight loss in kg at 12 months. As this was a feasibility trial no statistical analyses were carried out, but we present means, confidence intervals and effect sizes for weight loss in each group, uptake and retention, and completion of intervention components and outcome measures. Results All randomised patients were included in the weight loss analyses (using Last Observation Carried Forward). At 12 months mean weight loss was: usual care group (n = 43) 2.44 kg; web-based only group (n = 45) 2.30 kg; basic nurse support group (n = 44) 4.31 kg; regular nurse support group (n = 47) 2.50 kg. Intervention effect sizes compared with usual care were: d = 0.01 web-based; d = 0.34 basic nurse support; d = 0.02 regular nurse support. Two practices deviated from protocol by providing considerable weight management support to their usual care patients. Conclusions This study demonstrated the feasibility of delivering a web-based weight management intervention supported by practice nurses in primary care, and suggests that the combination of the web-based intervention with basic nurse support could provide an effective solution to weight management support in a primary care context. Trial registration Current Controlled Trials ISRCTN31685626. PMID:24886516

Counselling patients about behaviour change: the challenge of talking about diet.

PubMed

Phillips, Katie; Wood, Fiona; Spanou, Clio; Kinnersley, Paul; Simpson, Sharon A; Butler, Christopher C

2012-01-01

As obesity levels increase, opportunistic behaviour change counselling from primary care clinicians in consultations about healthy eating is ever more important. However, little is known about the approaches clinicians take with patients. To describe the content of simulated consultations on healthy eating in primary care, and compare this with the content of smoking cessation consultations. Qualitative study of 23 audiotaped simulated healthy eating and smoking cessation consultations between an actor and primary care clinicians (GPs and nurses) within a randomised controlled trial looking at behaviour change counselling. Consultations were audiotaped and transcribed verbatim, then analysed inductively using thematic analysis. A thematic framework was developed by all authors and applied to the data. The content of healthy eating consultations was contrasted with that given for smoking cessation. There was a lack of consistency and clarity when clinicians discussed healthy eating compared with smoking; in smoking cessation consultations, the content was clearer to both the clinician and patient. There was a lack of specificity about what dietary changes should be made, how changes could be achieved, and how progress could be monitored. Barriers to change were addressed in more depth within the smoking cessation consultations than within the healthy eating encounters. At present, dietary counselling by clinicians in primary care does not typically contain consistent, clear suggestions for specific change, how these could be achieved, and how progress would be monitored. This may contribute to limited uptake and efficacy of dietary counselling in primary care.

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.

Can brief behavioral health interventions reduce suicidal and self-harm ideation in primary care patients?

PubMed

Dueweke, Aubrey R; Rojas, Sasha M; Anastasia, Elizabeth A; Bridges, Ana J

2017-09-01

We examined whether brief behavioral health visits reduced suicidal and self-harm ideation among primary care patients and compared the effectiveness of interventions that targeted ideation directly (i.e., safety planning) with those that targeted ideation indirectly through management of underlying mental illness (e.g., behavioral activation). We examined first- and last-visit data from 31 primary care patients with suicidal or self-harm ideation seen by behavioral health consultants. Patients reported significantly lower frequencies of suicidal and self-harm ideation at their final visit than at their initial visit. Patients whose ideation was targeted directly showed greater improvements than patients whose ideation was targeted indirectly. Although preliminary, results suggest mild to moderate suicidal ideation could be addressed in primary care through integration of behavioral health consultants into the medical team. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

An assessment of routine primary care health information system data quality in Sofala Province, Mozambique

PubMed Central

2011-01-01

Background Primary health care is recognized as a main driver of equitable health service delivery. For it to function optimally, routine health information systems (HIS) are necessary to ensure adequate provision of health care and the development of appropriate health policies. Concerns about the quality of routine administrative data have undermined their use in resource-limited settings. This evaluation was designed to describe the availability, reliability, and validity of a sample of primary health care HIS data from nine health facilities across three districts in Sofala Province, Mozambique. HIS data were also compared with results from large community-based surveys. Methodology We used a methodology similar to the Global Fund to Fight AIDS, Tuberculosis and Malaria data verification bottom-up audit to assess primary health care HIS data availability and reliability. The quality of HIS data was validated by comparing three key indicators (antenatal care, institutional birth, and third diptheria, pertussis, and tetanus [DPT] immunization) with population-level surveys over time. Results and discussion The data concordance from facility clinical registries to monthly facility reports on five key indicators--the number of first antenatal care visits, institutional births, third DPT immunization, HIV testing, and outpatient consults--was good (80%). When two sites were excluded from the analysis, the concordance was markedly better (92%). Of monthly facility reports for immunization and maternity services, 98% were available in paper form at district health departments and 98% of immunization and maternity services monthly facility reports matched the Ministry of Health electronic database. Population-level health survey and HIS data were strongly correlated (R = 0.73), for institutional birth, first antenatal care visit, and third DPT immunization. Conclusions Our results suggest that in this setting, HIS data are both reliable and consistent, supporting their use in primary health care program monitoring and evaluation. Simple, rapid tools can be used to evaluate routine data and facilitate the rapid identification of problem areas. PMID:21569533

African Americans Are Less Likely to Receive Care by a Cardiologist During an Intensive Care Unit Admission for Heart Failure.

PubMed

Breathett, Khadijah; Liu, Wenhui G; Allen, Larry A; Daugherty, Stacie L; Blair, Irene V; Jones, Jacqueline; Grunwald, Gary K; Moss, Marc; Kiser, Tyree H; Burnham, Ellen; Vandivier, R William; Clark, Brendan J; Lewis, Eldrin F; Mazimba, Sula; Battaglia, Catherine; Ho, P Michael; Peterson, Pamela N

2018-05-01

This study sought to determine whether the likelihood of receiving primary intensive care unit (ICU) care by a cardiologist versus a noncardiologist was greater for Caucasians than for African Americans admitted to an ICU for heart failure (HF). The authors further evaluated whether primary ICU care by a cardiologist is associated with higher in-hospital survival, irrespective of race. Increasing data demonstrate an association between better HF outcomes and care by a cardiologist. It is unclear if previously noted racial differences in cardiology care persist in an ICU setting. Using the Premier database, adult patients admitted to an ICU with a primary discharge diagnosis of HF from 2010 to 2014 were included. Hierarchical logistic regression models were used to determine the association between race and primary ICU care by a cardiologist, adjusting for patient and hospital variables. Cox regression with inverse probability weighting was used to assess the association between cardiology care and in-hospital mortality. Among 104,835 patients (80.3% Caucasians, 19.7% African Americans), Caucasians had higher odds of care by a cardiologist than African Americans (adjusted odds ratio: 1.42; 95% confidence interval: 1.34 to 1.51). Compared with a noncardiologist, primary ICU care by a cardiologist was associated with higher in-hospital survival (adjusted hazard ratio: 1.20, 95% confidence interval: 1.11 to 1.28). The higher likelihood of survival did not differ by patient race (interaction p = 0.32). Among patients admitted to an ICU for HF, African Americans were less likely than Caucasians to receive primary care by a cardiologist. Primary care by a cardiologist was associated with higher survival for both Caucasians and African Americans. Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Prevalence of Depressive Disorder of Outpatients Visiting Two Primary Care Settings

PubMed Central

Jo, Sun-Jin; Yim, Hyeon Woo; Jeong, Hyunsuk; Song, Hoo Rim; Ju, Sang Yhun; Kim, Jong Lyul; Jun, Tae-Youn

2015-01-01

Objectives: Although the prevalence of depressive disorders in South Korea’s general population is known, no reports on the prevalence of depression among patients who visit primary care facilities have been published. This preliminary study was conducted to identify the prevalence of depressive disorder in patients that visit two primary care facilities. Methods: Among 231 consecutive eligible patients who visited two primary care settings, 184 patients consented to a diagnostic interview for depression by psychiatrists following the Diagnostic and Statistical Manual of Mental Disorders-IV criteria. There were no significant differences in sociodemographic characteristics such as gender, age, or level of education between the groups that consented and declined the diagnostic examination. The prevalence of depressive disorder and the proportion of newly diagnosed patients among depressive disorder patients were calculated. Results: The prevalence of depressive disorder of patients in the two primary care facilities was 14.1% (95% confidence interval [CI], 9.1 to 19.2), with major depressive disorder 5.4% (95% CI, 2.1 to 8.7), dysthymia 1.1% (95% CI, 0.0 to 2.6), and depressive disorder, not otherwise specified 7.6% (95% CI, 3.7 to 11.5). Among the 26 patients with depressive disorder, 19 patients were newly diagnosed. Conclusions: As compared to the general population, a higher prevalence of depressive disorders was observed among patients at two primary care facilities. Further study is needed with larger samples to inform the development of a primary care setting-based depression screening, management, and referral system to increase the efficiency of limited health care resources. PMID:26429292

Prevalence of Depressive Disorder of Outpatients Visiting Two Primary Care Settings.

PubMed

Jo, Sun-Jin; Yim, Hyeon Woo; Jeong, Hyunsuk; Song, Hoo Rim; Ju, Sang Yhun; Kim, Jong Lyul; Jun, Tae-Youn

2015-09-01

Although the prevalence of depressive disorders in South Korea's general population is known, no reports on the prevalence of depression among patients who visit primary care facilities have been published. This preliminary study was conducted to identify the prevalence of depressive disorder in patients that visit two primary care facilities. Among 231 consecutive eligible patients who visited two primary care settings, 184 patients consented to a diagnostic interview for depression by psychiatrists following the Diagnostic and Statistical Manual of Mental Disorders-IV criteria. There were no significant differences in sociodemographic characteristics such as gender, age, or level of education between the groups that consented and declined the diagnostic examination. The prevalence of depressive disorder and the proportion of newly diagnosed patients among depressive disorder patients were calculated. The prevalence of depressive disorder of patients in the two primary care facilities was 14.1% (95% confidence interval [CI], 9.1 to 19.2), with major depressive disorder 5.4% (95% CI, 2.1 to 8.7), dysthymia 1.1% (95% CI, 0.0 to 2.6), and depressive disorder, not otherwise specified 7.6% (95% CI, 3.7 to 11.5). Among the 26 patients with depressive disorder, 19 patients were newly diagnosed. As compared to the general population, a higher prevalence of depressive disorders was observed among patients at two primary care facilities. Further study is needed with larger samples to inform the development of a primary care setting-based depression screening, management, and referral system to increase the efficiency of limited health care resources.

Clinical productivity of primary care nurse practitioners in ambulatory settings.

PubMed

Xue, Ying; Tuttle, Jane

Nurse practitioners are increasingly being integrated into primary care delivery to help meet the growing demand for primary care. It is therefore important to understand nurse practitioners' productivity in primary care practice. We examined nurse practitioners' clinical productivity in regard to number of patients seen per week, whether they had a patient panel, and patient panel size. We further investigated practice characteristics associated with their clinical productivity. We conducted cross-sectional analysis of the 2012 National Sample Survey of Nurse Practitioners. The sample included full-time primary care nurse practitioners in ambulatory settings. Multivariable survey regression analyses were performed to examine the relationship between practice characteristics and nurse practitioners' clinical productivity. Primary care nurse practitioners in ambulatory settings saw an average of 80 patients per week (95% confidence interval [CI]: 79-82), and 64% of them had their own patient panel. The average patient panel size was 567 (95% CI: 522-612). Nurse practitioners who had their own patient panel spent a similar percent of time on patient care and documentation as those who did not. However, those with a patient panel were more likely to provide a range of clinical services to most patients. Nurse practitioners' clinical productivity was associated with several modifiable practice characteristics such as practice autonomy and billing and payment policies. The estimated number of patients seen in a typical week by nurse practitioners is comparable to that by primary care physicians reported in the literature. However, they had a significantly smaller patient panel. Nurse practitioners' clinical productivity can be further improved. Copyright © 2016 Elsevier Inc. All rights reserved.

Health Care's Other "Big Deal": Direct Primary Care Regulation in Contemporary American Health Law.

PubMed

Chappell, Glenn E

2017-03-01

Direct primary care is a promising, market-based alternative to the fee-for-service payment structure that shapes doctor–patient relationships in America. Instead of billing patients and insurers service by service, direct primary care doctors charge their patients a periodic, prenegotiated fee in exchange for providing a wide range of healthcare services and increased availability compared to traditional practices. This “subscription” model is intended to eliminate the administrative burdens associated with insurer interaction, which, in theory, allows doctors to spend more time with their patients and less time doing paperwork. Direct practices have become increasingly popular since Congress passed the Affordable Care Act (ACA). This growth has been driven by legislation in several states that resolves a number of legal questions that slowed the model’s growth and by the ACA’s recognition of the model as a permissible way to cover primary care in "approved" health plans. Yet legal scholars have hardly focused on direct primary care. Given the model’s growth, however, the time is ripe for a more focused legal inquiry. This Note begins that inquiry. After tracing the model’s evolution and its core components, this Note substantively examines the laws in states that regulate direct practices and analyzes how those laws address a number of potential policy concerns. It then analyzes direct primary care’s broader role in the contemporary American healthcare marketplace. Based upon that analysis, this Note concludes that direct primary care is a beneficial innovation that harmonizes well with a cooperative-federalism-based healthcare policy model.

Association between Women Veterans’ Experiences with VA Outpatient Healthcare and Designation as a Women’s Health Provider in Primary Care Clinics

PubMed Central

Bastian, Lori A.; Trentalange, Mark; Murphy, Terrence E.; Brandt, Cynthia; Bean-Mayberry, Bevanne; Maisel, Natalya C.; Wright, Steven M.; Gaetano, Vera S.; Allore, Heather; Skanderson, Melissa; Reyes-Harvey, Evelyn; Yano, Elizabeth M.; Rose, Danielle; Haskell, Sally

2016-01-01

Background Women Veterans comprise a small percentage of VA healthcare users. Prior research on women Veterans’ experiences with primary care has focused on VA site differences and not individual provider characteristics. In 2010, the VA established policy requiring the provision of comprehensive women’s healthcare by designated women’s health providers (DWHPs). Little is known about the quality of healthcare delivered by DWHPs and women Veterans’ experience with care from these providers. Methods Secondary data were obtained from the VA Survey of Healthcare Experience of Patients (SHEP) using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient-centered medical home (PCMH) survey from March 2012 through February 2013, a survey designed to measure patient experience with care and the DWHPs Assessment of Workforce Capacity (DAWC) that discerns between DWHPs versus non-DWHPs. Findings Of the 28,994 surveys mailed to women Veterans, 24,789 were seen by primary care providers and 8,151 women responded to the survey (response rate 32%). A total of 3,147 providers were evaluated by the SHEP-CAHPS-PCMH survey (40%; n=1,267 were DWHPs). In a multivariable model, patients seen by DWHPs (RR=1.02 95% CI=1.01−1.04) reported higher overall experiences with care compared to patients seen by non-DWHPs. Conclusions The main finding is that women Veterans’ overall experiences with outpatient healthcare are slightly better for those receiving care from DWHPs compared to those receiving care from non-DWHPs. Our findings have important policy implications for how to continue to improve women Veterans’ experiences. Our work provides support to increase access to DWHPs at VA primary care clinics. PMID:25442706

Quality of Care for Childhood Attention-Deficit/Hyperactivity Disorder in a Managed Care Medicaid Program

ERIC Educational Resources Information Center

Zima, Bonnie T.; Bussing, Regina; Tang, Lingqi; Zhang, Lily; Ettner, Susan; Belin, Thomas R.; Wells, Kenneth B.

2010-01-01

Objective: To examine whether clinical severity is greater among children receiving attention-deficit/hyperactivity disorder (ADHD) care in primary care compared with those in specialty mental health clinics, and to examine how care processes and clinical outcomes vary by sector across three 6-month time intervals. Method: This was a longitudinal…

A comparison of the recording of comorbidity in primary and secondary care by using the Charlson Index to predict short-term and long-term survival in a routine linked data cohort.

PubMed

Crooks, C J; West, J; Card, T R

2015-06-05

Hospital admission records provide snapshots of clinical histories for a subset of the population admitted to hospital. In contrast, primary care records provide continuous clinical histories for complete populations, but might lack detail about inpatient stays. Therefore, combining primary and secondary care records should improve the ability of comorbidity scores to predict survival in population-based studies, and provide better adjustment for case-mix differences when assessing mortality outcomes. Cohort study. English primary and secondary care 1 January 2005 to 1 January 2010. All patients 20 years and older registered to a primary care practice contributing to the linked Clinical Practice Research Datalink from England. The performance of the Charlson index with mortality was compared when derived from either primary or secondary care data or both. This was assessed in relation to short-term and long-term survival, age, consultation rate, and specific acute and chronic diseases. 657,264 people were followed up from 1 January 2005. Although primary care recorded more comorbidity than secondary care, the resulting C statistics for the Charlson index remained similar: 0.86 and 0.87, respectively. Higher consultation rates and restricted age bands reduced the performance of the Charlson index, but the index's excellent performance persisted over longer follow-up; the C statistic was 0.87 over 1 year, and 0.85 over all 5 years of follow-up. The Charlson index derived from secondary care comorbidity had a greater effect than primary care comorbidity in reducing the association of upper gastrointestinal bleeding with mortality. However, they had a similar effect in reducing the association of diabetes with mortality. These findings support the use of the Charlson index from linked data and show that secondary care comorbidity coding performed at least as well as that derived from primary care in predicting survival. 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.

Implementing shared-decision-making for diabetes care across country settings: What really matters to people?

PubMed

Tinelli, Michela; Petrou, Panagiotis; Samoutis, George; Traynor, Vivie; Olympios, George; McGuire, Alistair

2017-07-01

Growing evidence of improved clinical outcomes and patient/professional satisfaction supports shared-decision-making (SDM) services as an effective primary care interventions for diabetes. However, only a few countries have actually adopted them (e.g. England). In other European countries (e.g. Cyprus) there is awareness that patients play a crucial role in decision-making, and SDM services could be considered as innovative strategies to promote the actual implementation of patient rights legislation and strengthen primary care. to understand preferences of people with diabetes when choosing their care, and how they value alternative SDM services compared to their 'current' option. Preferences were collected from patients based in England, where SDM is already in place at national level, and Cyprus, where people are new to it, using a discrete-choice-experiment (DCE) survey. Cypriots valued choosing alternative SDM services compared to their 'current' option, whereas the English preferred their status quo to other services. Having the primary-care-physician as healthcare provider, receiving compassionate care, receiving detailed and accurate information about their care, continuity of care, choosing their care management and treatment, and reduced waiting time were the SDM characteristics that Cypriots valued; the English preferred similar factors, apart from information/continuity of care. People with diabetes do value SDM and different SDM models may fit different groups according to their personal experience and country specific settings. Copyright © 2017 Elsevier B.V. All rights reserved.

The Cost Effectiveness of Embedding a Behavioral Health Clinician into an Existing Primary Care Practice to Facilitate the Integration of Care: A Prospective, Case-Control Program Evaluation.

PubMed

Ross, Kaile M; Klein, Betsy; Ferro, Katherine; McQueeney, Debra A; Gernon, Rebecca; Miller, Benjamin F

2018-04-30

This project evaluated the cost effectiveness of integrating behavioral health services into a primary care practice using a prospective, case-control design. New Directions Behavioral Health collaborated with a large Kansas City primary care practice to integrate a licensed psychologist (i.e., behavioral health clinician) into the practice. Patient claims data were examined 21 months prior to and 14 months after the psychologist began providing full-time behavioral health services within the practice. Claims data from patients with Blue Cross Blue Shield of Kansas City insurance (BCBSKC) who had at least one encounter with the psychologist (N = 239) were compared to control patients (BCBSKC fully insured patients at large) to calculate cost savings. The results demonstrated that integrating behavioral health services into the practice was associated with $860.16 per member per year savings or 10.8% savings in costs for BCBSKC patients. Integrating behavioral health services into primary care may lead to reductions in health care costs.

Childhood obesity: knowledge, attitudes, and practices of European pediatric care providers.

PubMed

Mazur, Artur; Matusik, Pawel; Revert, Krista; Nyankovskyy, Sergey; Socha, Piotr; Binkowska-Bury, Monika; Grzegorczyk, Joanna; Caroli, Margherita; Hassink, Sandra; Telega, Grzegorz; Malecka-Tendera, Ewa

2013-07-01

To determine and compare attitudes, skills, and practices in childhood obesity management in 4 European countries with different obesity prevalence, health care systems, and economic situations. A cross-sectional survey was distributed to primary health care providers from France, Italy, Poland, and Ukraine. The questionnaire was returned by 1119 participants with a response rate of 32.4%. The study revealed that most of the primary health care providers were convinced of their critical role in obesity management but did not feel sufficiently competent to perform effectively. The adherence to recommended practices such as routine weight and height measurements, BMI calculation, and plotting growth parameters on recommended growth charts was poor. Most primary health care providers recognized the need for continuing professional education in obesity management, stressing the importance of appropriate dietary counseling. The study underlines insufficient implementation of national guidelines for management of obesity regardless of the country and its health system. It also makes clear that the critical problem is not elaboration of guidelines but rather creating support systems for implementation of the medical standards among the primary care practitioners.

The effectiveness of a stratified care model for non-specific low back pain in Danish primary care compared to current practice: study protocol of a randomised controlled trial.

PubMed

Morso, Lars; Schiøttz-Christensen, Berit; Søndergaard, Jens; Andersen, Nils-Bo de Vos; Pedersen, Flemming; Olsen, Kim Rose; Jensen, Morten Sall; Hill, Jonathan; Christiansen, David Høyrup

2018-06-08

Prior studies indicate that stratified care for low back pain results in better clinical outcome and reduced costs in healthcare compared to current practice. Stratified care may be associated with clinical benefits for patients with low back pain at a lower cost, but evidence is sparse. Hence this study aims to evaluate the clinical effects and cost-effectiveness of stratified care in patients with non-specific low back pain compared to current practice. The study is a two-armed randomised controlled trial in primary care in the Regions of Southern and Central Denmark (2.5 million citizens). Patients with non-specific low back will be recruited by paticpating GPs. Patients are randomised to either (1) stratified care or (2) current practice at participating physiotherapy clinics. In the stratified care arm, the intervention is based on the patient's STarT Back Tool classification and trained accordingly, whereas physiotherapists in the current pratice arm are blinded to the STarT score. Primary outcomes in the trial will be group differences in time off work, improvement in LBP disability measured by the Roland Morris Disability Questionnaire (RMDQ) and patient-reported global change. Secondary measures will be pain intensity, patient satisfaction, data on patient healthcare resource utilisation and quality-adjusted life year based on the EQ-5D-5L. Stratified care that effectively targets treatment to relevant sub-groups of patients has potentially great impact on the treatment pathways of low back pain. Thus, if effective, this could result in better patient outcomes and at the same time reduce the costs for treatment of low back pain. ClinicalTrials.gov , NCT02612467 . Registered on 16 November 2015.

The Efficacy of Mindfulness-Based Interventions in Primary Care: A Meta-Analytic Review.

PubMed

Demarzo, Marcelo M P; Montero-Marin, Jesús; Cuijpers, Pim; Zabaleta-del-Olmo, Edurne; Mahtani, Kamal R; Vellinga, Akke; Vicens, Caterina; López-del-Hoyo, Yolanda; García-Campayo, Javier

2015-11-01

Positive effects have been reported after mindfulness-based interventions (MBIs) in diverse clinical and nonclinical populations. Primary care is a key health care setting for addressing common chronic conditions, and an effective MBI designed for this setting could benefit countless people worldwide. Meta-analyses of MBIs have become popular, but little is known about their efficacy in primary care. Our aim was to investigate the application and efficacy of MBIs that address primary care patients. We performed a meta-analytic review of randomized controlled trials addressing the effect of MBIs in adult patients recruited from primary care settings. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines were followed. Effect sizes were calculated with the Hedges g in random effects models. The meta-analyses were based on 6 trials having a total of 553 patients. The overall effect size of MBI compared with a control condition for improving general health was moderate (g = 0.48; P = .002), with moderate heterogeneity (I(2) = 59; P <.05). We found no indication of publication bias in the overall estimates. MBIs were efficacious for improving mental health (g = 0.56; P = .007), with a high heterogeneity (I(2) = 78; P <.01), and for improving quality of life (g = 0.29; P = .002), with a low heterogeneity (I(2) = 0; P >.05). Although the number of randomized controlled trials applying MBIs in primary care is still limited, our results suggest that these interventions are promising for the mental health and quality of life of primary care patients. We discuss innovative approaches for implementing MBIs, such as complex intervention and stepped care. © 2015 Annals of Family Medicine, Inc.

The Efficacy of Mindfulness-Based Interventions in Primary Care: A Meta-Analytic Review

PubMed Central

Demarzo, Marcelo M.P.; Montero-Marin, Jesús; Cuijpers, Pim; Zabaleta-del-Olmo, Edurne; Mahtani, Kamal R.; Vellinga, Akke; Vicens, Caterina; López-del-Hoyo, Yolanda; García-Campayo, Javier

2015-01-01

PURPOSE Positive effects have been reported after mindfulness-based interventions (MBIs) in diverse clinical and nonclinical populations. Primary care is a key health care setting for addressing common chronic conditions, and an effective MBI designed for this setting could benefit countless people worldwide. Meta-analyses of MBIs have become popular, but little is known about their efficacy in primary care. Our aim was to investigate the application and efficacy of MBIs that address primary care patients. METHODS We performed a meta-analytic review of randomized controlled trials addressing the effect of MBIs in adult patients recruited from primary care settings. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines were followed. Effect sizes were calculated with the Hedges g in random effects models. RESULTS The meta-analyses were based on 6 trials having a total of 553 patients. The overall effect size of MBI compared with a control condition for improving general health was moderate (g = 0.48; P = .002), with moderate heterogeneity (I2 = 59; P <.05). We found no indication of publication bias in the overall estimates. MBIs were efficacious for improving mental health (g = 0.56; P = .007), with a high heterogeneity (I2 = 78; P <.01), and for improving quality of life (g = 0.29; P = .002), with a low heterogeneity (I2 = 0; P >.05). CONCLUSIONS Although the number of randomized controlled trials applying MBIs in primary care is still limited, our results suggest that these interventions are promising for the mental health and quality of life of primary care patients. We discuss innovative approaches for implementing MBIs, such as complex intervention and stepped care. PMID:26553897

Good progress for children coupled with recalcitrant inequalities for adults in New Zealand's journey towards Universal Health Coverage over the last decade.

PubMed

Matheson, Don; Reidy, Johanna; Tan, Lee; Carr, Julia

2015-05-29

This article explores how primary health care policy changes in New Zealand over the last decade have impacted on primary care access equity and avoidable hospital admissions. The national Ambulatory Sensitive Hospitalisations (ASH) data trends by age, ethnicity and area level deprivation were analysed in relation to the Primary Health Care policy initiatives for the period 2002 to 2014. Changes in primary care access over the decade have led to improvement in ASH indicators for parts of the population, but not for others. ASH rates decreased very significantly for children, especially in the 0-4 age group. These trends began in 2004, with decreases most marked for Pacific children, and those from the most deprived neighbourhoods. Inequalities in ASH rates for children between ethnic groups and levels of deprivation have substantially decreased. On the other hand, there has been a significant increase in ASH rates and inequalities for Pacific peoples in the 45 to 64 age group. Māori in the same age band show a modest reduction in ASH rates, with inequalities compared with the rest of the population remaining unchanged. Inequalities in ASH rates between 45-65 year olds living in different levels of deprivation remain large and unchanged, indicative of the recalcitrant nature of inequalities in primary care access for the adult population. Major policy initiatives undertaken by the government during this period have significantly affected primary care access. These include the New Zealand Health Strategy, the Primary Health Care Strategy, the creation of District Health Boards and Primary Health Organisations, and free care to under 6-year-olds. In the latter part of the decade, high-level target setting by successive Ministers is also affecting system performance. We conclude that the success in reducing inequality in access to primary care for children needs to be intensified, and the same principles applied to the adult population groups.

A comparative analysis of centralized waiting lists for patients without a primary care provider implemented in six Canadian provinces: study protocol.

PubMed

Breton, Mylaine; Green, Michael; Kreindler, Sara; Sutherland, Jason; Jbilou, Jalila; Wong, Sabrina T; Shaw, Jay; Crooks, Valorie A; Contandriopoulos, Damien; Smithman, Mélanie Ann; Brousselle, Astrid

2017-01-21

Having a regular primary care provider (i.e., family physician or nurse practitioner) is widely considered to be a prerequisite for obtaining healthcare that is timely, accessible, continuous, comprehensive, and well-coordinated with other parts of the healthcare system. Yet, 4.6 million Canadians, approximately 15% of Canada's population, are unattached; that is, they do not have a regular primary care provider. To address the critical need for attachment, especially for more vulnerable patients, six Canadian provinces have implemented centralized waiting lists for unattached patients. These waiting lists centralize unattached patients' requests for a primary care provider in a given territory and match patients with providers. From the little information we have on each province's centralized waiting list, we know the way they work varies significantly from province to province. The main objective of this study is to compare the different models of centralized waiting lists for unattached patients implemented in six provinces of Canada to each other and to available scientific knowledge to make recommendations on ways to improve their design in an effort to increase attachment of patients to a primary care provider. A logic analysis approach developed in three steps will be used. Step 1: build logic models that describe each province's centralized waiting list through interviews with key stakeholders in each province; step 2: develop a conceptual framework, separate from the provincially informed logic models, that identifies key characteristics of centralized waiting lists for unattached patients and factors influencing their implementation through a literature review and interviews with experts; step 3: compare the logic models to the conceptual framework to make recommendations to improve centralized waiting lists in different provinces during a pan Canadian face-to-face exchange with decision-makers, clinicians and researchers. This study is based on an inter-provincial learning exchange approach where we propose to compare centralized waiting lists and analyze variations in strategies used to increase attachment to a regular primary care provider. Fostering inter-provincial healthcare systems connectivity to improve centralized waiting lists' practices across Canada can lever attachment to a regular provider for timely access to continuous, comprehensive and coordinated healthcare for all Canadians and particular for those who are vulnerable.

Continuity of care: what matters to women when they are referred from primary to secondary care during labour? a qualitative interview study in the Netherlands.

PubMed

de Jonge, Ank; Stuijt, Rosan; Eijke, Iva; Westerman, Marjan J

2014-03-17

Continuity of care during labour is important for women. Women with an intrapartum referral from primary to secondary care look back more negatively on their birh experience compared to those who are not referred. It is not clear which aspects of care contribute to this negative birth experience. This study aimed to explore in-depth the experiences of women who were referred during labour from primary to secondary care with regard to the different aspects of continuity of care. A qualitative interview study was conducted in the Netherlands among women who were in primary care at the onset of labour and were referred to secondary care before the baby was born. Through purposive sampling 27 women were selected. Of these, nine women planned their birth at home, two in an alongside midwifery unit and 16 in hospital. Thematic analysis was used. Continuity of care was a very important issue for women because it contributed to their feeling of safety during labour. Important details were sometimes not handed over between professionals within and between primary and secondary care, in particular about women's personal preferences. In case of referral of care from primary to secondary care, it was important for women that midwives handed over the care in person and stayed until they felt safe with the hospital team. Personal continuity of care, in which case the midwife stayed until the end of labour, was highly appreciated but not always expected.Fear of transportion during or after labour was a reason for women to choose hospital birth but also to opt for home birth. Choice of place of birth emerged as a fluid concept; most women planned their place of birth during pregnancy and were aware that they would spend some time at home and possibly some time in hospital. In case of referral from primary to secondary care during labour, midwives should hand over their care in person and preferrably stay with women throughout labour. Planned place of birth should be regarded as a fluid concept rather than a dichotomous choice.

Continuity of care: what matters to women when they are referred from primary to secondary care during labour? a qualitative interview study in the Netherlands

PubMed Central

2014-01-01

Background Continuity of care during labour is important for women. Women with an intrapartum referral from primary to secondary care look back more negatively on their birh experience compared to those who are not referred. It is not clear which aspects of care contribute to this negative birth experience. This study aimed to explore in-depth the experiences of women who were referred during labour from primary to secondary care with regard to the different aspects of continuity of care. Methods A qualitative interview study was conducted in the Netherlands among women who were in primary care at the onset of labour and were referred to secondary care before the baby was born. Through purposive sampling 27 women were selected. Of these, nine women planned their birth at home, two in an alongside midwifery unit and 16 in hospital. Thematic analysis was used. Results Continuity of care was a very important issue for women because it contributed to their feeling of safety during labour. Important details were sometimes not handed over between professionals within and between primary and secondary care, in particular about women’s personal preferences. In case of referral of care from primary to secondary care, it was important for women that midwives handed over the care in person and stayed until they felt safe with the hospital team. Personal continuity of care, in which case the midwife stayed until the end of labour, was highly appreciated but not always expected. Fear of transportion during or after labour was a reason for women to choose hospital birth but also to opt for home birth. Choice of place of birth emerged as a fluid concept; most women planned their place of birth during pregnancy and were aware that they would spend some time at home and possibly some time in hospital. Conclusions In case of referral from primary to secondary care during labour, midwives should hand over their care in person and preferrably stay with women throughout labour. Planned place of birth should be regarded as a fluid concept rather than a dichotomous choice. PMID:24636135

How many referrals to a pediatric orthopaedic hospital specialty clinic are primary care problems?

PubMed

Hsu, Eric Y; Schwend, Richard M; Julia, Leamon

2012-01-01

Many primary care physicians believe that there are too few pediatric orthopaedic specialists available to meet their patients' needs. However, a recent survey by the Practice Management Committee of the Pediatric Orthopaedic Society of North America found that new referrals were often for cases that could have been managed by primary care practitioners. We wished to determine how many new referral cases seen by pediatric orthopaedic surgeons are in fact conditions that can be readily managed by a primary care physician should he/she chose to do so. We prospectively studied all new referrals to our hospital-based orthopaedic clinic during August 2010. Each new referral was evaluated for whether it met the American Board of Pediatrics criteria for being a condition that could be managed by a primary care pediatrician. Each referral was also evaluated for whether it met the American Academy of Pediatrics Surgery Advisory Panel guidelines recommending referral to an orthopaedic specialist, regardless of whether it is for general orthopaedics or pediatric orthopaedics. On the basis of these criteria, we classified conditions as either a condition manageable by primary care physicians or a condition that should be referred to an orthopaedic surgeon or a pediatric orthopaedic surgeon. We used these guidelines not to identify diagnosis that primary care physicians should treat but, rather, to compare the guideline-delineated referrals with the actual referrals our specialty pediatric orthopaedic clinic received over a period of 1 month. A total of 529 new patient referrals were seen during August 2010. A total of 246 (47%) were considered primary care conditions and 283 (53%) orthopaedic specialty conditions. The most common primary care condition was a nondisplaced phalanx fracture (25/246, 10.1%) and the most common specialty condition was a displaced single-bone upper extremity fracture needing reduction (36/283, 13%). Only 77 (14.6%) of the total cases met the strict American Academy of Pediatrics Surgery Advisory Panel guidelines recommending referral to pediatric orthopaedics, with scoliosis being the most frequent condition. For 38 (7.2%) cases, surgical treatment was required or recommended. Patient age, referral source, or type of insurance did not influence whether the condition was a primary care or a specialty care case. A total of 134 (25%) cases were referred without having an initial diagnosis made by the referring clinician. These patients were more likely to have been referred from a primary care practitioner than from a tertiary care practitioner whether the diagnosis eventually made was considered to be a primary care condition (P=0.03; relative risk, 1.9; 95% confidence interval, 96-3.86). Almost half of all new referrals to a tertiary pediatric orthopaedic clinic were for conditions considered to be manageable by primary care physicians should they chose to do so. This has implications for pediatric orthopaedic workforce availability, reimbursement under the Affordable Care Act, and pediatric musculoskeletal training needs for providers of primary care.

Specialist outreach clinics in primary care and rural hospital settings.

PubMed

Gruen, R L; Weeramanthri, T S; Knight, S E; Bailie, R S

2004-01-01

Specialist medical practitioners have conducted clinics in primary care and rural hospital settings for a variety of reasons in many different countries. Such clinics have been regarded as an important policy option for increasing the accessibility and effectiveness of specialist services and their integration with primary care services. To undertake a descriptive overview of studies of specialist outreach clinics and to assess the effectiveness of specialist outreach clinics on access, quality, health outcomes, patient satisfaction, use of services, and costs. We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialised register (March 2002), the Cochrane Controlled Trials Register (CCTR) (Cochrane Library Issue 1, 2002), MEDLINE (including HealthStar) (1966 to May 2002), EMBASE (1988 to March 2002), CINAHL (1982 to March 2002), the Primary-Secondary Care Database previously maintained by the Centre for Primary Care Research in the Department of General Practice at the University of Manchester, a collection of studies from the UK collated in "Specialist Outreach Clinics in General Practice" (Roland 1998), and the reference lists of all retrieved articles. Randomised trials, controlled before and after studies and interrupted time series analyses of visiting specialist outreach clinics in primary care or rural hospital settings, either providing simple consultations or as part of complex multifaceted interventions. The participants were patients, specialists, and primary care providers. The outcomes included objective measures of access, quality, health outcomes, satisfaction, service use, and cost. Four reviewers working in pairs independently extracted data and assessed study quality. 73 outreach interventions were identified covering many specialties, countries and settings. Nine studies met the inclusion criteria. Most comparative studies came from urban non-disadvantaged populations in developed countries. Simple 'shifted outpatients' styles of specialist outreach were shown to improve access, but there was no evidence of impact on health outcomes. Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services was associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. The additional costs of outreach may be balanced by improved health outcomes. This review supports the hypothesis that specialist outreach can improve access, outcomes and service use, especially when delivered as part of a multifaceted intervention. The benefits of simple outreach models in urban non-disadvantaged settings seem small. There is a need for good comparative studies of outreach in rural and disadvantaged settings where outreach may confer most benefit to access and health outcomes.

Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education.

PubMed

Solomon, Daniel H; Katz, Jeffrey N; Finkelstein, Joel S; Polinski, Jennifer M; Stedman, Margaret; Brookhart, M Alan; Arnold, Marilyn; Gauthier, Suzanne; Avorn, Jerry

2007-11-01

We conducted a randomized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries. Primary care physicians and their patients were randomized to usual care, patient intervention only, physician intervention only, or both interventions. There was no difference in the probability of the primary composite endpoint (BMD test or osteoporosis medication) or in either of its components comparing the combined intervention group with usual care (risk ratio = 1.04; 95% CI, 0.85-1.26). Fractures from osteoporosis are associated with substantial morbidity, mortality, and cost. However, only a minority of at-risk older adults receives screening and/or treatment for this condition. We evaluated the effect of educational interventions for osteoporosis targeting at-risk patients, primary care physicians, or both. We conducted a randomized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries. Primary care physicians and their patients were randomized to usual care, patient intervention only, physician intervention only, or both interventions. The at-risk patients were women >or=65 yr of age, men and women >or=65 yr of age with a prior fracture, and men and women >or=65 yr of age who used oral glucocorticoids. The primary outcome studied was a composite of either undergoing a BMD test or initiating a medication used for osteoporosis. The secondary outcome was a hip, humerus, spine, or wrist fracture. We randomized 828 primary care physicians and their 13,455 eligible at-risk patients into four study arms. Physician and patient characteristics were very similar across all four groups. Across all four groups, the rate of the composite outcome was 10.3 per 100 person-years and did not differ between the usual care and the combined intervention groups (p = 0.5). In adjusted Cox proportional hazards models, there was no difference in the probability of the primary composite endpoint comparing the combined intervention group with usual care (risk ratio = 1.04; 95% CI, 0.85-1.26). There was also no difference in either of the components of the composite endpoint. The probability of fracture during follow-up was 4.2 per 100 person-years and did not differ by treatment assignment (p = 0.9). In this trial, a relatively brief program of patient and/or physician education did not work to improve the management of osteoporosis. More intensive efforts should be considered for future quality improvement programs for osteoporosis.

Mindfulness as a complementary intervention in the treatment of overweight and obesity in primary health care: study protocol for a randomised controlled trial.

PubMed

Salvo, Vera; Kristeller, Jean; Marin, Jesus Montero; Sanudo, Adriana; Lourenço, Bárbara Hatzlhoffer; Schveitzer, Mariana Cabral; D'Almeida, Vania; Morillo, Héctor; Gimeno, Suely Godoy Agostinho; Garcia-Campayo, Javier; Demarzo, Marcelo

2018-05-11

Mindfulness has been applied in the United States and Europe to improve physical and psychological health; however, little is known about its feasibility and efficacy in a Brazilian population. Mindfulness may also be relevant in tackling obesity and eating disorders by decreasing binge eating episodes-partly responsible for weight regain for a large number of people-and increasing awareness of emotional and other triggers for overeating. The aim of the present study protocol is to evaluate and compare the feasibility and efficacy of two mindfulness-based interventions (MBIs) addressing overweight and obesity in primary care patients: a general programme called Mindfulness-Based Health Promotion and a targeted mindful eating protocol called Mindfulness-Based Eating Awareness Training. A randomised controlled trial will be conducted to compare treatment as usual separately in primary care with both programmes (health promotion and mindful eating) added to treatment as usual. Two hundred forty adult women with overweight and obesity will be enrolled. The primary outcome will be an assessment of improvement in eating behaviour. Secondary outcomes will be (1) biochemical control; (2) anthropometric parameters, body composition, dietary intake and basal metabolism; and (3) levels of mindfulness, stress, depression, self-compassion and anxiety. At the end of each intervention, a focus group will be held to assess the programme's impact on the participants' lives, diet and health. A feasibility study on access to benefits from and importance of MBIs at primary care facilities will be conducted among primary care health care professionals and participants. Monthly maintenance sessions lasting at least 1 hour will be offered, according to each protocol, during the 3-month follow-up periods. This clinical trial will result in more effective mindfulness-based interventions as a complementary treatment in primary care for people with overweight and obesity. If the findings of this study confirm the effectiveness of mindfulness programmes in this population, it will be possible to improve quality of life and health while optimising public resources and reaching a greater number of people. In addition, on the basis of the evaluation of the feasibility of implementing this intervention in primary care facilities, we expect to be able to suggest the intervention for incorporation into public policy. ClinicalTrials.gov, NCT02893150 . Registered retrospectively on 30 March 2017.

A qualitative comparison of primary care clinicians’ and their patients’ perspectives on achieving depression care: implications for improving outcomes

PubMed Central

2014-01-01

Background Improving the patient experience of primary care is a stated focus of efforts to transform primary care practices into “Patient-centered Medical Homes” (PCMH) in the United States, yet understanding and promoting what defines a positive experience from the patient’s perspective has been de-emphasized relative to the development of technological and communication infrastructure at the PCMH. The objective of this qualitative study was to compare primary care clinicians’ and their patients’ perceptions of the patients’ experiences, expectations and preferences as they try to achieve care for depression. Methods We interviewed 6 primary care clinicians along with 30 of their patients with a history of depressive disorder attending 4 small to medium-sized primary care practices from rural and urban settings. Results Three processes on the way to satisfactory depression care emerged: 1. a journey, often from fractured to connected care; 2. a search for a personal understanding of their depression; 3. creation of unique therapeutic spaces for treating current depression and preventing future episodes. Relative to patients’ observations regarding stigma’s effects on accepting a depression diagnosis and seeking treatment, clinicians tended to underestimate the presence and effects of stigma. Patients preferred clinicians who were empathetic listeners, while clinicians worried that discussing depression could open “Pandora’s box” of lengthy discussions and set them irrecoverably behind in their clinic schedules. Clinicians and patients agreed that somatic manifestations of mental distress impeded the patients’ ability to understand their suffering as depression. Clinicians reported supporting several treatment modalities beyond guideline-based approaches for depression, yet also displayed surface-level understanding of the often multifaceted support webs their patient described. Conclusions Improving processes and outcomes in primary care may demand heightened ability to understand and measure the patients’ experiences, expectations and preferences as they receive primary care. Future research would investigate a potential mismatch between clinicians’ and patients’ perceptions of the effects of stigma on achieving care for depression, and on whether time spent discussing depression during the clinical visit improves outcomes. Improving care and outcomes for chronic disorders such as depression may require primary care clinicians to understand and support their patients’ unique ‘therapeutic spaces.’ PMID:24428952

Correlation of the Care by Design primary care practice redesign model and the principles of the patient-centered medical home.

PubMed

Egger, Marlene J; Day, Julie; Scammon, Debra L; Li, Yao; Wilson, Andrew; Magill, Michael K

2012-01-01

Health care reform requires major changes in the organization and delivery of primary care. In 2003, the University of Utah Community Clinics began developing Care by Design (CBD), a primary care model emphasizing access, care teams, and planned care. In 2007, leading primary care organizations published joint principles of the patient-centered medical home (PCMH), the basis for recognition of practices as PCMHs by the National Committee for Quality Assurance (NCQA). The objective of this study was to compare CBD and PCMH metrics conceptually and statistically. This was an observational study in 10 urban and rural primary care clinics including 56 providers. A self-evaluation included the CBD Extent of Use survey and self-estimated PCMH values. The main and secondary outcome measures were CBD scores and PCMH values, respectively. CBD and PCMH principles share common themes such as appropriate access, team-based care, the use of an augmented electronic medical record, planned care, and self-management support. CBD focuses more on the process of practice transformation. The NCQA PCMH standards focus more on structure, including policy, capacity, and populated electronic medical record fields. The Community Clinics' clinic-level PCMH/CBD correlations were low (P > .05.) Practice redesign requires an ability to assess uptake of the redesign as a transformation progresses. The correlation of CBD and PCMH is substantial conceptually but low statistically. PCMH and CBD focus on complementary aspects of redesign: PCMH on structure and CBD on process. Both domains should be addressed in practice reform. Both metrics are works in progress.

Depression and use of health care services in patients with advanced cancer

PubMed Central

Lo, Christopher; Calzavara, Andrew; Kurdyak, Paul; Barbera, Lisa; Shepherd, Frances; Zimmermann, Camilla; Moore, Malcolm J.; Rodin, Gary

2013-01-01

Abstract Objective To examine whether depression in patients with advanced cancer is associated with increased rates of physician visits, especially to primary care. Design Retrospective, observational study linking depression survey data to provincial health administration data. Setting Toronto, Ont. Participants A total of 737 patients with advanced cancer attending Princess Margaret Hospital, who participated in the Will to Live Study from 2002 to 2008. Main outcome measures Frequency of visits to primary care, oncology, surgery, and psychiatry services, before and after the depression assessment. Results Before the assessment, depression was associated with an almost 25% increase in the rate of primary care visits for reasons not related to mental health (rate ratio [RR] = 1.23, 95% CI 1.00 to 1.50), adjusting for medical morbidity and other factors. After assessment, depression was associated with a 2-fold increase in the rate of primary care visits for mental health–related reasons (RR = 2.35, 95% CI 1.18 to 4.66). However, depression was also associated during this time with an almost 25% reduction in the rate of oncology visits (RR = 0.78, 95% CI 0.65 to 0.94). Conclusion Depression affects health care service use in patients with advanced cancer. Individuals with depression were more likely to see primary care physicians but less likely to see oncologists, compared with individuals without depression. However, the frequent association of disease-related factors with depression in patients with advanced cancer highlights the need for communication between oncologists and primary care physicians about the medical and psychosocial care of these patients. PMID:23486819

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.

Sustaining quality in the community: trends in the performance of a structured diabetes care programme in primary care over 16 years.

PubMed

Riordan, F; McHugh, S M; Harkins, V; Marsden, P; Kearney, P M

2018-04-29

To examine the quality of care delivered by a structured primary care-led programme for people with Type 2 diabetes mellitus in 1999-2016. The Midland Diabetes Structured Care Programme provides structured primary care-led management. Trends over time in care processes were examined (using a chi-squared trend test and age- and gender-adjusted logistic regression). Screening and annual review attendance were reviewed. A composite of eight National Institute for Health and Care Excellence-recommended processes was used as a quality indicator. Participants who were referred to diabetes nurse specialists were compared with those not referred (Student's t-test, Pearson's chi-squared test, Wilcoxon-Mann-Whitney test). Proportions achieving outcome targets [HbA 1c ≤58 mmol/mol (7.5%), blood pressure ≤140/80 mmHg, cholesterol <5.0 mmol/l] were calculated. Data were available for people with diabetes aged ≥18 years: 1998/1999 (n=336); 2003 (n=843); 2008 (n=988); and 2016 (n=1029). Recording of some processes improved significantly over time (HbA 1c , cholesterol, blood pressure, creatinine), and in 2016 exceeded 97%. Foot assessment and annual review attendance declined. In 2016, only 29% of participants had all eight National Institute for Health and Care Excellence processes recorded. A higher proportion of people with diabetes who were referred to a diabetes nurse specialist had poor glycaemic control compared with those not referred. The proportions meeting blood pressure and lipid targets increased over time. Structured primary care led to improvements in the quality of care over time. Poorer recording of some processes, a decline in annual review attendance, and participants remaining at high risk suggest limits to what structured care alone can achieve. Engagement in continuous quality improvement to target other factors, including attendance and self-management, may deliver further improvements. © 2018 Diabetes UK.

Comparison of physician referral and insurance claims data-based risk prediction as approaches to identify patients for care management in primary care: an observational study.

PubMed

Freund, Tobias; Gondan, Matthias; Rochon, Justine; Peters-Klimm, Frank; Campbell, Stephen; Wensing, Michel; Szecsenyi, Joachim

2013-10-20

Primary care-based care management (CM) could reduce hospital admissions in high-risk patients. Identification of patients most likely to benefit is needed as resources for CM are limited. This study aimed to compare hospitalization and mortality rates of patients identified for CM either by treating primary care physicians (PCPs) or predictive modelling software for hospitalization risk (PM). In 2009, a cohort of 6,026 beneficiaries of a German statutory health insurance served as a sample for patient identification for CM by PCPs or commercial PM (CSSG 0.8, Verisk Health). The resulting samples were compared regarding hospitalization and mortality rates in 2010 and in the two year period before patient selection. No CM-intervention was delivered until the end of 2010 and PCPs were blinded for the assessment of hospitalization rates. In 2010, hospitalization rates of PM-identified patients were 80% higher compared to PCP-identified patients. Mortality rates were also 8% higher in PM-identified patients if compared to PCP-identified patients (10% vs. 2%). The hospitalization rate of patients independently identified by both PM and PCPs was numerically between PM- and PCP-identified patients. Time trend between 2007 and 2010 showed decreasing hospitalization rates in PM-identified patients (-15% per year) compared to increasing rates in PCP-identified patients (+34% per year). PM identified patients with higher hospitalization and mortality rates compared to PCP-referred patients. But the latter showed increasing hospitalization rates over time thereby suggesting that PCPs may be able to predict future deterioration in patients with relatively good current health status. These patients may most likely benefit from preventive services like CM.

Use of antihypertensive medications and diagnostic tests among privately insured adolescents and young adults with primary versus secondary hypertension.

PubMed

Yoon, Esther Y; Cohn, Lisa; Freed, Gary; Rocchini, Albert; Kershaw, David; Ascione, Frank; Clark, Sarah

2014-07-01

To compare the use of antihypertensive medications and diagnostic tests among adolescents and young adults with primary versus secondary hypertension. We conducted retrospective cohort analysis of claims data for adolescents and young adults (12-21 years of age) with ≥3 years of insurance coverage (≥11 months/year) in a large private managed care plan during 2003-2009 with diagnosis of primary hypertension or secondary hypertension. We examined their use of antihypertensive medications and identified demographic characteristics and the presence of obesity-related comorbidities. For the subset receiving antihypertensive medications, we examined their diagnostic test use (echocardiograms, renal ultrasounds, and electrocardiograms). The study sample included 1,232 adolescents and young adults; 84% had primary hypertension and 16% had secondary hypertension. The overall prevalence rate of hypertension was 2.6%. One quarter (28%) with primary hypertension had one or more antihypertensive medications, whereas 65% with secondary hypertension had one or more antihypertensive medications. Leading prescribers of antihypertensives for subjects with primary hypertension were primary care physicians (80%), whereas antihypertensive medications were equally prescribed by primary care physicians (43%) and sub-specialists (37%) for subjects with secondary hypertension. The predominant hypertension diagnosis among adolescents and young adults is primary hypertension. Antihypertensive medication use was higher among those with secondary hypertension compared with those with primary hypertension. Further study is needed to determine treatment effectiveness and patient outcomes associated with differential treatment patterns used for adolescents and young adults with primary versus secondary hypertension. Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care.

PubMed

Dogan, Kemal; Kraaij, Linda; Aarts, Edo O; Koehestanie, Parweez; Hammink, Edwin; van Laarhoven, Cees J H M; Aufenacker, Theo J; Janssen, Ignace M C; Berends, Frits J

2015-01-01

Due to the increased incidence of morbid obesity, the demand for bariatric surgery is increasing. Therefore, the methods for optimising perioperative care for the improvement of surgical outcome and to increase efficacy are necessary. The aim of this prospective matched cohort study is to objectify the effect of the fast-track surgery (FTS) programme in patients undergoing primary Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) surgery compared to conventional perioperative care (CPC). This study compared the perioperative outcome data of two groups of 75 consecutive morbid obese patients who underwent a primary LRYGB according to international guidelines in the periods January 2011-April 2011 (CPC group) and April 2012-June 2012 (FTS group). The two groups were matched for age and sex. Primary endpoints were surgery and hospitalisation time, while secondary endpoints were intraoperative medication use and complication rates. Baseline patient characteristics for age, sex, weight and ASA classification were similar (p > 0.05) for CPC and FTS patients. BMI and waist circumference were significantly lower (p < 0.05) in the FTS compared to CPC. The total time from arrival at the operating room to the arrival at the recovery was reduced from 119 to 82 min (p < 0.001). Surgery time was reduced from 80 to 56 min (p < 0.001); mean hospital stay was reduced from 65 to 43 h (p < 0.001). Major complications occurred in 3 versus 4 % in the FTS and CPC, respectively. The introduction of a fast-track programme after primary LRYGB improves short-term recovery and may reduces direct hospital-related resources.

Comparison of patients' experiences in public and private primary care clinics in Malta.

PubMed

Pullicino, Glorianne; Sciortino, Philip; Calleja, Neville; Schäfer, Willemijn; Boerma, Wienke; Groenewegen, Peter

2015-06-01

Demographic changes, technological developments and rising expectations require the analysis of public-private primary care (PC) service provision to inform policy makers. We conducted a descriptive, cross-sectional study using the dataset of the Maltese arm of the QUALICOPC Project to compare the PC patients' experiences provided by public-funded and private (independent) general practitioners in Malta. Seven hundred patients from 70 clinics completed a self-administered questionnaire. Direct logistic regression showed that patients visiting the private sector experienced better continuity of care with more difficulty in accessing out-of-hours care. Such findings help to improve (primary) healthcare service provision and resource allocation. © The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

Trauma and posttraumatic stress disorder in a rural primary care population in South Africa.

PubMed

Peltzer, K; Seakamela, M J; Manganye, L; Mamiane, K G; Motsei, M S; Mathebula, T T M

2007-06-01

The aim of this study was to assess trauma events experienced and PTSD among 250 consecutive rural primary clinic patients (all Black Africans, 24% male and 76% female; M age 31.1 yr., SD = 11.8; range 18-65 years) in South Africa using the Trauma History Questionnaire and the PTSD Checklist-Civilian Version, interview administered. Results indicated that the mean number of traumatic events reported was 3.5 (SD = 2.9, range = 0-19) and was significantly higher among men (M= 4.9, SD = 3.5) than women (M = 3.0, SD = 2.6). Among the most frequently endorsed traumas among men were seeing someone seriously injured or killed (60%), serious accident (43.3%), and seeing dead bodies (43.3%), and among women natural disaster (mostly floods) (51.6%), news of a serious injury, life-threatening illness or unexpected death of someone close (31.1%), and seeing someone seriously injured or killed (30%). A current diagnosis of PTSD was found in 12.4% of the sample. Trauma incidence figures were high (M = 3.5) and were comparable with an urban Xhosa primary care population in South Africa (M = 3.8). A current indicative diagnosis of PTSD of 12.4% also compares with other studies; 19.9% among urban Xhosa primary care patients and 11.8% among American primary care patients.

Trends and quality of care in outpatient visits to generalist and specialist physicians delivering primary care in the United States, 1997-2010.

PubMed

Edwards, Samuel T; Mafi, John N; Landon, Bruce E

2014-06-01

Although many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain. To describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs. Cross-sectional study and time trend analysis. Nationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997-2010. Proportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality. Among 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p = 0.04). The proportion of medical specialist visits in which the physician self-identified as the patient's PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p < 0.01). Medical specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p < 0.01), primarily for preventive care (54.0 %, p < 0.01). Quality of care for cardiovascular disease was better in visits to cardiologists than in visits to generalists, but was similar or better in visits to generalists compared to visits to other medical specialists. Medical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.

Using systems science for population health management in primary care.

PubMed

Li, Yan; Kong, Nan; Lawley, Mark A; Pagán, José A

2014-10-01

Population health management is becoming increasingly important to organizations managing and providing primary care services given ongoing changes in health care delivery and payment systems. The objective of this study is to show how systems science methodologies could be incorporated into population health management to compare different interventions and improve health outcomes. The New York Academy of Medicine Cardiovascular Health Simulation model (an agent-based model) and data from the Behavioral Risk Factor Surveillance System were used to evaluate a lifestyle program that could be implemented in primary care practice settings. The program targeted Medicare-age adults and focused on improving diet and exercise and reducing weight. The simulation results suggest that there would be significant reductions projected in the proportion of the Medicare-age population with diabetes after the implementation of the proposed lifestyle program for a relatively long term (3 and 5 years). Similar results were found for the subpopulations with high cholesterol, but the proposed intervention would not have a significant effect in the proportion of the population with hypertension over a time period of <5 years. Systems science methodologies can be useful to compare the health outcomes of different interventions. These tools can become an important component of population health management because they can help managers and other decision makers evaluate alternative programs in primary care settings. © The Author(s) 2014.

The CIPRUS study, a nurse-led psychological treatment for patients with undifferentiated somatoform disorder in primary care: study protocol for a randomised controlled trial.

PubMed

Sitnikova, Kate; Leone, Stephanie S; Zonneveld, Lyonne N L; van Marwijk, Harm W J; Bosmans, Judith E; van der Wouden, Johannes C; van der Horst, Henriëtte E

2017-05-03

Up to a third of patients presenting medically unexplained physical symptoms in primary care may have a somatoform disorder, of which undifferentiated somatoform disorder (USD) is the most common type. Psychological interventions can reduce symptoms associated with USD and improve functioning. Previous research has either been conducted in secondary care or interventions have been provided by general practitioners (GPs) or psychologists in primary care. As efficiency and cost-effectiveness are imperative in primary care, it is important to investigate whether nurse-led interventions are effective as well. The aim of this study is to examine the effectiveness and cost-effectiveness of a short cognitive behavioural therapy (CBT)-based treatment for patients with USD provided by mental health nurse practitioners (MHNPs), compared to usual care. In a cluster randomised controlled trial, 212 adult patients with USD will be assigned to the intervention or care as usual. The intervention group will be offered a short, individual CBT-based treatment by the MHNP in addition to usual GP care. The main goal of the intervention is that patients become less impaired by their physical symptoms and cope with symptoms in a more effective way. In six sessions patients will receive problem-solving treatment. The primary outcome is improvement in physical functioning, measured by the physical component summary score of the RAND-36. Secondary outcomes include health-related quality of life measured by the separate subscales of the RAND-36, somatization (PHQ-15) and symptoms of depression and anxiety (HADS). Problem-solving skills, health anxiety, illness perceptions, coping, mastery and working alliance will be assessed as potential mediators. Assessments will be done at 0, 2, 4, 8 and 12 months. An economic evaluation will be conducted from a societal perspective with quality of life as the primary outcome measure assessed by the EQ-5D-5L. Health care, patient and lost productivity costs will be assessed with the Tic-P. We expect that the intervention will improve physical functioning and is cost-effective compared to usual care. If so, more patients might successfully be treated in general practice, decreasing the number of referrals to specialist care. Dutch Trial Registry, identifier: NTR4686 , Registered on 14 July 2014.

Independence, institutionalization, death and treatment costs 18 months after rehabilitation of older people in two different primary health care settings.

PubMed

Johansen, Inger; Lindbak, Morten; Stanghelle, Johan K; Brekke, Mette

2012-11-14

The optimal setting and content of primary health care rehabilitation of older people is not known. Our aim was to study independence, institutionalization, death and treatment costs 18 months after primary care rehabilitation of older people in two different settings. Eighteen months follow-up of an open, prospective study comparing the outcome of multi-disciplinary rehabilitation of older people, in a structured and intensive Primary care dedicated inpatient rehabilitation (PCDIR, n=202) versus a less structured and less intensive Primary care nursing home rehabilitation (PCNHR, n=100). 302 patients, disabled from stroke, hip-fracture, osteoarthritis and other chronic diseases, aged ≥65years, assessed to have a rehabilitation potential and being referred from general hospital or own residence. Primary: Independence, assessed by Sunnaas ADL Index(SI). Secondary: Hospital and short-term nursing home length of stay (LOS); institutionalization, measured by institutional residence rate; death; and costs of rehabilitation and care. Statistical tests: T-tests, Correlation tests, Pearson's χ2, ANCOVA, Regression and Kaplan-Meier analyses. Overall SI scores were 26.1 (SD 7.2) compared to 27.0 (SD 5.7) at the end of rehabilitation, a statistically, but not clinically significant reduction (p=0.003 95%CI(0.3-1.5)). The PCDIR patients scored 2.2points higher in SI than the PCNHR patients, adjusted for age, gender, baseline MMSE and SI scores (p=0.003, 95%CI(0.8-3.7)). Out of 49 patients staying >28 days in short-term nursing homes, PCNHR-patients stayed significantly longer than PCDIR-patients (mean difference 104.9 days, 95%CI(0.28-209.6), p=0.05). The institutionalization increased in PCNHR (from 12%-28%, p=0.001), but not in PCDIR (from 16.9%-19.3%, p= 0.45). The overall one year mortality rate was 9.6%. Average costs were substantially higher for PCNHR versus PCDIR. The difference per patient was 3528€ for rehabilitation (p<0.001, 95%CI(2455-4756)), and 10134€ for the at-home care (p=0.002, 95%CI(4066-16202)). The total costs of rehabilitation and care were 18702€ (=1.6 times) higher for PCNHR than for PCDIR. At 18 months follow-up the PCDIR-patients maintained higher levels of independence, spent fewer days in short-term nursing homes, and did not increase the institutionalization compared to PCNHR. The costs of rehabilitation and care were substantially lower for PCDIR. More communities should consider adopting the PCDIR model. Clinicaltrials.gov ID NCT01457300.

Networks In ACA Marketplaces Are Narrower For Mental Health Care Than For Primary Care.

PubMed

Zhu, Jane M; Zhang, Yuehan; Polsky, Daniel

2017-09-01

There is increasing concern about the extent to which narrow-network plans, generally defined as those including fewer than 25 percent of providers in a given health insurance market, affect consumers' choice of and access to specialty providers-particularly in mental health care. Using data for 2016 from 531 unique provider networks in the Affordable Care Act Marketplaces, we evaluated how network size and the percentage of providers who participate in any network differ between mental health care providers and a control group of primary care providers. Compared to primary care networks, participation in mental health networks was low, with only 42.7 percent of psychiatrists and 19.3 percent of nonphysician mental health care providers participating in any network. On average, plan networks included 24.3 percent of all primary care providers and 11.3 percent of all mental health care providers practicing in a given state-level market. These findings raise important questions about provider-side barriers to meeting the goal of mental health parity regulations: that insurers cover mental health services on a par with general medical and surgical services. Concerted efforts to increase network participation by mental health care providers, along with greater regulatory attention to network size and composition, could improve consumer choice and complement efforts to achieve mental health parity. Project HOPE—The People-to-People Health Foundation, Inc.

Comparative effectiveness research in DARTNet primary care practices: point of care data collection on hypoglycemia and over-the-counter and herbal use among patients diagnosed with diabetes.

PubMed

Libby, Anne M; Pace, Wilson; Bryan, Cathy; Anderson, Heather Orton; Ellis, Samuel L; Allen, Richard Read; Brandt, Elias; Huebschmann, Amy G; West, David; Valuck, Robert J

2010-06-01

The Distributed Ambulatory Research in Therapeutics Network (DARTNet) is a federated network of electronic health record (EHR) data, designed as a platform for next-generation comparative effectiveness research in real-world settings. DARTNet links information from nonintegrated primary care clinics that use EHRs to deliver ambulatory care to overcome limitations with traditional observational research. Test the ability to conduct a remote, electronic point of care study in DARTNet practices by prompting clinic staff to obtain specific information during a patient encounter. Prospective survey of patients identified through queries of clinical data repositories in federated network organizations. On patient visit, survey is triggered and data are relinked to the EHR, de-identified, and copied for evaluation. Adult patients diagnosed with diabetes mellitus that scheduled a clinic visit for any reason in a 2-week period in DARTNet primary care practices. Survey on hypoglycemic events (past month) and over-the-counter and herbal supplement use. DARTNet facilitated point of care data collection triggered by an electronic prompt for additional information at a patient visit. More than one-third of respondents (33% response rate) reported either mild (45%) or severe hypoglycemic events (5%) in the month before the survey; only 3 of those were also coded using the ICD-9 (a significant difference in detection rates 37% vs. 1%). Nearly one-quarter of patients reported taking an OTC/herbal, 4% specifically for the treatment of symptoms of diabetes. Prospective data collection is feasible in DARTNet and can enable comparative effectiveness and safety research.

What is the impact of primary care model type on specialist referral rates? A cross-sectional study.

PubMed

Liddy, Clare; Singh, Jatinderpreet; Kelly, Ryan; Dahrouge, Simone; Taljaard, Monica; Younger, Jamie

2014-02-03

Several new primary care models have been implemented in Ontario, Canada over the past two decades. These practice models differ in team structure, physician remuneration, and group size. Few studies have examined the impact of these models on specialist referrals. We compared specialist referral rates amongst three primary care models: 1) Enhanced Fee-for-service, 2) Capitation- Non-Interdisciplinary (CAP-NI), 3) Capitation - Interdisciplinary (CAP-I). We conducted a cross-sectional study using health administrative data from primary care practices in Ontario from April 1st, 2008 to March 31st, 2010. The analysis included all family physicians providing comprehensive care in one of the three models, had at least 100 patients, and did not have a prolonged absence (eight consecutive weeks). The primary outcome was referral rate (# of referrals to all medical specialties/1000 patients/year). A multivariable clustered Poisson regression analysis was used to compare referral rates between models while adjusting for provider (sex, years since graduation, foreign trained, time in current model) and patient (age, sex, income, rurality, health status) characteristics. Fee-for-service had a significantly lower adjusted referral rate (676, 95% CI: 666-687) than the CAP-NI (719, 95% confidence interval (CI): 705-734) and CAP-I (694, 95% CI: 681-707) models and the interdisciplinary CAP-I group had a 3.5% lower referral rate than the CAP-NI group (RR = 0.965, 95% CI: 0.943-0.987, p = 0.002). Female and Canadian-trained physicians referred more often, while female, older, sicker and urban patients were more likely to be referred. Primary care model is significantly associated with referral rate. On a study population level, these differences equate to 111,059 and 37,391 fewer referrals by fee-for-service versus CAP-NI and CAP-I, respectively - a difference of $22.3 million in initial referral appointment costs. Whether a lower rate of referral is more appropriate or not is not known and requires further investigation. Physician remuneration and team structure likely account for the differences; however, further investigation is also required to better understand whether other organizational factors associated with primary care model also impact referral.

Effectiveness of a structured motivational intervention including smoking cessation advice and spirometry information in the primary care setting: the ESPITAP study.

PubMed

Martin-Lujan, Francisco; Piñol-Moreso, Josep L I; Martin-Vergara, Nuria; Basora-Gallisa, Josep; Pascual-Palacios, Irene; Sagarra-Alamo, Ramon; Llopis, Estefania Aparicio; Basora-Gallisa, Maria T; Pedret-Llaberia, Roser

2011-11-11

There is current controversy about the efficacy of smoking cessation interventions that are based on information obtained by spirometry. The objective of this study is to evaluate the effectiveness in the primary care setting of structured motivational intervention to achieve smoking cessation, compared with usual clinical practice. Multicentre randomized clinical trial with an intervention and a control group. 12 primary care centres in the province of Tarragona (Spain). 600 current smokers aged between 35 and 70 years with a cumulative habit of more than 10 packs of cigarettes per year, attended in primary care for any reason and who did not meet any of the exclusion criteria for the study, randomly assigned to structured intervention or standard clinical attention. Usual advice to quit smoking by a general practitioner as well as a 20-minute personalized visit to provide detailed information about spirometry results, during which FEV1, FVC, FEF 25-75% and PEF measurements were discussed and interpreted in terms of theoretical values. Additional information included the lung age index (defined as the average age of a non-smoker with the same FEV1 as the study participant), comparing this with the chronological age to illustrate the pulmonary deterioration that results from smoking. Spirometry during the initial visit. Structured interview questionnaire administered at the primary care centre at the initial visit and at 12-month follow-up. Telephone follow-up interview at 6 months. At 12-month follow-up, expired CO was measured in patients who claimed to have quit smoking. Smoking cessation at 12 months. Data will be analyzed on the basis of "intention to treat" and the unit of analysis will be the individual smoker. Among active smokers treated in primary care we anticipate significantly higher smoking cessation in the intervention group than in the control group. Application of a motivational intervention based on structured information about spirometry results, improved abstinence rates among smokers seen in actual clinical practice conditions in primary care. ClinicalTrial.gov, number NCT01194596.

Effectiveness of a structured motivational intervention including smoking cessation advice and spirometry information in the primary care setting: the ESPITAP study

PubMed Central

2011-01-01

Background There is current controversy about the efficacy of smoking cessation interventions that are based on information obtained by spirometry. The objective of this study is to evaluate the effectiveness in the primary care setting of structured motivational intervention to achieve smoking cessation, compared with usual clinical practice. Methods Design Multicentre randomized clinical trial with an intervention and a control group. Setting 12 primary care centres in the province of Tarragona (Spain). Subjects of study 600 current smokers aged between 35 and 70 years with a cumulative habit of more than 10 packs of cigarettes per year, attended in primary care for any reason and who did not meet any of the exclusion criteria for the study, randomly assigned to structured intervention or standard clinical attention. Intervention Usual advice to quit smoking by a general practitioner as well as a 20-minute personalized visit to provide detailed information about spirometry results, during which FEV1, FVC, FEF 25-75% and PEF measurements were discussed and interpreted in terms of theoretical values. Additional information included the lung age index (defined as the average age of a non-smoker with the same FEV1 as the study participant), comparing this with the chronological age to illustrate the pulmonary deterioration that results from smoking. Measurements Spirometry during the initial visit. Structured interview questionnaire administered at the primary care centre at the initial visit and at 12-month follow-up. Telephone follow-up interview at 6 months. At 12-month follow-up, expired CO was measured in patients who claimed to have quit smoking. Main variables Smoking cessation at 12 months. Analysis Data will be analyzed on the basis of "intention to treat" and the unit of analysis will be the individual smoker. Expected results Among active smokers treated in primary care we anticipate significantly higher smoking cessation in the intervention group than in the control group. Discussion Application of a motivational intervention based on structured information about spirometry results, improved abstinence rates among smokers seen in actual clinical practice conditions in primary care. Trial registration ClinicalTrial.gov, number NCT01194596. PMID:22078490

Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial

PubMed Central

Ell, Kathleen; Jin, Haomiao; Vidyanti, Irene; Chou, Chih-Ping; Lee, Pey-Jiuan; Gross-Schulman, Sandra; Sklaroff, Laura Myerchin; Belson, David; Nezu, Arthur M; Hay, Joel; Wang, Chien-Ju; Scheib, Geoffrey; Di Capua, Paul; Hawkins, Caitlin; Liu, Pai; Ramirez, Magaly; Wu, Brian W; Richman, Mark; Myers, Caitlin; Agustines, Davin; Dasher, Robert; Kopelowicz, Alex; Allevato, Joseph; Roybal, Mike; Ipp, Eli; Haider, Uzma; Graham, Sharon; Mahabadi, Vahid; Guterman, Jeffrey

2018-01-01

Background Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. Objective The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. Methods DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. Results DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001). Conclusions Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality. PMID:29685872

Pain symptoms and stooling patterns do not drive diagnostic costs for children with functional abdominal pain and irritable bowel syndrome in primary or tertiary care.

PubMed

Lane, Mariella M; Weidler, Erica M; Czyzewski, Danita I; Shulman, Robert J

2009-03-01

The objectives of this study were to (1) compare the cost of medical evaluation for children with functional abdominal pain or irritable bowel syndrome brought to a pediatric gastroenterologist versus children who remained in the care of their pediatrician, (2) compare symptom characteristics for the children in primary versus tertiary care, and (3) examine if symptom characteristics predicted the cost of medical evaluation. Eighty-nine children aged 7 to 10 years with functional abdominal pain or irritable bowel syndrome seen by a gastroenterologist (n = 46) or seen only by a pediatrician (n = 43) completed daily pain and stool diaries for 2 weeks. Mothers provided retrospective reports of their children's symptoms in the previous year. Cost of medical evaluation was calculated via chart review of diagnostic tests and application of prices as if the patients were self-pay. Child-reported diary data reflected no significant group differences with respect to pain, interference with activities, or stool characteristics. In contrast, mothers of children evaluated by a gastroenterologist viewed their children as having higher maximum pain intensity in the previous year. Excluding endoscopy costs, cost of medical evaluation was fivefold higher for children evaluated by a gastroenterologist, with higher cost across blood work, stool studies, breath testing, and diagnostic imaging. Symptom characteristics did not predict cost of care for either group. Despite the lack of difference in symptom characteristics between children in primary and tertiary care, a notable differential in cost of evaluation exists in accordance with level of care. Symptom characteristics do not seem to drive diagnostic evaluation in either primary or tertiary care. Given the lack of differences in child-reported symptoms and the maternal perspective that children evaluated by a gastroenterologist had more severe pain, we speculate that parent perception of child symptoms may be a primary factor in seeking tertiary care.

Cost-Effectiveness and Value of Information Analysis of Brief Interventions to Promote Physical Activity in Primary Care.

PubMed

Gc, Vijay Singh; Suhrcke, Marc; Hardeman, Wendy; Sutton, Stephen; Wilson, Edward C F

2018-01-01

Brief interventions (BIs) delivered in primary care have shown potential to increase physical activity levels and may be cost-effective, at least in the short-term, when compared with usual care. Nevertheless, there is limited evidence on their longer term costs and health benefits. To estimate the cost-effectiveness of BIs to promote physical activity in primary care and to guide future research priorities using value of information analysis. A decision model was used to compare the cost-effectiveness of three classes of BIs that have been used, or could be used, to promote physical activity in primary care: 1) pedometer interventions, 2) advice/counseling on physical activity, and (3) action planning interventions. Published risk equations and data from the available literature or routine data sources were used to inform model parameters. Uncertainty was investigated with probabilistic sensitivity analysis, and value of information analysis was conducted to estimate the value of undertaking further research. In the base-case, pedometer interventions yielded the highest expected net benefit at a willingness to pay of £20,000 per quality-adjusted life-year. There was, however, a great deal of decision uncertainty: the expected value of perfect information surrounding the decision problem for the National Health Service Health Check population was estimated at £1.85 billion. Our analysis suggests that the use of pedometer BIs is the most cost-effective strategy to promote physical activity in primary care, and that there is potential value in further research into the cost-effectiveness of brief (i.e., <30 minutes) and very brief (i.e., <5 minutes) pedometer interventions in this setting. Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Electronic health records and patient safety: co-occurrence of early EHR implementation with patient safety practices in primary care settings.

PubMed

Tanner, C; Gans, D; White, J; Nath, R; Pohl, J

2015-01-01

The role of electronic health records (EHR) in enhancing patient safety, while substantiated in many studies, is still debated. This paper examines early EHR adopters in primary care to understand the extent to which EHR implementation is associated with the workflows, policies and practices that promote patient safety, as compared to practices with paper records. Early adoption is defined as those who were using EHR prior to implementation of the Meaningful Use program. We utilized the Physician Practice Patient Safety Assessment (PPPSA) to compare primary care practices with fully implemented EHR to those utilizing paper records. The PPPSA measures the extent of adoption of patient safety practices in the domains: medication management, handoffs and transition, personnel qualifications and competencies, practice management and culture, and patient communication. Data from 209 primary care practices responding between 2006-2010 were included in the analysis: 117 practices used paper medical records and 92 used an EHR. Results showed that, within all domains, EHR settings showed significantly higher rates of having workflows, policies and practices that promote patient safety than paper record settings. While these results were expected in the area of medication management, EHR use was also associated with adoption of patient safety practices in areas in which the researchers had no a priori expectations of association. Sociotechnical models of EHR use point to complex interactions between technology and other aspects of the environment related to human resources, workflow, policy, culture, among others. This study identifies that among primary care practices in the national PPPSA database, having an EHR was strongly empirically associated with the workflow, policy, communication and cultural practices recommended for safe patient care in ambulatory settings.

STI in remote communities: improved and enhanced primary health care (STRIVE) study protocol: a cluster randomised controlled trial comparing ‘usual practice’ STI care to enhanced care in remote primary health care services in Australia

PubMed Central

2013-01-01

Background Despite two decades of interventions, rates of sexually transmissible infections (STI) in remote Australian Aboriginal communities remain unacceptably high. Routine notifications data from 2011 indicate rates of chlamydia and gonorrhoea among Aboriginal people in remote settings were 8 and 61 times higher respectively than in the non-Indigenous population. Methods/design STRIVE is a stepped-wedge cluster randomised trial designed to compare a sexual health quality improvement program (SHQIP) to usual STI clinical care delivered in remote primary health care services. The SHQIP is a multifaceted intervention comprising annual assessments of sexual health service delivery, implementation of a sexual health action plan, six-monthly clinical service activity data reports, regular feedback meetings with a regional coordinator, training and financial incentive payments. The trial clusters comprise either a single community or several communities grouped together based on geographic proximity and cultural ties. The primary outcomes are: prevalence of chlamydia, gonorrhoea and trichomonas in Aboriginal residents aged 16–34 years, and performance in clinical management of STIs based on best practice indicators. STRIVE will be conducted over five years comprising one and a half years of trial initiation and community consultation, three years of trial conditions, and a half year of data analysis. The trial was initiated in 68 remote Aboriginal health services in the Northern Territory, Queensland and Western Australia. Discussion STRIVE is the first cluster randomised trial in STI care in remote Aboriginal health services. The trial will provide evidence to inform future culturally appropriate STI clinical care and control strategies in communities with high STI rates. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12610000358044 PMID:24016143

Frequent users of rural primary care: comparisons with randomly selected users.

PubMed

Mehl-Madrona, L E

1998-01-01

Frequent users of primary care have not been adequately characterized. The unique characteristics of this population was sought--why they come so often, what their care costs, and whether psychosocial factors play a role in their high utilization of health care. The billing system of a rural primary care clinic was used to find the frequency of visits for all patients attending the clinic for the previous 12 months. The 211 most frequent visitors were selected. A comparison group of 250 patients was drawn from the billing records using a random number generator. Charts were reviewed to compare diagnoses (by frequency), number of procedures, amount billed for care, amount received from those billings, number of psychotropic medications prescribed, and response to medication. A subgroup of each group was interviewed to confirm chart review findings and to inquire about personal reasons for coming to the clinic. Compared with patients who were random users, patients who were frequent users were more likely to come from the younger and older age groups, they averaged significantly more emergency department visits and visits to other specialists (P < 0.0001), and they had more mental health problems diagnosed (P < 0.01). Significantly more frequent users were insured by Medicaid and fewer were insured by Medicare. They had more detailed office visits and more laboratory tests. They received twice as much psychotherapy and had a higher percentage of problem-focused office visits. Chart audits and interviews of selected patients revealed that many nonmedical reasons were related to visits in addition to psychosocial stressors. Nonmedical factors are important among the most frequent users of a primary care clinic. Proposals to improve care for frequent users should consider the psychosocial needs of this population.

RCT of a care manager intervention for major depression in primary care: 2-year costs for patients with physical vs psychological complaints.

PubMed

Dickinson, L Miriam; Rost, Kathryn; Nutting, Paul A; Elliott, Carl E; Keeley, Robert D; Pincus, Harold

2005-01-01

Depression care management for primary care patients results in sustained improvement in clinical outcomes with diminishing costs over time. Clinical benefits, however, are concentrated primarily in patients who report to their primary care clinicians psychological rather than exclusively physical symptoms. This study proposes to determine whether the intervention affects outpatient costs differentially when comparing patients who have psychological with patients who have physical complaints. We undertook a group-randomized controlled trial (RCT) of depression comparing intervention with usual care in 12 primary care practices. Intervention practices encouraged depressed patients to engage in active treatment, using nurses to provide regularly scheduled care management for 24 months. The study sample included 200 adults beginning a new depression treatment episode where patient presentation style could be identified. Outpatient costs were defined as intervention plus outpatient treatment costs for the 2 years. Cost-offset analysis used general linear mixed models, 2-part models, and bootstrapping to test hypotheses regarding a differential intervention effect by patients' style, and to obtain 95% confidence intervals for costs. Intervention effects on outpatient costs over time differed by patient style (P <.05), resulting in a $980 cost decrease for depressed patients who complain of psychological symptoms and a 1,378 dollars cost increase for depressed patients who complain of physical symptoms only. Depression intervention for a 2-year period produced observable clinical benefit with decreased outpatient costs for depressed patients who complain of psychological symptoms. It produced limited clinical benefit with increased costs, however, for depressed patients who complain exclusively of physical symptoms, suggesting the need for developing new intervention approaches for this group.

Cost-effectiveness analysis of a collaborative care programme for depression in primary care.

PubMed

Aragonès, Enric; López-Cortacans, Germán; Sánchez-Iriso, Eduardo; Piñol, Josep-Lluís; Caballero, Antonia; Salvador-Carulla, Luis; Cabasés, Juan

2014-04-01

Collaborative care programmes lead to better outcomes in the management of depression. A programme of this nature has demonstrated its effectiveness in primary care in Spain. Our objective was to evaluate the cost-effectiveness of this programme compared to usual care. A bottom-up cost-effectiveness analysis was conducted within a randomized controlled trial (2007-2010). The intervention consisted of a collaborative care programme with clinical, educational and organizational procedures. Outcomes were monitored over a 12 months period. Primary outcomes were incremental cost-effectiveness ratios (ICER): mean differences in costs divided by quality-adjusted life years (QALY) and mean differences in costs divided by depression-free days (DFD). Analyses were performed from a healthcare system perspective (considering healthcare costs) and from a society perspective (including healthcare costs plus loss of productivity costs). Three hundred and thirty-eight adult patients with major depression were assessed at baseline. Only patients with complete data were included in the primary analysis (166 in the intervention group and 126 in the control group). From a healthcare perspective, the average incremental cost of the programme compared to usual care was €182.53 (p<0.001). Incremental effectiveness was 0.045 QALY (p=0.017) and 40.09 DFD (p=0.011). ICERs were €4,056/QALY and €4.55/DFD. These estimates and their uncertainty are graphically represented in the cost-effectiveness plane. The amount of 13.6% of patients with incomplete data may have introduced a bias. Available data about non-healthcare costs were limited, although they may represent most of the total cost of depression. The intervention yields better outcomes than usual care with a modest increase in costs, resulting in favourable ICERs. This supports the recommendation for its implementation. Copyright © 2014 Elsevier B.V. All rights reserved.

Comparison of Health Care Spending and Utilization Among Children With Medicaid Insurance

PubMed Central

Kuo, Dennis Z.; Hall, Matt; Agrawal, Rishi; Cohen, Eyal; Feudtner, Chris; Goodman, Denise M.; Neff, John M.; Berry, Jay G.

2015-01-01

BACKGROUND AND OBJECTIVES: Opportunities to improve health care quality and contain spending may differ between high and low resource users. This study’s objectives were to assess health care and spending among children with Medicaid insurance by their resource use. METHODS: Retrospective cross-sectional analysis of 2012 Medicaid health administrative data from 10 states of children ages 11 months to 18 years. Subjects were categorized into 4 spending groups, each representing ∼25% of total spending: the least expensive 80% of children (n = 2 868 267), the next 15% expensive (n = 537 800), the next 4% expensive (n = 143 413), and the top 1% (n = 35 853). We compared per-member-per-month (PMPM) spending across the groups using the Kruskal–Wallis test. RESULTS: PMPM spending was $68 (least expensive 80%), $349 (next 15%), $1200 (next 4%), and $6738 (top 1%). Between the least and most expensive groups, percentages of total spending were higher for inpatient (<1% vs 46%) and mental health (7% vs 24%) but lower for emergency (15% vs 1%) and primary (23% vs 1%) care (all Ps < .001). From the least to most expensive groups, increases in PMPM spending were smallest for primary care (from $15 to $33) and much larger for inpatient ($0.28 to $3129), mental health ($4 to $1609), specialty care ($8 to $768), and pharmacy ($4 to $699). CONCLUSIONS: As resource use increases in children with Medicaid, spending rises unevenly across health services: Spending on primary care rises modestly compared with other health services. Future studies should assess whether more spending on primary care leads to better quality and cost containment for high resource users. PMID:26574588

Primary care: choices and opportunities for racial/ethnic minority populations in the USA and UK--a comparative analysis.

PubMed

Smith, M B

1999-08-01

This paper examines and compares the choices made and the opportunities provided by the United States and the United Kingdom in delivering primary care services to their racial/ethnic minority populations. While both nations agree that the most effective strategy for health service delivery to a diverse population lies in primary care, their approaches to obtaining this goal have been quite different. Sociological theories of functionalism and conflict perspective provide the analytical and organizing framework of the paper. Within this theoretical context, the health systems in place in each country are examined as an outgrowth of the larger socio-political, economic and cultural structures of the US and UK. Analysis of the advance of managed care in the US and the recent NHS reforms are also discussed in terms of lessons learned and the difficulties that lay ahead in order to ensure that these new developments contribute significantly to eliminating the disproportionately worse health status of racial ethnic minorities. Towards that goal the paper identifies opportunities for collaboration and specific recommendations for future action by both countries.

Effectiveness of Collaborative Care for Depression in Public-Sector Primary Care Clinics Serving Latinos.

PubMed

Lagomasino, Isabel T; Dwight-Johnson, Megan; Green, Jennifer M; Tang, Lingqi; Zhang, Lily; Duan, Naihua; Miranda, Jeanne

2017-04-01

Quality improvement interventions for depression care have been shown to be effective for improving quality of care and depression outcomes in settings with primarily insured patients. The aim of this study was to determine the impact of a collaborative care intervention for depression that was tailored for low-income Latino patients seen in public-sector clinics. A total of 400 depressed patients from three public-sector primary care clinics were enrolled in a randomized controlled trial of a tailored collaborative care intervention versus enhanced usual care. Social workers without previous mental health experience served as depression care specialists for the intervention patients (N=196). Depending on patient preference, they delivered a cognitive-behavioral therapy (CBT) intervention or facilitated antidepressant medication given by primary care providers or both. In enhanced usual care, patients (N=204) received a pamphlet about depression, a letter for their primary care provider stating that they had a positive depression screen, and a list of local mental health resources. Intent-to-treat analyses examined clinical and process-of-care outcomes at 16 weeks. Compared with patients in the enhanced usual care group, patients in the intervention group had significantly improved depression, quality of life, and satisfaction outcomes (p<.001 for all). Intervention patients also had significantly improved quality-of-care indicators, including the proportion of patients receiving either psychotherapy or antidepressant medication (77% versus 21%, p<.001). Collaborative care for depression can greatly improve care and outcomes in public-sector clinics. Social workers without prior mental health experience can effectively provide CBT and manage depression care.

Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care: A Randomized Clinical Trial.

PubMed

Engel, Charles C; Jaycox, Lisa H; Freed, Michael C; Bray, Robert M; Brambilla, Donald; Zatzick, Douglas; Litz, Brett; Tanielian, Terri; Novak, Laura A; Lane, Marian E; Belsher, Bradley E; Olmsted, Kristine L Rae; Evatt, Daniel P; Vandermaas-Peeler, Russ; Unützer, Jürgen; Katon, Wayne J

2016-07-01

It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression. To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care. The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014. Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment. Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use. Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (-6.07 [0.68] vs -3.54 [0.72]) and SCL-20 depression scores -0.56 [0.05] vs -0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, -1.37 [95% CI, -2.26 to -0.47]) and mental health-related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use. Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care. clinicaltrials.gov Identifier: NCT01492348.

Innovative approach to patient-centered care coordination in primary care practices.

PubMed

Clarke, Robin; Bharmal, Nazleen; Di Capua, Paul; Tseng, Chi-Hong; Mangione, Carol M; Mittman, Brian; Skootsky, Samuel A

2015-09-01

Although care coordination is an essential component of the patient-centered medical home structure, current case manager models have limited usefulness to population health because they typically serve a small group of patients defined based on disease or utilization. Our objective was to support our health system's population health by implementing and evaluating a program that embedded nonlicensed coordinators within our primary care practices to support physicians in executing care plans and communicating with patients. Matched case-control differences-in-differences. Comprehensive care coordinators (CCC) were introduced into 14 of the system's 28 practice sites in 2 waves. After a structured training program, CCCs identified, engaged, and intervened among patients within the practice in conjunction with practice primary care providers. We counted and broadly coded CCC activities that were documented in the intervention database. We examined the impact of CCC intervention on emergency department (ED) utilization at the practice level using a negative binomial multivariate regression model controlling for age, gender, and medical complexity. CCCs touched 10,500 unique patients over a 1-year period. CCC interventions included execution of care (38%), coordination of transitions (32%), self-management support/link to community resources (15%), monitor and follow-up (10%), and patient assessment (1%). The CCC intervention group had a 20% greater reduction in its prepost ED visit rate compared with the control group (P < .0001). Our CCC intervention demonstrated a significant reduction in ED visits by focusing on the centrality of the primary care provider and practice. Our model may serve as a cost-effective and scalable alternative for care coordination in primary care.

Insurance Type and Access to Health Care Providers and Appointments Under the Affordable Care Act.

PubMed

Alcalá, Héctor E; Roby, Dylan H; Grande, David T; McKenna, Ryan M; Ortega, Alexander N

2018-02-01

Millions of adults have gained insurance through the Affordable Care Act (ACA). However, disparities in access to care persist. This study examined differences in access to primary and specialty care among patients insured by private individual market insurance plans (both on-exchange and off-exchange) and Medicaid compared with those with employer-sponsored insurance. Using data from the 2014 and 2015 California Health Interview Survey, logistic regression analyses were used to calculate the odds of being unable to access primary care providers, access specialty care providers and receive a needed doctor's appointment in a timely manner, with insurance type serving as the independent variable. Interaction terms examined if the expiration of the ACA's optional Medicaid primary care fee increase in 2014 modified any of these associations. Findings showed poorer access to providers among those insured through Medicaid and the individual market (whether purchased through the state's health insurance exchange or off-exchange) relative to employer-based insurance. Poor access to primary care providers was seen among private coverage purchased via exchanges, relative to private coverage purchased on the individual market. In addition, findings showed that reduction of Medicaid fees coincided with reduced ability to see primary care providers. However, a similar trend was seen among those with employer-based coverage, which suggests that this change may not be attributable to reductions in Medicaid fees. Despite ACA-related gains in insurance coverage, those with on-exchange and off-exchange individual private insurance plans and Medicaid encounter more barriers to care than those with employer-based insurance.

The effect of mental comorbidity on service delivery planning in primary care: an analysis with particular reference to patients who request referral without prior assessment.

PubMed

Schneider, Antonius; Hilbert, Bernadett; Hörlein, Elisabeth; Wagenpfeil, Stefan; Linde, Klaus

2013-09-01

In their everyday practice, primary-care physicians are often asked to refer patients to a specialist without a prior appointment in primary care. Such referrals are problematic, and one might suspect that patients who make such requests are more likely to have mental comorbidities predisposing them toward higher utilization of health-care services. In a cross-sectional study, 307 patients of 13 primary-care practices who requested referral to a specialist without a prior appointment in primary care were given a Patient Health Questionnaire (PHQ) containing questions that related to depression, anxiety, panic disorder, and somatoform disorder (independent variables). Further information was obtained about these patients' primary-care contacts, referrals, and days taken off from work with a medical excuse over the course of one year (dependent variables). A regression model was used to compare these patients with 977 other primary-care patients. The groups of patients who did and did not request specialist referral without a primary-care appointment did not differ to any statistically significant extent with respect to mental comorbidity. In the overall group, somatoform disorder was found to be associated with a high rate of primary-care contacts (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.4-4.3). High rates of referral were strongly correlated (percentage of variance explained, R²) with depression (OR 2.1, 95% CI 1.1-4.0; R² = 35.3%), anxiety (OR 4.1, 95% CI 1.8-9.6; R² = 34.5%), panic disorder (OR 5.9, 95% CI 2.1-16.4; R² = 34.3%), and somatoform disorder (OR 2.2, 95% CI 1.2-4.0; R² = 34.6%). Taking a long time off from work with a medical excuse was correlated with depression (OR 2.5, 95% CI 1.2-4.8), anxiety (OR 4.2, 95% CI 1.7-10.5), and somatoform disorder (OR 2.2, 95% CI 1.2-4.2). Mental comorbidity contributes to the increased utilization of health-care services. This should be borne in mind whenever a patient requests many referrals to specialists (either with or without a prior appointment in primary care). It is important to identify "doctor-hopping" patients so that the causes of their behavior can be recognized, discussed, and properly treated.

Prevalence of Intimate Partner Violence among Women Veterans who Utilize Veterans Health Administration Primary Care.

PubMed

Kimerling, Rachel; Iverson, Katherine M; Dichter, Melissa E; Rodriguez, Allison L; Wong, Ava; Pavao, Joanne

2016-08-01

The objectives of this study were to identify the prevalence of past-year intimate partner violence (IPV) among women Veterans utilizing Veterans Health Administration (VHA) primary care, and to document associated demographic, military, and primary care characteristics. This was a retrospective cohort design, where participants completed a telephone survey in 2012 (84% participation rate); responses were linked to VHA administrative data for utilization in the year prior to the survey. A national stratified random sample of 6,287 women Veteran VHA primary care users participated in the study. Past-year IPV was assessed using the HARK screening tool. Self-report items and scales assessed demographic and military characteristics. Primary care characteristics were assessed via self-report and VHA administrative data. The prevalence of past-year IPV among women Veterans was 18.5% (se = 0.5%), with higher rates (22.2% - 25.5%) among women up to age 55. Other demographic correlates included indicators of economic hardship, lesbian or bisexual orientation, and being a parent/guardian of a child less than 18 years old. Military correlates included service during Vietnam to post-Vietnam eras, less than 10 years of service, and experiences of Military Sexual Trauma (MST). Most (77.3%, se = 1.2%) women who experienced IPV identified a VHA provider as their usual provider. Compared with women who did not report past-year IPV, women who reported IPV had more primary care visits, yet experienced lower continuity of care across providers. The high prevalence of past-year IPV among women beyond childbearing years, the majority of whom primarily rely on VHA as a source of health care, reinforces the importance of screening all women for IPV in VHA primary care settings. Key considerations for service implementation include sensitivity with respect to sexual orientation, race/ethnicity, and other aspects of diversity, as well as care coordination and linkages with social services and MST-related care.

Trends in Primary Care Provision to Medicare Beneficiaries by Physicians, Nurse Practitioners, or Physician Assistants: 2008-2014

PubMed Central

Xue, Ying; Goodwin, James S.; Adhikari, Deepak; Raji, Mukaila A.; Kuo, Yong-Fang

2017-01-01

Objectives: To document the temporal trends in alternative primary care models in which physicians, nurse practitioners (NPs), or physician assistants (PAs) engaged in care provision to the elderly, and examine the role of these models in serving elders with multiple chronic conditions and those residing in rural and health professional shortage areas (HPSAs). Design: Serial cross-sectional analysis of Medicare claims data for years 2008, 2011, and 2014. Setting: Primary care outpatient setting. Participants: Medicare fee-for-service beneficiaries who had at least 1 primary care office visit in each study year. The sample size is 2 471 498. Measurements: Physician model—Medicare beneficiary’s primary care office visits in a year were conducted exclusively by physicians; shared care model—conducted by a group of professionals that included physicians and either NPs or PAs or both; NP/PA model: conducted either by NPs or PAs or both. Results: There was a decrease in the physician model (85.5% to 70.9%) and an increase in the shared care model (11.9% to 23.3%) and NP/PA model (2.7% to 5.9%) from 2008 to 2014. Compared with the physician model, the adjusted odds ratio (AOR) of receiving NP/PA care was 3.97 (95% CI 3.80-4.14) in rural and 1.26 (95% CI 1.23-1.29) in HPSAs; and the AOR of receiving shared care was 1.66 (95% CI 1.61-1.72) and 1.14 (95% CI 1.13-1.15), respectively. Beneficiaries with 3 or more chronic conditions were most likely to received shared care (AOR = 1.67, 95% CI 1.65-1.70). Conclusion: The increase in shared care practice signifies a shift toward bolstering capacity of the primary care delivery system to serve elderly populations with growing chronic disease burden and to improve access to care in rural and HPSAs. PMID:29047322

Attitudes of Arab and Jewish patients toward integration of complementary medicine in primary care clinics in Israel: a cross-cultural study.

PubMed

Ben-Arye, Eran; Karkabi, Khaled; Karkabi, Sonia; Keshet, Yael; Haddad, Maria; Frenkel, Moshe

2009-01-01

The purpose of this cross-cultural study was to evaluate patient perspectives on complementary and alternative medicine (CAM) integration within primary care clinics. It is one of the first multiethnic studies to explore patients' perspectives on the best model for integrating CAM into the conventional care setting. We developed a 13-item questionnaire that addresses issues of CAM use, expectations from the primary care physicians concerning CAM, and attitudes toward CAM integration within a patient's primary care clinic. We constructed the questionnaire with cross-cultural sensitivity concerning the core concepts of CAM and traditional medicine in both the Arab and Jewish communities in northern Israel. Data for statistical analysis were obtained from 3840 patients attending seven primary care clinics. Of the 3713 respondents who were willing to identify their religion, 2184 defined themselves as Muslims, Christians, or Druze and 1529 as Jews. Respondents in the two groups were equally distributed by sex but differed significantly by age, education, self-rated religiosity, and self-reported chronic diseases in their medical background. Respondents in the two groups reported comparable overall CAM use during the previous year, but the Arab respondents reported more use of herbs and traditional medicine. Respondents in both groups stated that their primary expectation from a family physician concerning CAM was to refer them appropriately and safely to a CAM practitioner. Respondents in both groups greatly supported a theoretical scenario of CAM integration into primary medical care. However, Arab respondents were more supportive of the option that non-physician CAM practitioners would provide CAM rather than physicians.

Accounting for graduate medical education production of primary care physicians and general surgeons: timing of measurement matters.

PubMed

Petterson, Stephen; Burke, Matthew; Phillips, Robert; Teevan, Bridget

2011-05-01

Legislation proposed in 2009 to expand GME set institutional primary care and general surgery production eligibility thresholds at 25% at entry into training. The authors measured institutions' production of primary care physicians and general surgeons on completion of first residency versus two to four years after graduation to inform debate and explore residency expansion and physician workforce implications. Production of primary care physicians and general surgeons was assessed by retrospective analysis of the 2009 American Medical Association Masterfile, which includes physicians' training institution, residency specialty, and year of completion for up to six training experiences. The authors measured production rates for each institution based on physicians completing their first residency during 2005-2007 in family or internal medicine, pediatrics, or general surgery. They then reassessed rates to account for those who completed additional training. They compared these rates with proposed expansion eligibility thresholds and current workforce needs. Of 116,004 physicians completing their first residency, 54,245 (46.8%) were in primary care and general surgery. Of 683 training institutions, 586 met the 25% threshold for expansion eligibility. At two to four years out, only 29,963 physicians (25.8%) remained in primary care or general surgery, and 135 institutions lost eligibility. A 35% threshold eliminated 314 institutions collectively training 93,774 residents (80.8%). Residency expansion thresholds that do not account for production at least two to four years after completion of first residency overestimate eligibility. The overall primary care production rate from GME will not sustain the current physician workforce composition. Copyright © by the Association of American medical Colleges.

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

Primary Care Emergency Preparedness Network, New York City, 2015: Comparison of Member and Nonmember Sites

PubMed Central

Jean, Marc C.; Chen, Bei; Molinari, Noelle-Angelique M.; LeBlanc, Tanya T.

2017-01-01

Objectives. To assess whether Primary Care Emergency Preparedness Network member sites reported indicators of preparedness for public health emergencies compared with nonmember sites. The network—a collaboration between government and New York City primary care associations—offers technical assistance to primary care sites to improve disaster preparedness and response. Methods. In 2015, we administered an online questionnaire to sites regarding facility characteristics and preparedness indicators. We estimated differences between members and nonmembers with natural logarithm–linked binomial models. Open-ended assessments identified preparedness gaps. Results. One hundred seven sites completed the survey (23.3% response rate); 47 (43.9%) were nonmembers and 60 (56.1%) were members. Members were more likely to have completed hazard vulnerability analysis (risk ratio [RR] = 1.94; 95% confidence interval [CI] = 1.28, 2.93), to have identified essential services for continuity of operations (RR = 1.39; 95% CI = 1.03, 1.86), to have memoranda of understanding with external partners (RR = 2.49; 95% CI = 1.42, 4.36), and to have completed point-of-dispensing training (RR = 4.23; 95% CI = 1.76, 10.14). Identified preparedness gaps were improved communication, resource availability, and train-the-trainer programs. Public Health Implications. Primary Care Emergency Preparedness Network membership is associated with improved public health emergency preparedness among primary care sites. PMID:28892448

Design and methodology of the COACH-2 (Comparative study on guideline adherence and patient compliance in heart failure patients) study: HF clinics versus primary care in stable patients on optimal therapy.

PubMed

Luttik, M L A; Brons, M; Jaarsma, T; Hillege, H L; Hoes, A; de Jong, R; Linssen, G; Lok, D J; Berger, M; van Veldhuisen, D J

2012-08-01

Since the number of heart failure (HF) patients is still growing and long-term treatment of HF patients is necessary, it is important to initiate effective ways for structural involvement of primary care services in HF management programs. However, evidence on whether and when patients can be referred back to be managed in primary care is lacking. To determine whether long-term patient management in primary care, after initial optimisation of pharmacological and non-pharmacological treatment in a specialised HF clinic, is equally effective as long-term management in a specialised HF clinic in terms of guideline adherence and patient compliance. The study is designed as a randomised, controlled, non-inferiority trial. Two-hundred patients will be randomly assigned to be managed and followed in primary care or in a HFclinic. Patients are eligible to participate if they are (1) clinically stable, (2) optimally up-titrated on medication (according to ESC guidelines) and, (3) have received optimal education and counselling on pre-specified issues regarding HF and its treatment. Furthermore, close cooperation between secondary and primary care in terms of back referral to or consultation of the HF clinic will be provided.The primary outcome will be prescriber adherence and patient compliance with medication after 12 months. Secondary outcomes measures will be readmission rate, mortality, quality of life and patient compliance with other lifestyle changes. The results of the study will add to the understanding of the role of primary care and HF clinics in the long-term follow-up of HF patients.

You can't treat what you don't diagnose: An analysis of the recognition of somatic presentations of depression and anxiety in primary care.

PubMed

Gates, Kristin; Petterson, Stephen; Wingrove, Peter; Miller, Benjamin; Klink, Kathleen

2016-12-01

Research suggests that 13-25% of primary care patients who present with physical complaints have underlying depression or anxiety. The goal of this paper is to quantify and compare the frequency of the diagnosis of depression and anxiety in patients with a somatic reason for visit among primary care physicians across disciplines. Data obtained from the National Ambulatory Medical Care Survey (NAMCS) from 2002 to 2010 was used to quantify primary care patients with somatic presentations who were given a diagnosis of depression or anxiety. The Patient Health Questionnaire (PHQ)-15, Somatic Symptom Scale, and the Child Behavior Checklist for Ages 6-18 were used to define what constituted a somatic reason for visit in this study. Of the patients presenting with a somatic reason for visit in this nationally representative survey, less than 4% of patents in family or internal medicine were diagnosed with depression or anxiety. Less than 1% of patients were diagnosed with depression or anxiety in pediatrics or obstetrics and gynecology. Less than 2% of patients with somatic reasons for visit in any primary care specialty had documented screening for depression. The rates of diagnosis of depression and anxiety in patents presenting with somatic reasons for visit were significantly less than the prevalence reported in the literature across primary care disciplines. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Defining upper gastrointestinal bleeding from linked primary and secondary care data and the effect on occurrence and 28 day mortality.

PubMed

Crooks, Colin John; Card, Timothy Richard; West, Joe

2012-11-13

Primary care records from the UK have frequently been used to identify episodes of upper gastrointestinal bleeding in studies of drug toxicity because of their comprehensive population coverage and longitudinal recording of prescriptions and diagnoses. Recent linkage within England of primary and secondary care data has augmented this data but the timing and coding of concurrent events, and how the definition of events in linked data effects occurrence and 28 day mortality is not known. We used the recently linked English Hospital Episodes Statistics and General Practice Research Database, 1997-2010, to define events by; a specific upper gastrointestinal bleed code in either dataset, a specific bleed code in both datasets, or a less specific but plausible code from the linked dataset. This approach resulted in 81% of secondary care defined bleeds having a corresponding plausible code within 2 months in primary care. However only 62% of primary care defined bleeds had a corresponding plausible HES admission within 2 months. The more restrictive and specific case definitions excluded severe events and almost halved the 28 day case fatality when compared to broader and more sensitive definitions. Restrictive definitions of gastrointestinal bleeding in linked datasets fail to capture the full heterogeneity in coding possible following complex clinical events. Conversely too broad a definition in primary care introduces events not severe enough to warrant hospital admission. Ignoring these issues may unwittingly introduce selection bias into a study's results.

Effectiveness and cost effectiveness of counselling in primary care.

PubMed

Bower, P; Rowland, N; Mellor, C l; Heywood, P; Godfrey, C; Hardy, R

2002-01-01

Counsellors are prevalent in primary care settings. However, there are concerns about the clinical and cost-effectiveness of the treatments they provide, compared with alternatives such as usual care from the general practitioner, medication or other psychological therapies. To assess the effectiveness and cost effectiveness of counselling in primary care by reviewing cost and outcome data in randomised controlled trials, controlled clinical trials and controlled patient preference trials of counselling interventions in primary care, for patients with psychological and psychosocial problems considered suitable for counselling. The original search strategy included electronic searching of databases (including the CCDAN Register of RCTs and CCTs) along with handsearching of a specialist journal. Published and unpublished sources (clinical trials, books, dissertations, agency reports etc.) were searched, and their reference lists scanned to uncover further controlled trials. Contact was made with subject experts and CCDAN members in order to uncover further trials. For the updated review, searches were restricted to those databases judged to be high yield in the first version of the review: MEDLINE, EMBASE, PSYCLIT and CINAHL, the Cochrane Controlled Trials register and the CCDAN trials register. All controlled trials comparing counselling in primary care with other treatments for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of June 2001 were included in the review. Data were extracted using a standardised data extraction sheet. The relevant data were entered into the Review Manager software. Trials were quality rated, using CCDAN criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals. Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. In view of the diversity of counselling services in primary care (the range of treatments, patients and practitioners) tests of heterogeneity were done to assess the feasibility of aggregating measures of outcome from trials. Sensitivity analyses were undertaken to test the robustness of the results. Seven trials were included in the review. The main analyses showed significantly greater clinical effectiveness in the counselling group compared with 'usual care' in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n=772, 6 trials) but not the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n=475, 4 trials). Levels of satisfaction with counselling were high. Four studies reported similar total costs associated with counselling and usual care over the long-term. However, the economic analyses were likely to be underpowered. Counselling is associated with modest improvement in short-term outcome compared to 'usual care', but provides no additional advantages in the long-term. Patients are satisfied with counselling, and it may not be associated with increased costs.

Cost-utility of collaborative care for major depressive disorder in primary care in the Netherlands.

PubMed

Goorden, Maartje; Huijbregts, Klaas M L; van Marwijk, Harm W J; Beekman, Aartjan T F; van der Feltz-Cornelis, Christina M; Hakkaart-van Roijen, Leona

2015-10-01

Major depression is a great burden on society, as it is associated with high disability/costs. The aim of this study was to evaluate the cost-utility of Collaborative Care (CC) for major depressive disorder compared to Care As Usual (CAU) in a primary health care setting from a societal perspective. A cluster randomized controlled trial was conducted, including 93 patients that were identified by screening (45-CC, 48-CAU). Another 57 patients were identified by the GP (56-CC, 1-CAU). The outcome measures were TiC-P, SF-HQL and EQ-5D, respectively measuring health care utilization, production losses and general health related quality of life at baseline three, six, nine and twelve months. A cost-utility analysis was performed for patients included by screening and a sensitivity analysis was done by also including patients identified by the GP. The average annual total costs was €1131 (95% C.I., €-3158 to €750) lower for CC compared to CAU. The average quality of life years (QALYs) gained was 0.02 (95% C.I., -0.004 to 0.04) higher for CC, so CC was dominant from a societal perspective. Taking a health care perspective, CC was less cost-effective due to higher costs, €1173 (95% C.I., €-216 to €2726), of CC compared to CAU which led to an ICER of 53,717 Euro/QALY. The sensitivity analysis showed dominance of CC. The cost-utility analysis from a societal perspective showed that CC was dominant to CAU. CC may be a promising treatment for depression in the primary care setting. Further research should explore the cost-effectiveness of long-term CC. Netherlands Trial Register ISRCTN15266438. Copyright © 2015 Elsevier Inc. All rights reserved.

Assessment of hypertension management in primary health care settings in Kinshasa, Democratic Republic of Congo.

PubMed

Lulebo, Aimée M; Mapatano, Mala A; Kayembe, Patrick K; Mafuta, Eric M; Mutombo, Paulin B; Coppieters, Yves

2015-12-24

Hypertension-related complications have become more diagnosed at secondary and tertiary care levels, in the Democratic Republic of the Congo (DRC), probably indicative of poor management of hypertensive patients at primary health care level. This study aimed to assess the management of hypertension in primary health care settings by using guidelines of the International Forum for Prevention and Control of HTN in Africa (IFHA). A multi-center cross-sectional study was carried out in primary health care settings. A total of 102 nurses were surveyed using a structured interview. Mean and proportion comparisons were performed using the t Student test and the Chi-square test respectively. The Kinshasa Primary Health Care network facilities were compared with non-Kinshasa Primary Health Care network facilities. From the 102 nurses surveyed; 52.9% were female with a mean age of 41.1, (SD = 10) years, merely 9.5% benefited from in-job training on cardiovascular diseases or their risk factors, and 51.7% had guidelines on the management of hypertension. Less than a quarter of the nurses knew the cut-off values of hypertension, diabetes and obesity. Merely 14.7% knew the therapeutic goals for uncomplicated hypertension. Several of the indicators for immediate referral recommended by IFHA were unmentioned. The content of patient education was lacking, avoiding stress being the best advice provided to hypertensive patients. The antihypertensive most used were unlikely to be recommended by the IFHA. This study showed a considerable gap of knowledge and practices in the management of hypertensive patients at primary health care facilities in Kinshasa pertaining to the IFHA guidelines. We think that task-shifting for management of hypertension is feasible if appropriate guidelines are provided and nurses trained.

Health care systems in Sweden and China: Legal and formal organisational aspects

PubMed Central

2010-01-01

Background Sharing knowledge and experience internationally can provide valuable information, and comparative research can make an important contribution to knowledge about health care and cost-effective use of resources. Descriptions of the organisation of health care in different countries can be found, but no studies have specifically compared the legal and formal organisational systems in Sweden and China. Aim To describe and compare health care in Sweden and China with regard to legislation, organisation, and finance. Methods Literature reviews were carried out in Sweden and China to identify literature published from 1985 to 2008 using the same keywords. References in recent studies were scrutinized, national legislation and regulations and government reports were searched, and textbooks were searched manually. Results The health care systems in Sweden and China show dissimilarities in legislation, organisation, and finance. In Sweden there is one national law concerning health care while in China the law includes the "Hygienic Common Law" and the "Fundamental Health Law" which is under development. There is a tendency towards market-orientated solutions in both countries. Sweden has a well-developed primary health care system while the primary health care system in China is still under development and relies predominantly on hospital-based care concentrated in cities. Conclusion Despite dissimilarities in health care systems, Sweden and China have similar basic assumptions, i.e. to combine managerial-organisational efficiency with the humanitarian-egalitarian goals of health care, and both strive to provide better care for all. PMID:20569468

Phytotherapy in primary health care

PubMed Central

Antonio, Gisele Damian; Tesser, Charles Dalcanale; Moretti-Pires, Rodrigo Otavio

2014-01-01

OBJECTIVE To characterize the integration of phytotherapy in primary health care in Brazil. METHODS Journal articles and theses and dissertations were searched for in the following databases: SciELO, Lilacs, PubMed, Scopus, Web of Science and Theses Portal Capes, between January 1988 and March 2013. We analyzed 53 original studies on actions, programs, acceptance and use of phytotherapy and medicinal plants in the Brazilian Unified Health System. Bibliometric data, characteristics of the actions/programs, places and subjects involved and type and focus of the selected studies were analyzed. RESULTS Between 2003 and 2013, there was an increase in publications in different areas of knowledge, compared with the 1990-2002 period. The objectives and actions of programs involving the integration of phytotherapy into primary health care varied: including other treatment options, reduce costs, reviving traditional knowledge, preserving biodiversity, promoting social development and stimulating inter-sectorial actions. CONCLUSIONS Over the past 25 years, there was a small increase in scientific production on actions/programs developed in primary care. Including phytotherapy in primary care services encourages interaction between health care users and professionals. It also contributes to the socialization of scientific research and the development of a critical vision about the use of phytotherapy and plant medicine, not only on the part of professionals but also of the population. PMID:25119949

Comparison of Primary Care Experiences in Village Clinics with Different Ownership Models in Guangdong Province, China

PubMed Central

Feng, Shanshan; Shi, Leiyu; Zeng, Jiazhi; Chen, Wen; Ling, Li

2017-01-01

Objectives In order to improve the quality of services at village clinics (VCs), which are important primary care service providers in rural China, the Chinese government has encouraged the township hospitals to own and manage VCs. There are currently three models of ownership and management of VCs: township hospital-owned and -managed (HVC), village committee-owned and -managed (VVC), and private-owned and -managed (PVC). This study aims to examine the association between these ownership models of VCs and patients' primary care experiences. Methods Villagers were selected by multistage stratified sampling and their experiences with primary care were measured using the Primary Care Assessment Tool—Adult Edition (PCAT-AS). Data were collected through face-to-face interviews and the questionnaires administered by investigators in the cross-sectional study from February to April 2015. The PCAT scores were compared among the three models by covariance analysis, and multiple linear regression was used to analyze factors associated with the PCAT total scores. Results A total of 1491 questionnaires were collected. After controlling for covariates, HVCs reported the highest PCAT scores and satisfaction rate. In terms of the domains, HVC reported the highest scores in the coordination and comprehensiveness domains, while PVC had the highest scores in the first contact-accessibility domain. Multivariate linear regression showed that HVC, married participants, aged 60 and older, satisfied with the services, receiving six or more visits, and those with medical expenditures over 20% of their total family expenditures, were also positively associated with better primary care quality. Conclusions This study demonstrates that villagers receiving medical care at HVCs perceived better primary care than those at PVCs and VVCs. In order to improve the quality of primary care at VCs, it is necessary to increase government subsidies for public service packages, tighten the township hospital's supervision of PVCs and VVCs, and develop performance-based incentive plans to motivate improvements in the accessibility of HVCs. PMID:28056038

Entrustable professional activities in post-licensure training in primary care pediatrics: Necessity, development and implementation of a competency-based post-graduate curriculum.

PubMed

Fehr, Folkert; Weiß-Becker, Christoph; Becker, Hera; Opladen, Thomas

2017-01-01

There is an absence of broad-based and binding curricular requirements for structured competency-based post-graduate medical training in Germany, and thus no basis for comparing the competencies of physicians undergoing training in a medical specialty ( Ärzte im Weiterbildung ). In response, the German Society of Primary Care Pediatrics' working group on post-graduate education (DGAAP) has identified realistic entrustable professional activities (EPAs) in primary care, defined their number, scope and content, selected competency domains, specified required knowledge and skills, and described appropriate assessment methods. These guidelines are referred to as PaedCompenda and can be accessed electronically by educators in pediatric medicine; the use and effectiveness of these guidelines are monitored by the German Association for Medical Education's committee on post-graduate education (GMA). Teaching and training in pediatric medicine should take EPAs into consideration. To accomplish this, phases dedicated to primary care should be integrated into formal medical specialty training. Primary care pediatrics must enhance the sites where such training takes place into learning environments that prepare physicians trainees and turn the practicing specialists into mentoring educators.

Quality of life in Chinese patients with schizophrenia treated in primary care.

PubMed

Li, Yan; Hou, Cai-Lan; Ma, Xin-Rong; Zhong, Bao-Liang; Zang, Yu; Jia, Fu-Jun; Lin, Yong-Qiang; Lai, Kelly Y C; Chiu, Helen F K; Ungvari, Gabor S; Hall, Brian J; Cai, Mei-Ying; Ng, Chee H; Xiang, Yu-Tao

2017-08-01

In China, maintenance treatment for clinically stable patients with schizophrenia is usually provided by primary care physicians. This study examined the quality of life (QOL) in patients with schizophrenia treated in primary care and explored the demographic and clinical characteristics associated with QOL. Altogether, 612 patients with schizophrenia treated in 22 randomly selected primary care services in China formed the study sample. QOL, psychotic and depressive symptoms, extra-pyramidal symptoms and insight were assessed using standardized instruments. Data analyses were conducted with the one sample t-test and multiple linear regression analyses. Compared with the normative data for the Chinese general population, significantly lower scores in physical and mental QOL domains were found in the patient group. Older age, being unemployed, major medical conditions, no smoking, more severe depressive and negative symptoms, more frequent insomnia, and suicidality were independently associated with poor physical QOL. Male gender, more severe depressive and anxiety symptoms, more frequent insomnia, and suicidality were independently associated with poor mental QOL. Patients with schizophrenia treated in primary care had lower level of QOL in comparison with general population. Effective measures need to be implemented to improve their QOL. Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.

Fluoxetine and imipramine: are there differences in cost-utility for depression in primary care?

PubMed

Serrano-Blanco, Antoni; Suárez, David; Pinto-Meza, Alejandra; Peñarrubia, Maria T; Haro, Josep Maria

2009-02-01

Depressive disorders generate severe personal burden and high economic costs. Cost-utility analyses of the different therapeutical options are crucial to policy-makers and clinicians. Previous cost-utility studies, comparing selective serotonin reuptake inhibitors and tricyclic antidepressants, have used modelling techniques or have not included indirect costs in the economic analyses. To determine the cost-utility of fluoxetine compared with imipramine for treating depressive disorders in primary care. A 6-month randomized prospective naturalistic study comparing fluoxetine with imipramine was conducted in three primary care centres in Spain. One hundred and three patients requiring antidepressant treatment for a DSM-IV depressive disorder were included in the study. Patients were randomized either to fluoxetine (53 patients) or to imipramine (50 patients) treatment. Patients were treated with antidepressants according to their general practitioner's usual clinical practice. Outcome measures were the quality of life tariff of the European Quality of Life Questionnaire: EuroQoL-5D (five domains), direct costs, indirect costs and total costs. Subjects were evaluated at the beginning of treatment and after 1, 3 and 6 months. Incremental cost-utility ratios (ICUR) were obtained. To address uncertainty in the ICUR's sampling distribution, non-parametric bootstrapping was carried out. Taking into account adjusted total costs and incremental quality of life gained, imipramine dominated fluoxetine with 81.5% of the bootstrap replications in the dominance quadrant. Imipramine seems to be a better cost-utility antidepressant option for treating depressive disorders in primary care.

Effects of online palliative care training on knowledge, attitude and satisfaction of primary care physicians.

PubMed

Pelayo, Marta; Cebrián, Diego; Areosa, Almudena; Agra, Yolanda; Izquierdo, Juan Vicente; Buendía, Félix

2011-05-23

The Spanish Palliative Care Strategy recommends an intermediate level of training for primary care physicians in order to provide them with knowledge and skills. Most of the training involves face-to-face courses but increasing pressures on physicians have resulted in fewer opportunities for provision of and attendance to this type of training. The effectiveness of on-line continuing medical education in terms of its impact on clinical practice has been scarcely studied. Its effect in relation to palliative care for primary care physicians is currently unknown, in terms of improvement in patient's quality of life and main caregiver's satisfaction. There is uncertainty too in terms of any potential benefits of asynchronous communication and interaction among on-line education participants, as well as of the effect of the learning process.The authors have developed an on-line educational model for palliative care which has been applied to primary care physicians in order to measure its effectiveness regarding knowledge, attitude towards palliative care, and physician's satisfaction in comparison with a control group.The effectiveness evaluation at 18 months and the impact on the quality of life of patients managed by the physicians, and the main caregiver's satisfaction will be addressed in a different paper. Randomized controlled educational trial to compared, on a first stage, the knowledge and attitude of primary care physicians regarding palliative care for advanced cancer patients, as well as satisfaction in those who followed an on-line palliative care training program with tutorship, using a Moodle Platform vs. traditional education. 169 physicians were included, 85 in the intervention group and 84 in the control group, of which five were excluded. Finally 82 participants per group were analyzed. There were significant differences in favor of the intervention group, in terms of knowledge (mean 4.6; CI 95%: 2.8 to 6.5 (p = 0.0001), scale range 0-33), confidence in symptom management (p = 0.02) and confidence in terms of communication (p = 0.038). Useful aspects were pointed out, as well as others to be improved in future applications. The satisfaction of the intervention group was high. The results of this study show that there was a significant increase of knowledge of 14%-20% and a significant increase in the perception of confidence in symptom management and communication in the intervention group in comparison with the control group that received traditional methods of education in palliative care or no educational activity at all. The overall satisfaction with the intervention was good-very good for most participants.This on-line educational model seems a useful tool for palliative care training in primary care physicians who have a high opinion about the integration of palliative care within primary care. The results of this study support the suggestion that learning effectiveness should be currently investigated comparing different Internet interventions, instead of Internet vs. no intervention.

Effects of online palliative care training on knowledge, attitude and satisfaction of primary care physicians

PubMed Central

2011-01-01

Background The Spanish Palliative Care Strategy recommends an intermediate level of training for primary care physicians in order to provide them with knowledge and skills. Most of the training involves face-to-face courses but increasing pressures on physicians have resulted in fewer opportunities for provision of and attendance to this type of training. The effectiveness of on-line continuing medical education in terms of its impact on clinical practice has been scarcely studied. Its effect in relation to palliative care for primary care physicians is currently unknown, in terms of improvement in patient's quality of life and main caregiver's satisfaction. There is uncertainty too in terms of any potential benefits of asynchronous communication and interaction among on-line education participants, as well as of the effect of the learning process. The authors have developed an on-line educational model for palliative care which has been applied to primary care physicians in order to measure its effectiveness regarding knowledge, attitude towards palliative care, and physician's satisfaction in comparison with a control group. The effectiveness evaluation at 18 months and the impact on the quality of life of patients managed by the physicians, and the main caregiver's satisfaction will be addressed in a different paper. Methods Randomized controlled educational trial to compared, on a first stage, the knowledge and attitude of primary care physicians regarding palliative care for advanced cancer patients, as well as satisfaction in those who followed an on-line palliative care training program with tutorship, using a Moodle Platform vs. traditional education. Results 169 physicians were included, 85 in the intervention group and 84 in the control group, of which five were excluded. Finally 82 participants per group were analyzed. There were significant differences in favor of the intervention group, in terms of knowledge (mean 4.6; CI 95%: 2.8 to 6.5 (p = 0.0001), scale range 0-33), confidence in symptom management (p = 0.02) and confidence in terms of communication (p = 0.038). Useful aspects were pointed out, as well as others to be improved in future applications. The satisfaction of the intervention group was high. Conclusions The results of this study show that there was a significant increase of knowledge of 14%-20% and a significant increase in the perception of confidence in symptom management and communication in the intervention group in comparison with the control group that received traditional methods of education in palliative care or no educational activity at all. The overall satisfaction with the intervention was good-very good for most participants. This on-line educational model seems a useful tool for palliative care training in primary care physicians who have a high opinion about the integration of palliative care within primary care. The results of this study support the suggestion that learning effectiveness should be currently investigated comparing different Internet interventions, instead of Internet vs. no intervention. Trial Registration German Clinical Trials Register DRKS00000694 PMID:21605381

Association of Integrated Team-Based Care With Health Care Quality, Utilization, and Cost.

PubMed

Reiss-Brennan, Brenda; Brunisholz, Kimberly D; Dredge, Carter; Briot, Pascal; Grazier, Kyle; Wilcox, Adam; Savitz, Lucy; James, Brent

The value of integrated team delivery models is not firmly established. To evaluate the association of receiving primary care in integrated team-based care (TBC) practices vs traditional practice management (TPM) practices (usual care) with patient outcomes, health care utilization, and costs. A retrospective, longitudinal, cohort study to assess the association of integrating physical and mental health over time in TBC practices with patient outcomes and costs. Adult patients (aged ≥18 years) who received primary care at 113 unique Intermountain Healthcare Medical Group primary care practices from 2003 through 2005 and had yearly encounters with Intermountain Healthcare through 2013, including some patients who received care in both TBC and TPM practices. Receipt of primary care in TBC practices compared with TPM practices for patients treated in internal medicine, family practice, and geriatrics practices. Outcomes included 7 quality measures, 6 health care utilization measures, payments to the delivery system, and program investment costs. During the study period (January 2010-December 2013), 113,452 unique patients (mean age, 56.1 years; women, 58.9%) accounted for 163,226 person-years of exposure in 27 TBC practices and 171,915 person-years in 75 TPM practices. Patients treated in TBC practices compared with those treated in TPM practices had higher rates of active depression screening (46.1% for TBC vs 24.1% for TPM; odds ratio [OR], 1.91 [95% CI, 1.75 to 2.08), adherence to a diabetes care bundle (24.6% for TBC vs 19.5% for TPM; OR, 1.26 [95% CI, 1.11 to 1.42]), and documentation of self-care plans (48.4% for TBC vs 8.7% for TPM; OR, 5.59 [95% CI, 4.27 to 7.33]), lower proportion of patients with controlled hypertension (<140/90 mm Hg) (85.0% for TBC vs 97.7% for TPM; OR, 0.87 [95% CI, 0.80 to 0.95]), and no significant differences in documentation of advanced directives (9.6% for TBC vs 9.9% for TPM; OR, 0.97 [95% CI, 0.91 to 1.03]). Per 100 person-years, rates of health care utilization were lower for TBC patients compared with TPM patients for emergency department visits (18.1 for TBC vs 23.5 for TPM; incidence rate ratio [IRR], 0.77 [95% CI, 0.74 to 0.80]), hospital admissions (9.5 for TBC vs 10.6 for TPM; IRR, 0.89 [95% CI, 0.85 to 0.94]), ambulatory care sensitive visits and admissions (3.3 for TBC vs 4.3 for TPM; IRR, 0.77 [95% CI, 0.70 to 0.85]), and primary care physician encounters (232.8 for TBC vs 250.4 for TPM; IRR, 0.93 [95% CI, 0.92 to 0.94]), with no significant difference in visits to urgent care facilities (55.7 for TBC vs 56.2 for TPM; IRR, 0.99 [95% CI, 0.97 to 1.02]) and visits to specialty care physicians (213.5 for TBC vs 217.9 for TPM; IRR, 0.98 [95% CI, 0.97 to 0.99], P > .008). Payments to the delivery system were lower in the TBC group vs the TPM group ($3400.62 for TBC vs $3515.71 for TPM; β, -$115.09 [95% CI, -$199.64 to -$30.54]) and were less than investment costs of the TBC program. Among adults enrolled in an integrated health care system, receipt of primary care at TBC practices compared with TPM practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care utilization, and lower actual payments received by the delivery system.

A Strength Training Program for Primary Care Patients, Central Pennsylvania, 2012

PubMed Central

Patel, Vijay A.; Kraschnewski, Jennifer L.; Rovniak, Liza S.; Messina, Dino A.; Stuckey, Heather L.; Curry, William J.; Chuang, Cynthia H.; Sherwood, Lisa L.; Hess, Stacy L.

2014-01-01

Introduction Primary care providers can recommend strength training programs to use “Exercise as Medicine,” yet few studies have examined the interest of primary care patients in these programs. Methods We conducted a cross-sectional survey of primary care patients in central Pennsylvania. Interest in participating in free group-based strength training and weight control programs was assessed, in addition to patient demographics, medical history, and quality of life. Results Among 414 patients, most (61.0%) were aged 54 or older, and 64.0% were female. More patients were interested in a strength training program (55.3%) than in a weight control program (45.4%). Nearly three-quarters (72.8%) of those reporting 10 or more days of poor physical health were interested in a strength training program compared with 49.5% of those reporting no days of poor physical health. After adjusting for potential confounders, those reporting poorer physical health had 2.7 greater odds (95% confidence interval, 1.4–5.1) of being interested in a strength training program compared with those reporting better physical health. Patients with hypertension, diabetes, or high cholesterol were not more interested in a strength training program than those without these conditions. Conclusion Primary care practices may consider offering or referring patients to community-based strength training programs. This study observed high levels of interest in these widely available programs. Practices may also consider screening and referring those with poorer physical health, as they may be the most interested and have the most to gain from participating. PMID:24967829

Mental Health Screening in Primary Care: A Comparison of 3 Brief Measures of Psychological Distress

PubMed Central

Cano, Annmarie; Sprafkin, Robert P.; Scaturo, Douglas J.; Lantinga, Larry J.; Fiese, Barbara H.; Brand, Frank

2001-01-01

Background: The current study compared 3 brief mental health screening measures in a sample of older patients in a primary care outpatient setting. Previous mental health screening research has been conducted primarily with younger patients, often with only 1 screening measure, thereby limiting the generalizability of findings. In addition, measures have not yet been compared in terms of their ability to discriminate between cases and noncases of psychiatric disorder. Method: One hundred thirty-four male patients attending their appointments at a primary care clinic in a Department of Veterans Affairs Medical Center participated in this study. Participants completed the General Health Questionnaire-12 (GHQ-12), the Symptom Checklist-10 (SCL-10), and the Primary Care Evaluation of Mental Disorders screening questionnaire and interview. Results: Receiver operating characteristic analysis yielded the optimum cutoff scores on each brief mental health screening measure and showed that all 3 measures discriminated well between cases and noncases of psychiatric disorders. The 3 measures performed slightly better in terms of discriminating between cases and noncases of mood or anxiety disorders than between cases and noncases of any psychiatric disorder. There were no significant differences between the measures' abilities to accurately identify cases and noncases of disorder. Conclusion: Primary care physicians are encouraged to use brief mental health screening measures with their patients, since many report symptoms of psychological distress and disorder. It is recommended that the SCL-10 and GHQ-12 be used to detect mood or anxiety disorders in patients such as these because of the accuracy and brevity of these measures. PMID:15014574

How physician electronic health record screen sharing affects patient and doctor non-verbal communication in primary care.

PubMed

Asan, Onur; Young, Henry N; Chewning, Betty; Montague, Enid

2015-03-01

Use of electronic health records (EHRs) in primary-care exam rooms changes the dynamics of patient-physician interaction. This study examines and compares doctor-patient non-verbal communication (eye-gaze patterns) during primary care encounters for three different screen/information sharing groups: (1) active information sharing, (2) passive information sharing, and (3) technology withdrawal. Researchers video recorded 100 primary-care visits and coded the direction and duration of doctor and patient gaze. Descriptive statistics compared the length of gaze patterns as a percentage of visit length. Lag sequential analysis determined whether physician eye-gaze influenced patient eye gaze, and vice versa, and examined variations across groups. Significant differences were found in duration of gaze across groups. Lag sequential analysis found significant associations between several gaze patterns. Some, such as DGP-PGD ("doctor gaze patient" followed by "patient gaze doctor") were significant for all groups. Others, such DGT-PGU ("doctor gaze technology" followed by "patient gaze unknown") were unique to one group. Some technology use styles (active information sharing) seem to create more patient engagement, while others (passive information sharing) lead to patient disengagement. Doctors can engage patients in communication by using EHRs in the visits. EHR training and design should facilitate this. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Age Differences in Death and Suicidal Ideation in Anxious Primary Care Patients.

PubMed

Petkus, Andrew J; Wetherell, Julie Loebach; Stein, Murray B; Chavira, Denise A; Craske, Michelle G; Sherbourne, Cathy; Sullivan, Greer; Bystritsky, Alexander; Roy-Byrne, Peter

2018-01-01

The objective of this study was to examine age differences in the likelihood of endorsing of death and suicidal ideation in primary care patients with anxiety disorders. Participants were drawn from the Coordinated Anxiety Learning and Management (CALM) Study, an effectiveness trial for primary care patients with panic disorder (PD), generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and/or social anxiety disorder (SAD). Approximately one third of older adults with anxiety disorders reported feeling like they were better off dead. Older adults with PD and SAD were more likely to endorse suicidal ideation lasting at least more than half the prior week compared with younger adults with these disorders. Older adults with SAD endorsed higher rates of suicidal ideation compared with older adults with other anxiety disorders. Multivariate analyses revealed the importance of physical health, social support, and comorbid MDD in this association. Suicidal ideation is common in anxious, older, primary care patients and is particularly prevalent in socially anxious older adults. Findings speak to the importance of physical health, social functioning, and MDD in this association. When working with anxious older adults it is important to conduct a thorough suicide risk assessment and teach skills to cope with death and suicidal ideation-related thoughts.

A comparison of the 'cost per child treated' at a primary care-based sedation referral service, compared to a general anaesthetic in hospital.

PubMed

Jameson, K; Averley, P A; Shackley, P; Steele, J

2007-09-22

To compare the cost-effectiveness of dental sedation techniques used in the treatment of children, focusing on hospital-based dental general anaesthetic (DGA) and advanced conscious sedation in a controlled primary care environment. Data on fees, costs and treatment pathways were obtained from a primary care clinic specialising in advanced sedation techniques. For the hospital-based DGA cohort, data were gathered from hospital trusts in the same area. Comparison was via an average cost per child treated and subsequent sensitivity analysis. Analysing records spanning one year, the average cost per child treated via advanced conscious sedation was pound245.47. As some treatments fail (3.5% of cases attempted), and the technique is not deemed suitable for all patients (4-5%), DGA is still required and has been factored into this cost. DGA has an average cost per case treated of pound359.91, 46.6% more expensive than advanced conscious sedation. These cost savings were robust to plausible variation in all parameters. The costs of advanced conscious sedation techniques, applied in a controlled primary care environment, are substantially lower than the equivalent costs of hospital-based DGA, informing the debate about the optimum way of managing this patient group.

A Model for Catalyzing Educational and Clinical Transformation in Primary Care: Outcomes From a Partnership Among Family Medicine, Internal Medicine, and Pediatrics.

PubMed

Eiff, M Patrice; Green, Larry A; Holmboe, Eric; McDonald, Furman S; Klink, Kathleen; Smith, David Gary; Carraccio, Carol; Harding, Rose; Dexter, Eve; Marino, Miguel; Jones, Sam; Caverzagie, Kelly; Mustapha, Mumtaz; Carney, Patricia A

2016-09-01

To report findings from a national effort initiated by three primary care certifying boards to catalyze change in primary care training. In this mixed-method pilot study (2012-2014), 36 faculty in 12 primary care residencies (family medicine, internal medicine, pediatrics) from four institutions participated in a professional development program designed to prepare faculty to accelerate change in primary care residency training by uniting them in a common mission to create effective ambulatory clinical learning environments. Surveys administered at baseline and 12 months after initial training measured changes in faculty members' confidence and skills, continuity clinics, and residency training programs. Feasibility evaluation involved assessing participation. The authors compared quantitative data using Wilcoxon signed-rank and Bhapkar tests. Observational field notes underwent narrative analysis. Most participants attended two in-person training sessions (92% and 72%, respectively). Between baseline and 12 months, faculty members' confidence in leadership improved significantly for 15/19 (79%) variables assessed; their self-assessed skills improved significantly for 21/22 (95%) competencies. Two medical home domains ("Continuity of Care," "Support/Care Coordination") improved significantly (P < .05) between the two time periods. Analyses of qualitative data revealed that interdisciplinary learning communities formed during the program and served to catalyze transformational change. Results suggest that improvements in faculty perceptions of confidence and skills occurred and that the creation of interdisciplinary learning communities catalyzed transformation. Lengthening the intervention period, engaging other professions involved in training the primary care workforce, and a more discriminating evaluation design are needed to scale this model nationally.

Is physiotherapy self-referral with telephone triage viable, cost-effective and beneficial to musculoskeletal outpatients in a primary care setting?

PubMed

Mallett, Ross; Bakker, Edward; Burton, Maria

2014-12-01

The aim of the present study was to establish if physiotherapy self-referral (SR) is viable, cost effective and beneficial to musculoskeletal outpatients in a primary care setting. In an urban National Health Service (NHS) primary care physiotherapy service, waiting times, attendance rates and treatment ratios (thus, episode-of-care costs) were deemed unsustainable. The introduction of 'Any Qualified Provider' is imminent and will drive NHS physiotherapy services to compete directly with private counterparts. Current literature, healthcare policy and the Chartered Society of Physiotherapy strongly advocate SR to promote value for money and improve the patient experience. A repeated measure prospective cohort study introduced an SR pathway parallel to existing general practice (GP) referrals and compared costs, attendance and data relating to the patient experience across groups. SR referral groups were found to have a higher proportion of female patients presenting with acute conditions. Cost minimization analysis indicated an average 32.3% reduction in episode-of-care cost with an SR-initiated intervention. An estimated cost minimization of between £84,387.80 and £124,472.06 was calculated if SR were to be expanded service-wide. SR referral reduced waiting times and improved patient satisfaction relating to waiting times and communication compared with traditional pathways. The results of the present study showed that the introduction of the described SR pathway was feasible, cost-effective and offered comparable care. Certain aspects of the SR patient experience compared more favourably than those studied in traditional GP referral routes. They also added to an existing body of evidence supporting SR with a variety of administrative processes in various socioeconomic settings. Copyright © 2014 John Wiley & Sons, Ltd.

Exploring the cost-utility of stratified primary care management for low back pain compared with current best practice within risk-defined subgroups.

PubMed

Whitehurst, David G T; Bryan, Stirling; Lewis, Martyn; Hill, Jonathan; Hay, Elaine M

2012-11-01

Stratified management for low back pain according to patients' prognosis and matched care pathways has been shown to be an effective treatment approach in primary care. The aim of this within-trial study was to determine the economic implications of providing such an intervention, compared with non-stratified current best practice, within specific risk-defined subgroups (low-risk, medium-risk and high-risk). Within a cost-utility framework, the base-case analysis estimated the incremental healthcare cost per additional quality-adjusted life year (QALY), using the EQ-5D to generate QALYs, for each risk-defined subgroup. Uncertainty was explored with cost-utility planes and acceptability curves. Sensitivity analyses were performed to consider alternative costing methodologies, including the assessment of societal loss relating to work absence and the incorporation of generic (ie, non-back pain) healthcare utilisation. The stratified management approach was a cost-effective treatment strategy compared with current best practice within each risk-defined subgroup, exhibiting dominance (greater benefit and lower costs) for medium-risk patients and acceptable incremental cost to utility ratios for low-risk and high-risk patients. The likelihood that stratified care provides a cost-effective use of resources exceeds 90% at willingness-to-pay thresholds of £4000 (≈ 4500; $6500) per additional QALY for the medium-risk and high-risk groups. Patients receiving stratified care also reported fewer back pain-related days off work in all three subgroups. Compared with current best practice, stratified primary care management for low back pain provides a highly cost-effective use of resources across all risk-defined subgroups.

Cost-effectiveness of a primary care treatment program for depression in low-income women in Santiago, Chile.

PubMed

Araya, Ricardo; Flynn, Terry; Rojas, Graciela; Fritsch, Rosemarie; Simon, Greg

2006-08-01

The authors compared the incremental cost-effectiveness of a stepped-care, multicomponent program with usual care for the treatment of depressed women in primary care in Santiago, Chile. A cost-effectiveness study was conducted of a previous randomized controlled trial involving 240 eligible women with DSM-IV major depression who were selected from a consecutive sample of adult women attending primary care clinics. The patients were randomly allocated to usual care or a multicomponent stepped-care program led by a nonmedical health care worker. Depression-free days and health care costs derived from local sources were assessed after 3 and 6 months. A health service perspective was used in the economic analysis. Complete data were determined for 80% of the randomly assigned patients. After we adjusted for initial severity, women receiving the stepped-care program had a mean of 50 additional depression-free days over 6 months relative to patients allocated to usual care. The stepped-care program was marginally more expensive than usual care (an extra 216 Chilean pesos per depression-free day). There was a 90% probability that the incremental cost of obtaining an extra depression-free day with the intervention would not exceed 300 pesos (1.04 US dollars). The stepped-care program was significantly more effective and marginally more expensive than usual care for the treatment of depressed women in primary care. Small investments to improve depression appear to yield larger gains in poorer environments. Simple and inexpensive treatment programs tested in developing countries might provide good study models for developed countries.

Strengthening of Oral Health Systems: Oral Health through Primary Health Care

PubMed Central

Petersen, Poul Erik

2014-01-01

Around the globe many people are suffering from oral pain and other problems of the mouth or teeth. This public health problem is growing rapidly in developing countries where oral health services are limited. Significant proportions of people are underserved; insufficient oral health care is either due to low availability and accessibility of oral health care or because oral health care is costly. In all countries, the poor and disadvantaged population groups are heavily affected by a high burden of oral disease compared to well-off people. Promotion of oral health and prevention of oral diseases must be provided through financially fair primary health care and public health intervention. Integrated approaches are the most cost-effective and realistic way to close the gap in oral health between rich and poor. The World Health Organization (WHO) Oral Health Programme will work with the newly established WHO Collaborating Centre, Kuwait University, to strengthen the development of appropriate models for primary oral health care. PMID:24525450

A Qualitative Evaluation of Barriers to Care for Trauma-Related Mental Health Problems Among Low-Income Minorities in Primary Care

PubMed Central

Chung, Joyce Y.; Frank, Lori; Subramanian, Asha; Galen, Steve; Leonhard, Sarah; Green, Bonnie L.

2012-01-01

This study aimed to identify barriers and facilitators of mental health care for patients with trauma histories via qualitative methods with clinicians and administrators from primary care clinics for the underserved. Individual interviews were conducted, followed by a combined focus group with administrators from three jurisdictions; there were three focus groups with clinicians from each clinic system. Common themes were identified, and responses from groups were compared. Administrators and clinicians report extensive trauma histories among patients. Clinician barriers include lack of time, patient resistance, and inadequate referral options; administrators cite reimbursement issues, staff training, and lack of clarity about the term trauma. A key facilitator is doctor-patient relationship. There were differences in perceived barriers and facilitators at the institutional and clinical levels for mental health care for patients with trauma. Importantly, there is agreement about better access to and development of trauma-specific interventions. Findings will aid the development and implementation of trauma-focused interventions embedded in primary care. PMID:22551798

Inequities In Health Care Needs For Children With Medical Complexity

PubMed Central

Kuo, Dennis; Goudie, Anthony; Cohen, Eyal; Houtrow, Amy; Agrawal, Rishi; Carle, Adam C.; Wells, Nora

2015-01-01

Children with special health care needs are believed to be susceptible to inequities in health and health care access. Within the group with special needs, there is a smaller group of children with medical complexity: children who require medical services beyond what is typically required by children with special health care needs. We describe health care inequities for the children with medical complexity compared to children with special health care needs but without medical complexity, based on a secondary analysis of the 2005–06 and 2009–10 National Survey of Children with Special Health Care Needs. The survey examines the prevalence, health care service use, and needs of children and youth with special care needs, as reported by their families. The inequities we examined were those based on race or ethnicity, primary language in the household, insurance type, and poverty status. We found that children with medical complexity were twice as likely to have at least one unmet need, compared to children without medical complexity. Among the children with medical complexity, uninsured status was associated with more unmet needs than privately insured status. We conclude that medical complexity itself can be a primary determinant of unmet needs. PMID:25489038

Health system reforms, violence against doctors and job satisfaction in the medical profession: a cross-sectional survey in Zhejiang Province, Eastern China

PubMed Central

Wu, Dan; Wang, Yun; Lam, Kwok Fai; Hesketh, Therese

2014-01-01

Objective To explore the factors influencing doctors’ job satisfaction and morale in China, in the context of the ongoing health system reforms and the deteriorating doctor–patient relationship. Design Cross-sectional survey using self-completion questionnaires. Study setting The survey was conducted from March to May 2012 among doctors at the provincial, county and primary care levels in Zhejiang Province, China. Results The questionnaire was completed by 202 doctors. Factors which contributed most to low job satisfaction were low income and long working hours. Provincial level doctors were most dissatisfied while primary care doctors were the least dissatisfied. Three per cent of doctors at high-level hospitals and 27% of those in primary care were satisfied with the salary. Only 7% at high-level hospitals were satisfied with the work hours, compared to 43% in primary care. Less than 10% at high levels were satisfied with the amount of paid vacation time (3%) and paid sick leave (5%), compared with 38% and 41%, respectively, in primary care. Overall, 87% reported that patients were more likely to sue and that patient violence against doctors was increasing. Only 4.5% wanted their children to be doctors. Of those 125 who provided a reason, 34% said poor pay, 17% said it was a high-risk profession, and 9% expressed concerns about personal insecurity or patient violence. Conclusions Doctors have low job satisfaction overall. Recruitment and retention of doctors have become major challenges for the Chinese health system. Measures must be taken to address this, in order to ensure recruitment and retention of doctors in the future. These measures must first include reduction of doctors’ workload, especially at provincial hospitals, partly through incentivisation of appropriate utilisation of primary care, increase in doctors’ salary and more effective measures to tackle patient violence against doctors. PMID:25552614

The impact of the Brazilian family health on selected primary care sensitive conditions: A systematic review

PubMed Central

Menzies, Dick; Hone, Thomas; Dehghani, Kianoush; Trajman, Anete

2017-01-01

Background Brazil has the largest public health-system in the world, with 120 million people covered by its free primary care services. The Family Health Strategy (FHS) is the main primary care model, but there is no consensus on its impact on health outcomes. We systematically reviewed published evidence regarding the impact of the Brazilian FHS on selective primary care sensitive conditions (PCSC). Methods We searched Medline, Web of Science and Lilacs in May 2016 using key words in Portuguese and English, without language restriction. We included studies if intervention was the FHS; comparison was either different levels of FHS coverage or other primary health care service models; outcomes were the selected PCSC; and results were adjusted for relevant sanitary and socioeconomic variables, including the national conditional cash transfer program (Bolsa Familia). Due to differences in methods and outcomes reported, pooling of results was not possible. Results Of 1831 records found, 31 met our inclusion criteria. Of these, 25 were ecological studies. Twenty-one employed longitudinal quasi-experimental methods, 27 compared different levels the FHS coverage, whilst four compared the FHS versus other models of primary care. Fourteen studies found an association between higher FHS coverage and lower post-neonatal and child mortality. When the effect of Bolsa Familia was accounted for, the effect of the FHS on child mortality was greater. In 13 studies about hospitalizations due to PCSC, no clear pattern of association was found. In four studies, there was no effect on child and elderly vaccination or low-birth weight. No included studies addressed breast-feeding, dengue, HIV/AIDS and other neglected infectious diseases. Conclusions Among these ecological studies with limited quality evidence, increasing coverage by the FHS was consistently associated with improvements in child mortality. Scarce evidence on other health outcomes, hospitalization and synergies with cash transfer was found. PMID:28786997

Cervical and breast cancer screening uptake among women with serious mental illness: a data linkage study.

PubMed

Woodhead, Charlotte; Cunningham, Ruth; Ashworth, Mark; Barley, Elizabeth; Stewart, Robert J; Henderson, Max J

2016-10-21

Breast and cancer screening uptake has been found to be lower among women with serious mental illness (SMI). This study aims to corroborate these findings in the UK and to identify variation in screening uptake by illness/treatment factors, and primary care consultation frequency. Linked population-based primary and secondary care data from the London borough of Lambeth (UK) were used to compare breast and cervical screening receipt among linked eligible SMI patients (n = 625 and n = 1393), to those without SMI known only to primary care (n = 106,554 and n = 25,385) using logistic regression models adjusted first for socio-demographic factors and second, additionally for primary care consultation frequency. Eligible SMI patients were less likely to have received breast (adjusted odds ratio (OR) 0.69, 95 % confidence interval (CI), 0.57 - 0.84, p < 0.001) or cervical screening (adjusted OR 0.72, CI: 0.60 - 0.85, p < 0.001). Schizophrenia diagnosis, depot injectable antipsychotic prescription, and illness severity and risk were associated with the lowest odds of uptake of breast (adjusted ORs 0.46 to 0.59, all p < 0.001) and cervical screening (adjusted ORs 0.48 - 0.65, all p < 0.001). Adjustments for consultation frequency further reduced effect sizes for all subgroups of SMI patient, in particular for cervical screening. Women with SMI are less likely to receive breast and cervical cancer screening than comparable women without SMI. Higher primary care consultation rates among SMI patients is likely a mediating factor between SMI status and uptake, particularly for cervical screening - a service organised in primary care. To tackle health disparities linked to SMI, efforts at increasing screening uptake are key and should be targeted at women with other markers of illness severity or risk, beyond SMI status alone.

Impact of an ABCDE team triage process combined with public guidance on the division of work in an emergency department.

PubMed

Kantonen, Jarmo; Lloyd, Robert; Mattila, Juho; Kauppila, Timo; Menezes, Ricardo

2015-06-01

To study the effects of applying an emergency department (ED) triage system, combined with extensive publicity in local media about the "right" use of emergency services, on the division of work between ED nurses and general practitioners (GPs). An observational and quasi-experimental study based on before-after comparisons. Implementation of the ABCDE triage system in a Finnish combined ED where secondary care is adjacent, and in a traditional primary care ED where secondary care is located elsewhere. GPs and nurses from two different primary care EDs. Numbers of monthly visits to different professional groups before and after intervention in the studied primary care EDs and numbers of monthly visits to doctors in the local secondary care ED. The beginning of the triage process increased temporarily the number of independent consultations and patient record entries by ED nurses in both types of studied primary care EDs and reduced the number of patient visits to a doctor compared with previous years but had no effect on doctor visits in the adjacent secondary care ED. No further decrease in the number of nurse or GP visits was observed by inhibiting the entrance of non-urgent patients. The ABCDE triage system combined with public guidance may reduce non-urgent patient visits to doctors in different kinds of primary care EDs without increasing visits in the secondary care ED. However, the additional work to implement the ABCDE system is mainly directed to nurses, which may pose a challenge for staffing.

Associations Between Secondary Caregivers' Supportive Behavior and Psychological Distress of Primary Spousal Caregivers of Cognitively Intact and Impaired Elders.

PubMed

Lou, Vivian W Q; Kwan, Chi Wai; Chong, Ming Lin Alice; Chi, Iris

2015-08-01

This study examined associations between the availability and types of supportive behavior provided by secondary caregivers and the psychological distress of primary spousal caregivers of cognitively intact and impaired elders. A sample of 8,087 assessments using the validated Chinese version of the Minimum Data Set-Home Care of individuals applying for government-subsidized long-term care services from 2006 to 2009 in Hong Kong were selected based on inclusion criteria. More than 70% of primary caregivers had secondary caregivers; the rate was slightly lower for those caring for moderately or severely cognitively impaired spouses. More than half of the primary spousal caregivers had secondary caregivers who provided both emotional and instrumental support. Emotional support provided by secondary caregivers had a negative association with primary caregivers' psychological distress when their care recipients were cognitively intact. When secondary caregivers provided both instrumental and emotional support, primary caregivers had a higher likelihood of psychological distress when care recipients had greater negative mood symptoms as compared to those who had less negative mood symptoms. This is the first study that examined the association between availability and types of supportive behavior provided by secondary caregivers and the psychological distress of primary spousal caregivers of cognitively intact and impaired elders. The findings suggest a need to provide services that enhance the provision of emotional support from both secondary and primary caregivers to cognitively intact elders and support primary spousal caregivers to seek appropriate help according to the mood of care recipients. © The Author 2013. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Patient-centered professional practice models for managing low back pain in older adults: a pilot randomized controlled trial.

PubMed

Goertz, Christine M; Salsbury, Stacie A; Long, Cynthia R; Vining, Robert D; Andresen, Andrew A; Hondras, Maria A; Lyons, Kevin J; Killinger, Lisa Z; Wolinsky, Fredric D; Wallace, Robert B

2017-10-13

Low back pain is a debilitating condition for older adults, who may seek healthcare from multiple providers. Few studies have evaluated impacts of different healthcare delivery models on back pain outcomes in this population. The purpose of this study was to compare clinical outcomes of older adults receiving back pain treatment under 3 professional practice models that included primary medical care with or without chiropractic care. We conducted a pilot randomized controlled trial with 131 community-dwelling, ambulatory older adults with subacute or chronic low back pain. Participants were randomly allocated to 12 weeks of individualized primary medical care (Medical Care), concurrent medical and chiropractic care (Dual Care), or medical and chiropractic care with enhanced interprofessional collaboration (Shared Care). Primary outcomes were low back pain intensity rated on the numerical rating scale and back-related disability measured with the Roland-Morris Disability Questionnaire. Secondary outcomes included clinical measures, adverse events, and patient satisfaction. Statistical analyses included mixed-effects regression models and general estimating equations. At 12 weeks, participants in all three treatment groups reported improvements in mean average low back pain intensity [Shared Care: 1.8; 95% confidence interval (CI) 1.0 to 2.6; Dual Care: 3.0; 95% CI 2.3 to 3.8; Medical Care: 2.3; 95% CI 1.5 to 3.2)] and back-related disability (Shared Care: 2.8; 95% CI 1.6 to 4.0; Dual Care: 2.5; 95% CI 1.3 to 3.7; Medical Care: 1.5; 95% CI 0.2 to 2.8). No statistically significant differences were noted between the three groups on the primary measures. Participants in both models that included chiropractic reported significantly better perceived low back pain improvement, overall health and quality of life, and greater satisfaction with healthcare services than patients who received medical care alone. Professional practice models that included primary care and chiropractic care led to modest improvements in low back pain intensity and disability for older adults, with chiropractic-inclusive models resulting in better perceived improvement and patient satisfaction over the primary care model alone. Clinicaltrials.gov, NCT01312233 , 4 March 2011.

Incentive-Based Primary Care: Cost and Utilization Analysis.

PubMed

Hollander, Marcus J; Kadlec, Helena

2015-01-01

In its fee-for-service funding model for primary care, British Columbia, Canada, introduced incentive payments to general practitioners as pay for performance for providing enhanced, guidelines-based care to patients with chronic conditions. Evaluation of the program was conducted at the health care system level. To examine the impact of the incentive payments on annual health care costs and hospital utilization patterns in British Columbia. The study used Ministry of Health administrative data for Fiscal Year 2010-2011 for patients with diabetes, congestive heart failure, chronic obstructive pulmonary disease, and/or hypertension. In each disease group, cost and utilization were compared across patients who did, and did not, receive incentive-based care. Health care costs (eg, primary care, hospital) and utilization measures (eg, hospital days, readmissions). After controlling for patients' age, sex, service needs level, and continuity of care (defined as attachment to a general practice), the incentives reduced the net annual health care costs, in Canadian dollars, for patients with hypertension (by approximately Can$308 per patient), chronic obstructive pulmonary disease (by Can$496), and congestive heart failure (by Can$96), but not diabetes (incentives cost about Can$148 more per patient). The incentives were also associated with fewer hospital days, fewer admissions and readmissions, and shorter lengths of hospital stays for all 4 groups. Although the available literature on pay for performance shows mixed results, we showed that the funding model used in British Columbia using incentive payments for primary care might reduce health care costs and hospital utilization.

Efficacy of a cognitive and behavioural psychotherapy applied by primary care psychologists in patients with mixed anxiety-depressive disorder: a research protocol.

PubMed

Jauregui, Amale; Ponte, Joaquín; Salgueiro, Monika; Unanue, Saloa; Donaire, Carmen; Gómez, Maria Cruz; Burgos-Alonso, Natalia; Grandes, Gonzalo

2015-03-20

In contrast with the recommendations of clinical practice guidelines, the most common treatment for anxiety and depressive disorders in primary care is pharmacological. The aim of this study is to assess the efficacy of a cognitive-behavioural psychological intervention, delivered by primary care psychologists in patients with mixed anxiety-depressive disorder compared to usual care. This is an open-label, multicentre, randomized, and controlled study with two parallel groups. A random sample of 246 patients will be recruited with mild-to-moderate mixed anxiety-depressive disorder, from the target population on the lists of 41 primary care doctors. Patients will be randomly assigned to the intervention group, who will receive standardised cognitive-behavioural therapy delivered by psychologists together with usual care, or to a control group, who will receive usual care alone. The cognitive-behavioural therapy intervention is composed of eight individual 60-minute face-to face sessions conducted in eight consecutive weeks. A follow-up session will be conducted over the telephone, for reinforcement or referral as appropriate, 6 months after the intervention, as required. The primary outcome variable will be the change in scores on the Short Form-36 General Health Survey. We will also measure the change in the frequency and intensity of anxiety symptoms (State-Trait Anxiety Inventory) and depression (Beck Depression Inventory) at baseline, and 3, 6 and 12 months later. Additionally, we will collect information on the use of drugs and health care services. The aim of this study is to assess the efficacy of a primary care-based cognitive-behavioural psychological intervention in patients with mixed anxiety-depressive disorder. The international scientific evidence has demonstrated the need for psychologists in primary care. However, given the differences between health policies and health services, it is important to test the effect of these psychological interventions in our geographical setting. NCT01907035 (July 22, 2013).

Alerts in electronic medical records to promote a colorectal cancer screening programme: a cluster randomised controlled trial in primary care

PubMed Central

Guiriguet, Carolina; Muñoz-Ortiz, Laura; Burón, Andrea; Rivero, Irene; Grau, Jaume; Vela-Vallespín, Carmen; Vilarrubí, Mercedes; Torres, Miquel; Hernández, Cristina; Méndez-Boo, Leonardo; Toràn, Pere; Caballeria, Llorenç; Macià, Francesc; Castells, Antoni

2016-01-01

Background Participation rates in colorectal cancer screening are below recommended European targets. Aim To evaluate the effectiveness of an alert in primary care electronic medical records (EMRs) to increase individuals’ participation in an organised, population-based colorectal cancer screening programme when compared with usual care. Design and setting Cluster randomised controlled trial in primary care centres of Barcelona, Spain. Method Participants were males and females aged 50–69 years, who were invited to the first round of a screening programme based on the faecal immunochemical test (FIT) (n = 41 042), and their primary care professional. The randomisation unit was the physician cluster (n = 130) and patients were blinded to the study group. The control group followed usual care as per the colorectal cancer screening programme. In the intervention group, as well as usual care, an alert to health professionals (cluster level) to promote screening was introduced in the individual’s primary care EMR for 1 year. The main outcome was colorectal cancer screening participation at individual participant level. Results In total, 67 physicians and 21 619 patients (intervention group) and 63 physicians and 19 423 patients (control group) were randomised. In the intention-to-treat analysis screening participation was 44.1% and 42.2% respectively (odds ratio 1.08, 95% confidence interval [CI] = 0.97 to 1.20, P = 0.146). However, in the per-protocol analysis screening uptake in the intervention group showed a statistically significant increase, after adjusting for potential confounders (OR, 1.11; 95% CI = 1.02 to 1.22; P = 0.018). Conclusion The use of an alert in an individual’s primary care EMR is associated with a statistically significant increased uptake of an organised, FIT-based colorectal cancer screening programme in patients attending primary care centres. PMID:27266861

Improving cardiovascular outcomes among Aboriginal Australians: Lessons from research for primary care.

PubMed

Thompson, Sandra C; Haynes, Emma; Woods, John A; Bessarab, Dawn C; Dimer, Lynette A; Wood, Marianne M; Sanfilippo, Frank M; Hamilton, Sandra J; Katzenellenbogen, Judith M

2016-01-01

The Aboriginal people of Australia have much poorer health and social indicators and a substantial life expectancy gap compared to other Australians, with premature cardiovascular disease a major contributor to poorer health. This article draws on research undertaken to examine cardiovascular disparities and focuses on ways in which primary care practitioners can contribute to reducing cardiovascular disparities and improving Aboriginal health. The overall research utilised mixed methods and included data analysis, interviews and group processes which included Aboriginal people, service providers and policymakers. Workshop discussions to identify barriers and what works were recorded by notes and on whiteboards, then distilled and circulated to participants and other stakeholders to refine and validate information. Additional engagement occurred through circulation of draft material and further discussions. This report distils the lessons for primary care practitioners to improve outcomes through management that is attentive to the needs of Aboriginal people. Aspects of primordial, primary and secondary prevention are identified, with practical strategies for intervention summarised. The premature onset and high incidence of Aboriginal cardiovascular disease make prevention imperative and require that primary care practitioners understand and work to address the social underpinnings of poor health. Doctors are well placed to reinforce the importance of healthy lifestyle at all visits to involve the family and to reduce barriers which impede early care seeking. Ensuring better information for Aboriginal patients and better integrated care for patients who frequently have complex needs and multi-morbidities will also improve care outcomes. Primary care practitioners have an important role in improving Aboriginal cardiovascular care outcomes. It is essential that they recognise the special needs of their Aboriginal patients and work at multiple levels both outside and inside the clinic for prevention and management of disease. A toolkit of proactive and holistic opportunities for interventions is proposed.

Chemical intolerance in primary care settings: prevalence, comorbidity, and outcomes.

PubMed

Katerndahl, David A; Bell, Iris R; Palmer, Raymond F; Miller, Claudia S

2012-01-01

This study extends previous community-based studies on the prevalence and clinical characteristics of chemical intolerance in a sample of primary care clinic patients. We evaluated comorbid medical and psychiatric disorders, functional status, and rates of health care use. A total of 400 patients were recruited from 2 family medicine clinic waiting rooms in San Antonio, Texas. Patients completed the validated Quick Environmental Exposure and Sensitivity Inventory (QEESI) to assess chemical intolerance; the Primary Care Evaluation of Mental Disorders (PRIME-MD) screen for possible psychiatric disorders; the Dartmouth-Northern New England Primary Care Cooperative Information Project (Dartmouth COOP) charts for functional status; and the Healthcare Utilization Questionnaire. Overall, 20.3% of the sample met criteria for chemical intolerance. The chemically intolerant group reported significantly higher rates of comorbid allergies and more often met screening criteria for possible major depressive disorder, panic disorder, generalized anxiety disorder, and alcohol abuse disorder, as well as somatization disorder. The total number of possible mental disorders was correlated with chemical intolerance scores (P <.001). Controlling for demographics, patients with chemical intolerance were significantly more likely to have poorer functional status, with trends toward increased medical service use when compared with non-chemically intolerant patients. After controlling for comorbid psychiatric conditions, the groups differed significantly only regarding limitations of social activities. Chemical intolerance occurs in 1 of 5 primary care patients yet is rarely diagnosed by busy practitioners. Psychiatric comorbidities contribute to functional limitations and increased health care use. Chemical intolerance offers an etiologic explanation. Symptoms may resolve or improve with the avoidance of salient chemical, dietary (including caffeine and alcohol), and drug triggers. Given greater medication intolerances in chemical intolerance, primary care clinicians could use the QEESI to identify patients for appropriate triage to comprehensive nonpharmacologic care.

Impact of a low intensity and broadly inclusive ED care coordination intervention on linkage to primary care and ED utilization.

PubMed

Foster, Sean D; Hart, Kim; Lindsell, Christopher J; Miller, Christopher N; Lyons, Michael S

2018-04-05

We aim to evaluate the effectiveness of a broadly inclusive, comparatively low intensity intervention linking ED patients to a primary care home. This retrospective cohort study evaluated ED patients referred for primary care linkage in a large, urban, academic ED. A care coordination specialist performed a brief interview to gauge access barriers and provide a clinic referral with optional scheduling assistance. Data were abstracted from program records and the electronic medical record. The primary outcome was the proportion of referred individuals who attended at least one primary care appointment. Secondary outcomes included return ED encounters within one year, and factors associated with linkage outcomes. There were 2142 referrals made for 2064 patients; 1688/2142 accepted assistance. Linkage was successful for 1059/1688 (63%, CI95 60% to 65%). Among patients accepting assistance, those without successful linkage were younger (41 vs 45years, difference 3years, CI95 2 to 3), more often male (62% vs 55%,difference 7%, CI95 2% to 12%), and less likely to have a chronic medical condition (37% vs 45%, difference 8%; CI95 3% to 12%) or to have had an appointment scheduled within two weeks (26% vs 33%, difference 7%, CI95 2% to 12%). Insurance status and self-reported barriers to care were not associated with linkage success. Patterns of subsequent ED use were similar, regardless of referral status or linkage outcome. Low intensity, broadly inclusive, ED care coordination linked nearly 50% of patients referred for intervention, and two-thirds of willing participants, with a primary care home. Copyright © 2018 Elsevier Inc. All rights reserved.

Preliminary examination of metabolic syndrome response to motivational interviewing for weight loss as compared to an attentional control and usual care in primary care for individuals with and without binge-eating disorder.

PubMed

Barnes, Rachel D; Barber, Jessica A

2017-08-01

Motivational interviewing (MI) treatment for weight loss is being studied in primary care. The effect of such interventions on metabolic syndrome or binge eating disorder (BED), both highly related to excess weight, has not been examined in primary care. This study conducted secondary analyses from a randomized controlled trial to test the impact of MI for weight loss in primary care on metabolic syndrome. 74 adult participants with overweight/obesity recruited through primary care were randomized to 12weeks of either MI, an attentional control, or usual care. Participants completed measurements for metabolic syndrome at pre- and post-treatment. There were no statistically significant differences in metabolic syndrome rates at pre-, X 2 (2)=0.16, p=0.921, or post-, X 2 (2)=0.852, p=0.653 treatment. The rates in metabolic syndrome, however, decreased for MI (10.2%) and attentional control (13.8%) participants, but not for usual care. At baseline, metabolic syndrome rates did not differ significantly between participants with BED or without BED across treatments. At post-treatment, participants with BED were significantly more likely to meet criteria for metabolic syndrome than participants without BED, X 2 (1)=5.145, p=0.023, phi=0.273. Across treatments, metabolic syndrome remitted for almost a quarter of participants without BED (23.1%) but for 0% of those with BED. These preliminary results are based on a small sample and should be interpreted with caution, but they are the first to suggest that relatively low intensity MI weight loss interventions in primary care may decrease metabolic syndrome rates but not for individuals with BED. Copyright © 2017 Elsevier Ltd. All rights reserved.

Supporting the Integration of HIV Testing Into Primary Care Settings

PubMed Central

Bradley-Springer, Lucy; Kang Dufour, Mi-Suk; Koester, Kimberly A.; Beane, Stephanie; Warren, Nancy; Beal, Jeffrey; Frank, Linda Rose

2012-01-01

Objectives. We examined the efforts of the US network of AIDS Education and Training Centers (AETCs) to increase HIV testing capacity across a variety of clinical settings. Methods. We used quantitative process data from 8 regional AETCs for July 1, 2008, to June 30, 2009, and qualitative program descriptions to demonstrate how AETC education helped providers integrate HIV testing into routine clinical care with the goals of early diagnosis and treatment. Results. Compared with other AETC training, HIV testing training was longer and used a broader variety of strategies to educate more providers per training. During education, providers were able to understand their primary care responsibility to address public health concerns through HIV testing. Conclusions. AETC efforts illustrate how integration of the principles of primary care and public health can be promoted through professional training. PMID:22515867

An explorative study of factors contributing to the job satisfaction of primary care midwives.

PubMed

Warmelink, J Catja; Hoijtink, Kirsten; Noppers, Marloes; Wiegers, Therese A; de Cock, T Paul; Klomp, Trudy; Hutton, Eileen K

2015-04-01

the main objectives of our study was to gain an understanding of how primary care midwives in the Netherlands feel about their work and to identify factors associated with primary care midwives׳ job satisfaction and areas for improvement. a qualitative analysis was used, based on the constructivist/interpretative paradigm. Three open-ended questions in written or online questionnaire, analysed to identify factors that are linked with job satisfaction, were as follows: 'What are you very satisfied with, in your work as a midwife?', 'What would you most like to change about your work as a midwife?' and 'What could be improved in your work?'. 20 of the 519 primary care practices in the Netherlands in May 2010 were included. at these participating practices 99 of 108 midwives returned a written or online questionnaire. in general, most of the participating primary care midwives were satisfied with their job. The factors positively associated with their job satisfaction were their direct contact with clients, the supportive co-operation and teamwork with immediate colleagues, the organisation of and innovation within their practice group and the independence, autonomy, freedom, variety and opportunities that they experienced in their work. Regarding improvements, the midwives desired a reduction in non-client-related activities, such as paperwork and meetings. They wanted a lower level of work pressure, and a reduced case-load in order to have more time to devote to individual clients׳ needs. Participants identified that co-operation with other partners in the health care system could also be improved. our knowledge, our study is the first explorative study on factors associated with job satisfaction of primary care midwives. While there are several studies on job satisfaction in health care; little is known about the working conditions of midwives in primary care settings. Although the participating primary care midwives in the Netherlands were satisfied with their job, areas for improvement were identified. The results of our study can be relevant for countries that have a comparable obstetric system as in the Netherlands, or are implementing or scaling up midwifery-led care. Copyright © 2015 Elsevier Ltd. All rights reserved.

A randomized controlled trial testing the efficacy of a brief cannabis universal prevention program among adolescents in primary care.

PubMed

Walton, Maureen A; Resko, Stella; Barry, Kristen L; Chermack, Stephen T; Zucker, Robert A; Zimmerman, Marc A; Booth, Brenda M; Blow, Frederic C

2014-05-01

To examine the efficacy of a brief intervention delivered by a therapist (TBI) or a computer (CBI) in preventing cannabis use among adolescents in urban primary care clinics. A randomized controlled trial comparing: CBI and TBI versus control. Urban primary care clinics in the United States. Research staff recruited 714 adolescents (aged 12-18 years) who reported no life-time cannabis use on a screening survey for this study, which included a baseline survey, randomization (stratified by gender and grade) to conditions (control; CBI; TBI) and 3-, 6- and 12-month assessments. Using an intent-to-treat approach, primary outcomes were cannabis use (any, frequency); secondary outcomes included frequency of other drug use, severity of alcohol use and frequency of delinquency (among 85% completing follow-ups). Compared with controls, CBI participants had significantly lower rates of any cannabis use over 12 months (24.16%, 16.82%, respectively, P < 0.05), frequency of cannabis use at 3 and 6 months (P < 0.05) and other drug use at 3 months (P < 0.01). Compared with controls, TBI participants did not differ in cannabis use or frequency, but had significantly less other drug use at 3 months (P < 0.05), alcohol use at 6 months (P < 0.01) and delinquency at 3 months (P < 0.01). Among adolescents in urban primary care in the United States, a computer brief intervention appeared to prevent and reduce cannabis use. Both computer and therapist delivered brief interventions appeared to have small effects in reducing other risk behaviors, but these dissipated over time. © 2013 Society for the Study of Addiction.

Counselling for mental health and psychosocial problems in primary care.

PubMed

Bower, Peter; Knowles, Sarah; Coventry, Peter A; Rowland, Nancy

2011-09-07

The prevalence of mental health and psychosocial problems in primary care is high. Counselling is a potential treatment for these patients, but there is a lack of consensus over the effectiveness of this treatment in primary care. To assess the effectiveness and cost effectiveness of counselling for patients with mental health and psychosocial problems in primary care. To update the review, the following electronic databases were searched: the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers (to December 2010), MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials (to May 2011). Randomised controlled trials of counselling for mental health and psychosocial problems in primary care. Data were extracted using a standardised data extraction sheet by two reviewers. Trials were rated for quality by two reviewers using Cochrane risk of bias criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. There was no assessment of adverse events. Nine trials were included in the review, involving 1384 randomised participants. Studies varied in risk of bias, although two studies were identified as being at high risk of selection bias because of problems with concealment of allocation. All studies were from primary care in the United Kingdom and thus comparability was high. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in terms of mental health outcomes in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not in the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials), nor on measures of social function (standardised mean difference -0.09, 95% CI -0.29 to 0.11, n = 386, 3 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar. There were limited comparisons between counselling and other psychological therapies, medication, or other psychosocial interventions. Counselling is associated with significantly greater clinical effectiveness in short-term mental health outcomes compared to usual care, but provides no additional advantages in the long-term. Participants were satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs. The generalisability of these findings to settings outside the United Kingdom is unclear.

Primary language, income and the intensification of anti-glycemic medications in managed care: the (TRIAD) study.

PubMed

Duru, O Kenrik; Bilik, Dori; McEwen, Laura N; Brown, Arleen F; Karter, Andrew J; Curb, J David; Marrero, David G; Lu, Shou-En; Rodriguez, Michael; Mangione, Carol M

2011-05-01

Patients who speak Spanish and/or have low socioeconomic status are at greater risk of suboptimal glycemic control. Inadequate intensification of anti-glycemic medications may partially explain this disparity. To examine the associations between primary language, income, and medication intensification. Cohort study with 18-month follow-up. One thousand nine hundred and thirty-nine patients with Type 2 diabetes who were not using insulin enrolled in the Translating Research into Action for Diabetes Study (TRIAD), a study of diabetes care in managed care. Using administrative pharmacy data, we compared the odds of medication intensification for patients with baseline A1c ≥ 8%, by primary language and annual income. Covariates included age, sex, race/ethnicity, education, Charlson score, diabetes duration, baseline A1c, type of diabetes treatment, and health plan. Overall, 42.4% of patients were taking intensified regimens at the time of follow-up. We found no difference in the odds of intensification for English speakers versus Spanish speakers. However, compared to patients with incomes <$15,000, patients with incomes of $15,000-$39,999 (OR 1.43, 1.07-1.92), $40,000-$74,999 (OR 1.62, 1.16-2.26) or >$75,000 (OR 2.22, 1.53-3.24) had increased odds of intensification. This latter pattern did not differ statistically by race. Low-income patients were less likely to receive medication intensification compared to higher-income patients, but primary language (Spanish vs. English) was not associated with differences in intensification in a managed care setting. Future studies are needed to explain the reduced rate of intensification among low income patients in managed care.

Primary Care–Mental Health Integration Programs in the Veterans Affairs Health System Serve a Different Patient Population Than Specialty Mental Health Clinics

PubMed Central

Szymanski, Benjamin R.; Zivin, Kara; McCarthy, John F.; Valenstein, Marcia; Pfeiffer, Paul N.

2012-01-01

Objective: To assess whether Primary Care–Mental Health Integration (PC-MHI) programs within the Veterans Affairs (VA) health system provide services to patient subgroups that may be underrepresented in specialty mental health care, including older patients and women, and to explore whether PC-MHI served individuals with less severe mental health disorders compared to specialty mental health clinics. Method: Data were obtained from the VA National Patient Care Database for a random sample of VA patients, and primary care patients with an ICD-9-CM mental health diagnosis (N = 243,806) in 2009 were identified. Demographic and clinical characteristics between patients who received mental health treatment exclusively in a specialty mental health clinic (n = 128,248) or exclusively in a PC-MHI setting (n = 8,485) were then compared. Characteristics of patients who used both types of services were also explored. Results: Compared to patients treated in specialty mental health clinics, PC-MHI service users were more likely to be aged 65 years or older (26.4% vs 17.9%, P < .001) and female (8.6% vs 7.7%, P = .003). PC-MHI patients were more likely than specialty mental health clinic patients to be diagnosed with a depressive disorder other than major depression, an unspecified anxiety disorder, or an adjustment disorder (P < .001) and less likely to be diagnosed with more severe disorders, including bipolar disorder, posttraumatic stress disorder, psychotic disorders, and alcohol or substance dependence (P < .001). Conclusions: Primary Care–Mental Health Integration within the VA health system reaches demographic subgroups that are traditionally less likely to use specialty mental health care. By treating patients with less severe mental health disorders, PC-MHI appears to expand upon, rather than duplicate, specialty care services. PMID:23106026

Assessment of a primary care-based telemonitoring intervention for home care patients with heart failure and chronic lung disease. The TELBIL study

PubMed Central

2011-01-01

Background Telemonitoring technology offers one of the most promising alternatives for the provision of health care services at the patient's home. The primary aim of this study is to evaluate the impact of a primary care-based telemonitoring intervention on the frequency of hospital admissions. Methods/design A primary care-based randomised controlled trial will be carried out to assess the impact of a telemonitoring intervention aimed at home care patients with heart failure (HF) and/or chronic lung disease (CLD). The results will be compared with those obtained with standard health care practice. The duration of the study will be of one year. Sixty patients will be recruited for the study. In-home patients, diagnosed with HF and/or CLD, aged 14 or above and with two or more hospital admissions in the previous year will be eligible. For the intervention group, telemonitoring will consist of daily patient self-measurements of respiratory-rate, heart-rate, blood pressure, oxygen saturation, weight and body temperature. Additionally, the patients will complete a qualitative symptom questionnaire daily using the telemonitoring system. Routine telephone contacts will be conducted every fortnight and additional telephone contacts will be carried out if the data received at the primary care centre are out of the established limits. The control group will receive usual care. The primary outcome measure is the number of hospital admissions due to any cause that occurred in a period of 12 months post-randomisation. The secondary outcome measures are: duration of hospital stay, hospital admissions due to HF or CLD, mortality rate, use of health care resources, quality of life, cost-effectiveness, compliance and patient and health care professional satisfaction with the new technology. Discussion The results of this study will shed some light on the effects of telemonitoring for the follow-up and management of chronic patients from a primary care setting. The study may contribute to enhance the understanding of alternative modes of health care provision for medically unstable elderly patients, who bear a high degree of physical and functional deterioration. Trial Registration ISRCTN: ISRCTN89041993 PMID:21385401

Prescribing exercise for older adults: A needs assessment comparing primary care physicians, nurse practitioners, and physician assistants.

PubMed

Dauenhauer, Jason A; Podgorski, Carol A; Karuza, Jurgis

2006-01-01

To inform the development of educational programming designed to teach providers appropriate methods of exercise prescription for older adults, the authors conducted a survey of 177 physicians, physician assistants, and nurse practitioners (39% response rate). The survey was designed to better understand the prevalence of exercise prescriptions, attitudes, barriers, and educational needs of primary care practitioners toward older adults. Forty-seven percent of primary care providers report not prescribing exercise for older adults; 85% of the sample report having no formal training in exercise prescription. Practitioner attitudes were positive toward exercise, but were not predictive of their exercise prescribing behavior, which indicates that education efforts aimed at changing attitudes as a way of increasing exercise-prescribing behaviors would not be sufficient. In order to facilitate and reinforce practice changes to increase exercise-prescribing behaviors of primary care providers, results suggest the need for specific skill training on how to write an exercise prescription and motivate older adults to follow these prescriptions.

Organization Complexity and Primary Care Providers' Perceptions of Quality Improvement Culture Within the Veterans Health Administration.

PubMed

Korom-Djakovic, Danijela; Canamucio, Anne; Lempa, Michele; Yano, Elizabeth M; Long, Judith A

2016-01-01

This study examined how aspects of quality improvement (QI) culture changed during the introduction of the Veterans Health Administration (VHA) patient-centered medical home initiative and how they were influenced by existing organizational factors, including VHA facility complexity and practice location. A voluntary survey, measuring primary care providers' (PCPs') perspectives on QI culture at their primary care clinics, was administered in 2010 and 2012. Participants were 320 PCPs from hospital- and community-based primary care practices in Pennsylvania, West Virginia, Delaware, New Jersey, New York, and Ohio. PCPs in community-based outpatient clinics reported an improvement in established processes for QI, and communication and cooperation from 2010 to 2012. However, their peers in hospital-based clinics did not report any significant improvements in QI culture. In both years, compared with high-complexity facilities, medium- and low-complexity facilities had better scores on the scales assessing established processes for QI, and communication and cooperation. © The Author(s) 2014.

Hospitalization for primary care susceptible conditions, health spending and Family Health Strategy: an analysis of trends.

PubMed

Morimoto, Tissiani; Costa, Juvenal Soares Dias da

2017-03-01

The goal of this study was to analyze the trend over time of hospitalizations due to conditions susceptible to primary healthcare (HCSPC), and how it relates to healthcare spending and Family Health Strategy (FHS) coverage in the city of São Leopoldo, Rio Grande do Sul State, Brazil, between 2003 and 2012. This is an ecological, time-trend study. We used secondary data available in the Unified Healthcare System Hospital Data System, the Primary Care Department and Public Health Budget Data System. The analysis compared HCSPC using three-year moving averages and Poisson regressions or negative binomials. We found no statistical significance in decreasing HCSPC indicators and primary care spending in the period analyzed. Healthcare spending, per-capita spending and FHS coverage increased significantly, but we found no correlation with HCSPC. The results show that, despite increases in the funds invested and population covered by FHS, they are still insufficient to deliver the level of care the population requires.

A Pacific population's access to and use of health services in Dunedin.

PubMed

Sopoaga, Faafetai; Parkin, Lianne; Gray, Andrew

2012-10-26

Pacific peoples in New Zealand (mostly of Samoan, Tongan, or Cook Islands origin) have poor health compared to the total New Zealand population. Understanding their access to and use of health services is important in resolving this. A survey of Pacific peoples in Dunedin obtained information about their access to and use of health services. 372 questionnaires were analysed. Approximately one-quarter did not have a regular doctor or health service. At least 50% used hospital emergency services for non-urgent illnesses. Nearly two-thirds used a "walk-in" primary care service. A significant proportion of Pacific peoples did not have a regular GP or health service in Dunedin. It was surprising students were more likely to be in this category because student health services should be more affordable. A "walk-in" primary care facility has a role in the delivery of primary care services. Pacific organisations can assist primary care providers to encourage access to and the appropriate use of health services.

Effectiveness of the EMPOWER-PAR Intervention in Improving Clinical Outcomes of Type 2 Diabetes Mellitus in Primary Care: A Pragmatic Cluster Randomised Controlled Trial.

PubMed

Ramli, Anis Safura; Selvarajah, Sharmini; Daud, Maryam Hannah; Haniff, Jamaiyah; Abdul-Razak, Suraya; Tg-Abu-Bakar-Sidik, Tg Mohd Ikhwan; Bujang, Mohamad Adam; Chew, Boon How; Rahman, Thuhairah; Tong, Seng Fah; Shafie, Asrul Akmal; Lee, Verna K M; Ng, Kien Keat; Ariffin, Farnaza; Abdul-Hamid, Hasidah; Mazapuspavina, Md Yasin; Mat-Nasir, Nafiza; Chan, Chun W; Yong-Rafidah, Abdul Rahman; Ismail, Mastura; Lakshmanan, Sharmila; Low, Wilson H H

2016-11-14

The chronic care model was proven effective in improving clinical outcomes of diabetes in developed countries. However, evidence in developing countries is scarce. The objective of this study was to evaluate the effectiveness of EMPOWER-PAR intervention (based on the chronic care model) in improving clinical outcomes for type 2 diabetes mellitus using readily available resources in the Malaysian public primary care setting. This was a pragmatic, cluster-randomised, parallel, matched pair, controlled trial using participatory action research approach, conducted in 10 public primary care clinics in Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. Patients who fulfilled the criteria were recruited over a 2-week period by each clinic. The obligatory intervention components were designed based on four elements of the chronic care model i.e. healthcare organisation, delivery system design, self-management support and decision support. The primary outcome was the change in the proportion of patients achieving HbA1c < 6.5%. Secondary outcomes were the change in proportion of patients achieving targets for blood pressure, lipid profile, body mass index and waist circumference. Intention to treat analysis was performed for all outcome measures. A generalised estimating equation method was used to account for baseline differences and clustering effect. A total of 888 type 2 diabetes mellitus patients were recruited at baseline (intervention: 471 vs. 417). At 1-year, 96.6 and 97.8% of patients in the intervention and control groups completed the study, respectively. The baseline demographic and clinical characteristics of both groups were comparable. The change in the proportion of patients achieving HbA1c target was significantly higher in the intervention compared to the control group (intervention: 3.0% vs. -4.1%, P < 0.002). Patients who received the EMPOWER-PAR intervention were twice more likely to achieve HbA1c target compared to those in the control group (adjusted OR 2.16, 95% CI 1.34-3.50, P < 0.002). However, there was no significant improvement found in the secondary outcomes. This study demonstrates that the EMPOWER-PAR intervention was effective in improving the primary outcome for type 2 diabetes in the Malaysian public primary care setting. Registered with: ClinicalTrials.gov.: NCT01545401 . Date of registration: 1st March 2012.

Recruitment of private practices for primary care research: experience in a preventive services clinical trial.

PubMed

McBride, P E; Massoth, K M; Underbakke, G; Solberg, L I; Beasley, J W; Plane, M B

1996-10-01

Recruitment of community primary care practices for studies to improve health service delivery is important to many health care organizations. Prior studies have focused on individual physician recruitment or academic settings. This descriptive study evaluated the efficiency and utility of three different recruitment methods to encourage community practice participation in a preventive services research trial. Primary care practices in four midwestern states were recruited using different sources for initial mailings (physician lists, practice lists, and a managed care organization's primary care network) and different recruiting methods. Outcome measures included response rates, participation rates, and comparative costs of each method. Of the 86 eligible practices contacted, 52 (60%) consented to participate. Mailing to individual physicians was the most cumbersome and expensive method and had the lowest response rate. Initial contacts with practice medical directors increased the participation rate substantially, and practice recruitment meetings improved both study participation and practice-project communication. Experience with these three methods suggests that the most efficient way to recruit practices for participation in a preventive services research trial involves targeted mailings and phone calls to medical directors, followed by on-site practice meetings.

Chinese perspectives on primary care for common mental disorders: Barriers and policy implications.

PubMed

Sun, Kai Sing; Lam, Tai Pong; Wu, Dan

2018-05-01

The World Health Organization (WHO) has called for integration of mental health into primary care for a decade. In Western countries, around 15% to 25% of patients with common mental disorders including mood and anxiety disorders seek help from primary care physicians (PCPs). The rate is only about 5% in China. This article reviews the Chinese findings on the barriers to primary care for common mental disorders and how they compared with Western findings. A narrative literature review was conducted, focusing on literature published from mid-1990s in English or Chinese. Patient, PCP and health system factors were reviewed. Although Chinese and Western findings show similar themes of barriers, the Chinese have stronger barriers in most aspects, including under-recognition of the need for treatment, stigma on mental illness, somatization, worries about taking psychiatric drugs, uncertainties in the role, competency and legitimacy of PCPs in mental health care and short consultation time. Current policies in China emphasize enhancement of mental health facilities and workforce in the community. Our review suggests that patients' intention to seek help and PCPs' competency in mental health care are other fundamental factors to be addressed.

Case Study of an Aboriginal Community-Controlled Health Service in Australia

PubMed Central

Baum, Fran; Lawless, Angela; Labonté, Ronald; Sanders, David; Boffa, John; Edwards, Tahnia; Javanparast, Sara

2016-01-01

Abstract Universal health coverage provides a framework to achieve health services coverage but does not articulate the model of care desired. Comprehensive primary health care includes promotive, preventive, curative, and rehabilitative interventions and health equity and health as a human right as central goals. In Australia, Aboriginal community-controlled health services have pioneered comprehensive primary health care since their inception in the early 1970s. Our five-year project on comprehensive primary health care in Australia partnered with six services, including one Aboriginal community-controlled health service, the Central Australian Aboriginal Congress. Our findings revealed more impressive outcomes in several areas—multidisciplinary work, community participation, cultural respect and accessibility strategies, preventive and promotive work, and advocacy and intersectoral collaboration on social determinants of health—at the Aboriginal community-controlled health service compared to the other participating South Australian services (state-managed and nongovernmental ones). Because of these strengths, the Central Australian Aboriginal Congress’s community-controlled model of comprehensive primary health care deserves attention as a promising form of implementation of universal health coverage by articulating a model of care based on health as a human right that pursues the goal of health equity. PMID:28559679

A service evaluation of self-referral to military mental health teams

PubMed Central

Kennedy, I.; Jones, N.; Sharpley, J.; Greenberg, N.

2016-01-01

Background The UK military runs a comprehensive mental health service ordinarily accessed via primary care referrals. Aims To evaluate the feasibility of self-referral to mental health services within a military environment. Methods Three pilot sites were identified; one from each service (Royal Navy, Army, Air Force). Socio-demographic information included age, rank, service and career duration. Clinical data included prior contact with general practitioner (GP), provisional diagnosis and assessment outcome. Results Of the 57 self-referrals, 69% (n = 39) had not previously accessed primary care for their current difficulties. After their mental health assessment, 47 (82%) were found to have a formal mental health problem and 41 (72%) were offered a further mental health clinician appointment. The data compared favourably with a large military mental health department that reported 87% of primary care referrals had a formal mental health condition. Conclusions The majority of self-referrals had formal mental health conditions for which they had not previously sought help from primary care; most were offered further clinical input. This supports the view that self-referral may be a useful option to encourage military personnel to seek professional care over and above the usual route of accessing care through their GP. PMID:27121634

Implementing collaborative care for depression treatment in primary care: A cluster randomized evaluation of a quality improvement practice redesign

PubMed Central

2011-01-01

Background Meta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness. Methods The study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM. For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months. Results Interviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003). Conclusions Depression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed. Trial Registration ClinicalTrials.gov: NCT00105820 PMID:22032247

Primary health care, community participation and community-financing: experiences of two middle hill villages in Nepal.

PubMed

Sepehri, A; Pettigrew, J

1996-03-01

Although community involvement in health related activities is generally acknowledged by international and national health planners to be the key to the successful organization of primary health care, comparatively little is known about its potential and limitations. Drawing on the experiences of two middle hill villages in Nepal, this paper reports on research undertaken to compare and contrast the scope and extent of community participation in the delivery of primary health care in a community run and financed health post and a state run and financed health post. Unlike many other health posts in Nepal these facilities do provide effective curative services, and neither of them suffer from chronic shortage of drugs. However, community-financing did not appear to widen the scope and the extent of participation. Villagers in both communities relied on the health post for the treatment of less than one-third of symptoms, and despite the planners' intentions, community involvement outside participation in benefits was found to be very limited.

A meta-analysis of the efficacy of fibromyalgia treatment according to level of care

PubMed Central

Garcia-Campayo, Javier; Magdalena, Jesus; Magallón, Rosa; Fernández-García, Esther; Salas, Montserrat; Andrés, Eva

2008-01-01

Introduction The aim of this paper was to compare the efficacy of the treatments for fibromyalgia currently available in both primary care and specialised settings. Methods Published reports of randomised controlled trials (RCTs) researching pharmacological and non-pharmacological treatments in patients with fibromyalgia were found in the MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and PsychInfo databases. The most recent electronic search was undertaken in June 2006. Results We identified a total of 594 articles. Based on titles and abstracts, 102 full articles were retrieved, 33 of which met the inclusion criteria. These RCTs assessed 120 treatment interventions in 7789 patients diagnosed with primary fibromyalgia. Of them, 4505 (57.8%) were included in the primary care group of our study and 3284 (42.2%) in the specialised intervention group. The sample was mostly made up of middle-aged women, who have had fibromyalgia for a mean period of 6 to 10 years. The mean effect size of the efficacy of the 120 treatment interventions in patients with fibromyalgia compared with controls was 0.49 (95% confidence interval [CI] = 0.39 to 0.58; p < 0.001). In the primary care group it was 0.46 (95% CI = 0.33 to 0.58) while in specialised care it was 0.53 (95% CI = 0.38 to 0.69), with no statistical significance in the differences. We analysed the efficacy of treatments by comparing primary and specialised care in the different fibromyalgia groups and there were no significant differences. The variables of the studies that affected the improvements in the efficacy of fibromyalgia treatment were low quality of the studies and a shorter duration of treatment. However, both factors were biased by the heterogeneity of the studies. Other variables that also improved outcome and were not biased by the heterogeneity of the studies, were younger age of the patients and shorter duration of the disorder. On the contrary, gender and type of treatment (pharmacological vs. psychological) did not affect outcome. Conclusion Based on this meta-analysis and despite the heterogeneity of specialised care studies and of the other limitations described in this article, treating fibromyalgia in specialised care offers no clear advantages. PMID:18627602

Primary care quality in the Medicare Program: comparing the performance of Medicare health maintenance organizations and traditional fee-for-service medicare.

PubMed

Safran, Dana Gelb; Wilson, Ira B; Rogers, William H; Montgomery, Jana E; Chang, Hong

2002-04-08

Since 1972, Medicare beneficiaries have had the option of enrolling in a Medicare-qualified health maintenance organization (HMO). Little information exists to inform beneficiaries' choices between the traditional fee-for-service (FFS) Medicare program and an HMO. To compare the primary care received by seniors in Medicare HMOs with that of seniors in the traditional FFS Medicare program, and among HMOs, and to examine performance differences associated with HMO model-type and profit status. Data were derived from a cross-sectional observational survey of Medicare beneficiaries 65 years or older in the 13 states with mature, substantial Medicare HMO markets. Only beneficiaries continuously enrolled for 12 months or more in traditional FFS Medicare or a qualified Medicare HMO were eligible. Data were obtained using a 5-stage protocol involving mail and telephone (64% response rate). Analyses included respondents who identified a primary physician and had all required data elements (N = 8828). We compared FFS and HMO performance on 11 summary scales measuring 7 defining characteristics of primary care: (1) access, (2) continuity, (3) integration, (4) comprehensiveness, (5) "whole-person" orientation, (6) clinical interaction, and (7) sustained clinician-patient partnership. For 9 of 11 indicators, performance favored traditional FFS Medicare over HMOs (P<.001). Financial access favored HMOs (P<.001). Preventive counseling did not differ by system. Network-model HMOs performed more favorably than staff/group-model HMOs on 9 of 11 indicators (P<.001). Few differences were associated with HMO profit status. The findings are consistent with previous comparisons of indemnity insurance and network-model and staff/group-model HMOs in elderly and nonelderly populations. The stability of results across time, geography, and populations suggests that the relative strengths and weaknesses of each system are enduring attributes of their care. Medicare enrollees seem to face the perennial cost-quality trade-off: that is, deciding whether the advantages of primary care under traditional FFS Medicare are worth the higher out-of-pocket costs.

The FiCTION dental trial protocol – filling children’s teeth: indicated or not?

PubMed Central

2013-01-01

Background There is a lack of evidence for effective management of dental caries (decay) in children’s primary (baby) teeth and an apparent failure of conventional dental restorations (fillings) to prevent dental pain and infection for UK children in Primary Care. UK dental schools’ teaching has been based on British Society of Paediatric Dentistry guidance which recommends that caries in primary teeth should be removed and a restoration placed. However, the evidence base for this is limited in volume and quality, and comes from studies conducted in either secondary care or specialist practices. Restorations provided in specialist environments can be effective but the generalisability of this evidence to Primary Care has been questioned. The FiCTION trial addresses the Health Technology Assessment (HTA) Programme’s commissioning brief and research question “What is the clinical and cost effectiveness of restoration caries in primary teeth, compared to no treatment?” It compares conventional restorations with an intermediate treatment strategy based on the biological (sealing-in) management of caries and with no restorations. Methods/Design This is a Primary Care-based multi-centre, three-arm, parallel group, patient-randomised controlled trial. Practitioners are recruiting 1461 children, (3–7 years) with at least one primary molar tooth where caries extends into dentine. Children are randomized and treated according to one of three treatment approaches; conventional caries management with best practice prevention, biological management of caries with best practice prevention or best practice prevention alone. Baseline measures and outcome data (at review/treatment during three year follow-up) are assessed through direct reporting, clinical examination including blinded radiograph assessment, and child/parent questionnaires. The primary outcome measure is the incidence of either pain or infection related to dental caries. Secondary outcomes are; incidence of caries in primary and permanent teeth, patient quality of life, cost-effectiveness, acceptability of treatment strategies to patients and parents and their experiences, and dentists’ preferences. Discussion FiCTION will provide evidence for the most clinically-effective and cost-effective approach to managing caries in children’s primary teeth in Primary Care. This will support general dental practitioners in treatment decision making for child patients to minimize pain and infection in primary teeth. The trial is currently recruiting patients. Trial registration Protocol ID: NCTU: ISRCTN77044005 PMID:23725316

The FiCTION dental trial protocol - filling children's teeth: indicated or not?

PubMed

Innes, Nicola P T; Clarkson, Jan E; Speed, Chris; Douglas, Gail V A; Maguire, Anne

2013-06-01

There is a lack of evidence for effective management of dental caries (decay) in children's primary (baby) teeth and an apparent failure of conventional dental restorations (fillings) to prevent dental pain and infection for UK children in Primary Care. UK dental schools' teaching has been based on British Society of Paediatric Dentistry guidance which recommends that caries in primary teeth should be removed and a restoration placed. However, the evidence base for this is limited in volume and quality, and comes from studies conducted in either secondary care or specialist practices. Restorations provided in specialist environments can be effective but the generalisability of this evidence to Primary Care has been questioned. The FiCTION trial addresses the Health Technology Assessment (HTA) Programme’s commissioning brief and research question “What is the clinical and cost effectiveness of restoration caries in primary teeth, compared to no treatment?” It compares conventional restorations with an intermediate treatment strategy based on the biological (sealing-in) management of caries and with no restorations. This is a Primary Care-based multi-centre, three-arm, parallel group, patient-randomised controlled trial. Practitioners are recruiting 1461 children, (3-7 years) with at least one primary molar tooth where caries extends into dentine. Children are randomized and treated according to one of three treatment approaches; conventional caries management with best practice prevention, biological management of caries with best practice prevention or best practice prevention alone. Baseline measures and outcome data (at review/treatment during three year follow-up) are assessed through direct reporting, clinical examination including blinded radiograph assessment, and child/parent questionnaires. The primary outcome measure is the incidence of either pain or infection related to dental caries. Secondary outcomes are; incidence of caries in primary and permanent teeth, patient quality of life, cost-effectiveness, acceptability of treatment strategies to patients and parents and their experiences, and dentists’ preferences. FiCTION will provide evidence for the most clinically-effective and cost-effective approach to managing caries in children's primary teeth in Primary Care. This will support general dental practitioners in treatment decision making for child patients to minimize pain and infection in primary teeth. The trial is currently recruiting patients. Protocol ID: NCTU: ISRCTN77044005.

Does caregiver participation in decision making within child welfare agencies influence children's primary and mental health care service use?

PubMed

Jolles, M P; Wells, R

2017-03-01

Many children in contact with child welfare agencies do not receive needed health services. These agencies have used participatory decision making (PDM) practices as a way to increase families' use of recommended services. However, we lack evidence of whether caregiver participation in PDM increases children's use of health services. This study uses a national sample of children involved with child welfare to compare their health service use between those children serve through a PDM practice and those who did not experience it. Cross-sectional analyses using the 2009-2010 National Survey of Child and Adolescent Well-Being. Propensity score analysis accounted for observed selection bias. PDM practice was measured as whether the caregiver was included in decision-making during service planning meetings. Health service use was measured as child's receipt of any primary or mental health care services in the past year. Primary health care need was measured using standardized measures and caseworker report. The sample was comprised of children ages 2-17 with primary or mental health needs in contact with a child welfare agency. In the unmatched sample of 1,358 children, 14% were served through a PDM service practice, and 12% had a primary health care and 37% a mental health need. Families served through PDM were also reported by caseworkers as more cooperative during the child welfare investigation, and with fewer reports of domestic violence and agency re-referrals (P < 0.05). Analyses using matched samples showed that for primary health care, 59% of PDM children received services compared with 40% for non-PDM children (P = 0.004). Group differences were not significant for mental health services. Lower-risk families were more likely to be served through PDM which was positively associated with child use of primary health services. Inclusion of caregivers in decision making may not be sufficient to overcome barriers to children's mental health service use. © 2016 John Wiley & Sons Ltd.

Mental health treatment outcomes in a humanitarian emergency: a pilot model for the integration of mental health into primary care in Habilla, Darfur.

PubMed

Souza, Renato; Yasuda, Silvia; Cristofani, Susanna

2009-07-21

There is no description of outcomes for patients receiving treatment for mental illnesses in humanitarian emergencies. MSF has developed a model for integration of mental health into primary care in a humanitarian emergency setting based on the capacity of community health workers, clinical officers and health counsellors under the supervision of a psychiatrist trainer. Our study aims to describe the characteristics of patients first attending mental health services and their outcomes on functionality after treatment. A total of 114 patients received mental health care and 81 adult patients were evaluated with a simplified functionality assessment instrument at baseline, one month and 3 months after initiation of treatment. Most patients were diagnosed with epilepsy (47%) and psychosis (31%) and had never received treatment. In terms of follow up, 58% came for consultations at 1 month and 48% at 3 months. When comparing disability levels at baseline versus 1 month, mean disability score decreased from 9.1 (95%CI 8.1-10.2) to 7.1 (95%CI 5.9-8.2) p = 0.0001. At 1 month versus 3 months, mean score further decreased to 5.8 (95%CI 4.6-7.0) p < 0.0001. The findings suggest that there is potential to integrate mental health into primary care in humanitarian emergency contexts. Patients with severe mental illness and epilepsy are in particular need of mental health care. Different strategies for integration of mental health into primary care in humanitarian emergency settings need to be compared in terms of simplicity and feasibility.

Caregiver education to promote appropriate use of preventive asthma medications: what is happening in primary care?

PubMed

Frey, Sean M; Fagnano, Maria; Halterman, Jill S

2016-01-01

To describe actions taken by providers at primary care visits to promote daily use of preventive asthma medication, and determine whether patient or encounter variables are associated with the receipt of asthma medication education. As part of a larger study in Rochester, NY, caregivers of children (2-12 years old) with asthma were approached before an office visit for well-child, asthma-specific or other illness care from October 2009 to January 2013. Eligibility required persistent symptoms and a prescription for an inhaled asthma controller medication. Caregivers were interviewed within two weeks to discuss the health care encounter. We identified 185 eligible children from six urban primary care offices (27% Black, 38% Hispanic, 65% Medicaid). Overall, 42% of caregivers reported a discussion of appropriate preventive medication use, fewer than 25% received an asthma action plan, and 17% reported "ideal" medication education (both discussing proper medication use and completing an asthma action plan); no differences were seen upon comparing well-child and asthma-specific visits with other visits. Well-child and asthma-specific visits together were more likely, compared with other visits, to include a recommendation for a follow-up visit (43% versus 23%, p = 0.007). No patient factors were associated with report of preventive medication education. Guideline-recommended education for caregivers about preventive-asthma medication is not occurring in the majority of primary care visits for urban children with symptomatic persistent asthma. Novel methods to deliver asthma education may be needed to promote appropriate preventive medication use and reduce asthma morbidity.

Improving dementia diagnosis and management in primary care: a cohort study of the impact of a training and support program on physician competency, practice patterns, and community linkages.

PubMed

Lathren, Christine R; Sloane, Philip D; Hoyle, Joseph D; Zimmerman, Sheryl; Kaufer, Daniel I

2013-12-10

Primary care physicians routinely provide dementia care, but may lack the clinical skills and awareness of available resources to provide optimal care. We conducted a community-based pilot dementia training intervention designed to both improve clinical competency and increase utilization of local dementia care services. Physicians (N = 29) and affiliated staff (N = 24) participated in a one-day training program on dementia screening, diagnosis and management that included direct engagement with local support service providers. Questionnaires about their dementia care competency and referral patterns were completed before and 6 months after the training intervention. Physicians reported significantly higher overall confidence in their dementia care competency 6 months post-training compared to pre-training. The largest reported improvements were in their ability to educate patients and caregivers about dementia and making appropriate referrals to community care services. Participants also reported markedly increased use of cognitive screening tools in providing care. Community service providers recorded approximately 160 physician-initiated referrals over a 2 year-period post-training, compared to few beforehand. Combining a targeted physician practice-based educational intervention with community service engagement improves dementia care competency in clinicians and promotes linkages between clinical and community dementia care providers.

Characteristics and Service Use of Medicare Beneficiaries Using Federally Qualified Health Centers.

PubMed

Chang, Chiang-Hua; Lewis, Valerie A; Meara, Ellen; Lurie, Jon D; Bynum, Julie P W

2016-08-01

Federally Qualified Health Centers (FQHCs) provide primary care for millions of Americans, but little is known about Medicare beneficiaries who use FQHCs. To compare patient characteristics and health care service use among Medicare beneficiaries stratified by FQHC use. Cross-sectional analysis of 2011 Medicare fee-for-service beneficiaries aged 65 years and older. Subjects included beneficiaries with at least 1 evaluation and management (E&M) visit in 2011, categorized as FQHC users (≥1 E&M visit to FQHCs) or nonusers living in the same primary care service areas as FQHC users. Users were subclassified as predominant if the majority of their E&M visits were to FQHCs. Demographic characteristics, physician visits, and inpatient care use. Most FQHC users (56.6%) were predominant users. Predominant and nonpredominant users, compared with nonusers, markedly differed by prevalence of multiple chronic conditions (18.2%, 31.7% vs. 22.7%) and annual mortality (2.8%, 3.8% vs. 4.0%; all P<0.05). In adjusted analyses (reference: nonusers), predominant users had fewer physician visits (RR=0.81; 95% CI, 0.81-0.81) and fewer hospitalizations (RR=0.84; 95% CI, 0.84-0.85), whereas nonpredominant users had higher use of both types of service (RR=1.18, 95% CI, 1.18-1.18; RR=1.09, 95% CI, 1.08-1.10, respectively). Even controlling for primary care delivery markets, nonpredominant FQHC users had a higher burden of chronic illness and service use than predominant FQHC users. It will be important to monitor Medicare beneficiaries using FQHCs to understand whether primary care only payment incentives for FQHCs could induce fragmented care.

Detecting recurrent major depressive disorder within primary care rapidly and reliably using short questionnaire measures.

PubMed

Thapar, Ajay; Hammerton, Gemma; Collishaw, Stephan; Potter, Robert; Rice, Frances; Harold, Gordon; Craddock, Nicholas; Thapar, Anita; Smith, Daniel J

2014-01-01

Major depressive disorder (MDD) is often a chronic disorder with relapses usually detected and managed in primary care using a validated depression symptom questionnaire. However, for individuals with recurrent depression the choice of which questionnaire to use and whether a shorter measure could suffice is not established. To compare the nine-item Patient Health Questionnaire (PHQ-9), the Beck Depression Inventory, and the Hospital Anxiety and Depression Scale against shorter PHQ-derived measures for detecting episodes of DSM-IV major depression in primary care patients with recurrent MDD. Diagnostic accuracy study of adults with recurrent depression in primary care predominantly from Wales Scores on each of the depression questionnaire measures were compared with the results of a semi-structured clinical diagnostic interview using Receiver Operating Characteristic curve analysis for 337 adults with recurrent MDD. Concurrent questionnaire and interview data were available for 272 participants. The one-month prevalence rate of depression was 22.2%. The area under the curve (AUC) and positive predictive value (PPV) at the derived optimal cut-off value for the three longer questionnaires were comparable (AUC = 0.86-0.90, PPV = 49.4-58.4%) but the AUC for the PHQ-9 was significantly greater than for the PHQ-2. However, by supplementing the PHQ-2 score with items on problems concentrating and feeling slowed down or restless, the AUC (0.91) and the PPV (55.3%) were comparable with those for the PHQ-9. A novel four-item PHQ-based questionnaire measure of depression performs equivalently to three longer depression questionnaires in identifying depression relapse in patients with recurrent MDD.

Infection biomarkers in primary care patients with acute respiratory tract infections-comparison of Procalcitonin and C-reactive protein.

PubMed

Meili, Marc; Kutz, Alexander; Briel, Matthias; Christ-Crain, Mirjam; Bucher, Heiner C; Mueller, Beat; Schuetz, Philipp

2016-03-24

There is a lack of studies comparing the utility of C-reactive protein (CRP) with Procalcitonin (PCT) for the management of patients with acute respiratory tract infections (ARI) in primary care. Our aim was to study the correlation between these markers and to compare their predictive accuracy in regard to clinical outcome prediction. This is a secondary analysis using clinical and biomarker data of 458 primary care patients with pneumonic and non-pneumonic ARI. We used correlation statistics (spearman's rank test) and multivariable regression models to assess association of markers with adverse outcome, namely days with restricted activities and persistence of discomfort from infection at day 14. At baseline, CRP and PCT did not correlate well in the overall population (r(2) = 0.16) and particularly in the subgroup of patients with non-pneumonic ARI (r(2) = 0.08). Low correlation of biomarkers were also found when comparing cut-off ranges, day seven levels or changes from baseline to day seven. High baseline levels of CRP (>100 mg/dL, regression coefficient 1.6, 95 % CI 0.5 to 2.6, sociodemographic-adjusted model) as well as PCT (>0.5ug/L regression coefficient 2.0, 95 % CI 0.0 to 4.0, sociodemographic-adjusted model) were significantly associated with larger number of days with restricted activities. There were no associations of either biomarker with persistence of discomfort at day 14. CRP and PCT levels do not well correlate, but both have moderate prognostic accuracy in primary care patients with ARI to predict clinical outcomes. The low correlation between the two biomarkers calls for interventional research comparing these markers head to head in regard to their ability to guide antibiotic decisions. Current Controlled Trials, ISRCTN73182671.

[Comparing case management care models for people with dementia and their caregivers: the design of the COMPAS study].

PubMed

van Hout, H P J; Macneil Vroomen, J L; Van Mierlo, L D; Meiland, F J M; Moll van Charante, E P; Joling, K J; van den Dungen, P; Dröes, R M; van der Horst, H E; de Rooij, S E J A

2014-04-01

Dementia care in The Netherlands is shifting from fragmented, ad hoc care to more coordinated and personalized care. Case management contributes to this shift. The linkage model and a combination of intensive case management and joint agency care models were selected based on their emerging prominence in The Netherlands. It is unclear if these different forms of case management are more effective than usual care in improving or preserving the functioning and well-being at the patient and caregiver level and at the societal cost. The objective of this article is to describe the design of a study comparing these two case management care models against usual care. Clinical and cost outcomes are investigated while care processes and the facilitators and barriers for implementation of these models are considered. Mixed methods include a prospective, observational, controlled, cohort study among persons with dementia and their primary informal caregiver in regions of The Netherlands with and without case management including a qualitative process evaluation. Community-dwelling individuals with a dementia diagnosis with an informal caregiver are included. The primary outcome measure is the Neuropsychiatric Inventory for the people with dementia and the General Health Questionnaire for their caregivers. Costs are measured from a societal perspective. Semi-structured interviews with stakeholders based on the theoretical model of adaptive implementation are planned. 521 pairs of persons with dementia and their primary informal caregiver were included and are followed over two years. In the linked model substantially more impeding factors for implementation were identified compared with the model. This article describes the design of an evaluation study of two case management models along with clinical and economic data from persons with dementia and caregivers. The impeding and facilitating factors differed substantially between the two models. Further results on cost-effectiveness are expected by the beginning of 2015. This is a Dutch adaptation of MacNeil Vroomen et al., Comparing Dutch case management care models for people with dementia and their caregivers: The design of the COMPAS study.

DIABETES, DEPRESSION, AND DEATH: A RANDOMIZED CONTROLLED TRIAL OF A DEPRESSION TREATMENT PROGRAM FOR OLDER ADULTS BASED IN PRIMARY CARE (PROSPECT)

PubMed Central

Bogner, Hillary R; Morales, Knashawn H; Post, Edward P; Bruce, Martha L

2009-01-01

OBJECTIVE Our a priori hypothesis was that depressed patients with diabetes in practices implementing a depression management program would have a decreased risk of mortality compared to depressed patients with diabetes in usual care practices. RESEARCH DESIGN AND METHODS Multi-site practice-randomized controlled trial PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) with patient recruitment from 5/99-8/01 and supplemented with a search of the National Death Index. Twenty primary care practices participated from New York City, Philadelphia, and Pittsburgh. In all, 584 participants who were identified though a two-stage, age-stratified (60-74; 75+) depression screening of randomly sampled patients and were classified as depressed with complete information on diabetes status are included in these analyses. Of all the 584 participants, 123 (21.2%) reported a history of diabetes. A depression care manager worked with primary care physicians to provide algorithm-based care. Vital status was assessed at 5 years. RESULTS After a median follow-up of 52.0 months, 110 depressed patients had died. Depressed patients with diabetes in the Intervention Condition were less likely to have died during the 5-year follow-up interval than were depressed persons with diabetes in Usual Care after accounting for baseline differences among patients (adjusted hazard ratio 0.49, 95% CI [0.24, 0.98]). CONCLUSIONS Older depressed primary care patients with diabetes in practices implementing depression care management were less likely to die over the course of a 5-year interval than were depressed patients with diabetes in usual care practices. PMID:17717284

The effect of a nurse-led telephone-based care coordination program on the follow-up and control of cardiovascular risk factors in patients with coronary artery disease.

PubMed

Wong, Ningyan; Chua, Siang Jin Terrance; Gao, Fei; Sim, Sok Tiang Rosalind; Matchar, David; Wong, Sung Lung Aaron; Yeo, Khung Keong; Tan, Wei Chieh Jack; Chin, Chee Tang

2016-12-01

We sought to analyse the impact of a care coordination protocol on transiting patients with coronary artery disease who had undergone percutaneous coronary intervention (PCI) to primary care and its effect on cardiovascular risk factor control. A prospective observational study involving 492 patients who had undergone PCI either electively or after an acute coronary syndrome. A tertiary institution in Singapore. Patients who had undergone a PCI either electively or after an acute coronary syndrome. The SCORE (Standardized Care for Optimal Outcomes, Right-Siting and Rapid Re-evaluation) program was a nurse-led, telephone-based, care coordination protocol. Transition to primary care within 1 year of enrolment, the achievement of low-density lipoprotein (LDL) level of <2.6 mmol/l within 1 year and hospital admissions related to cardiovascular causes within 1 year were studied. Under the SCORE protocol, a significantly higher number of patients transited to primary care and achieved the LDL target within 1 year, as compared with non-SCORE patients. Discharge to primary care and achievement of target LDL continued to be higher among those under the SCORE protocol even after multivariate analysis. Rates of hospital admission due to cardiovascular causes were not significantly different. Care coordination improved the rate of transition of post-PCI patients to primary care and improved LDL control, with no difference in the rate of hospital admissions due to cardiovascular causes. These findings support the implementation of a standardized follow-up protocol in patients who have undergone PCI. © 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

Interdisciplinary team-based care for patients with chronic pain on long-term opioid treatment in primary care (PPACT) - Protocol for a pragmatic cluster randomized trial.

PubMed

DeBar, Lynn; Benes, Lindsay; Bonifay, Allison; Deyo, Richard A; Elder, Charles R; Keefe, Francis J; Leo, Michael C; McMullen, Carmit; Mayhew, Meghan; Owen-Smith, Ashli; Smith, David H; Trinacty, Connie M; Vollmer, William M

2018-04-01

Chronic pain is one of the most common, disabling, and expensive public health problems in the United States. Interdisciplinary pain management treatments that employ behavioral approaches have been successful in helping patients with chronic pain reduce symptoms and regain functioning. However, most patients lack access to such treatments. We are conducting a pragmatic clinical trial to test the hypothesis that patients who receive an interdisciplinary biopsychosocial intervention, the Pain Program for Active Coping and Training (PPACT), at their primary care clinic will have a greater reduction in pain impact in the year following than patients receiving usual care. This is an effectiveness-implementation hybrid pragmatic clinical trial in which we randomize clusters of primary care providers and their patients with chronic pain who are on long-term opioid therapy to 1) receive an interdisciplinary behavioral intervention in conjunction with their current health care or 2) continue with current health care services. Our primary outcome is pain impact (a composite of pain intensity and pain-related interference) measured using the PEG, a validated three-item assessment. Secondary outcomes include pain-related disability, patient satisfaction, opioids dispensed and health care utilization. An economic evaluation assesses the resources and costs necessary to deliver the intervention and its cost-effectiveness compared with usual care. A formative evaluation employs mixed methods to understand the context for implementation in the participating health care systems. This trial will inform the feasibility of implementing interdisciplinary behavioral approaches to pain management in the primary care setting, potentially providing a more effective, safer, and more satisfactory alternative to opioid-based chronic pain treatment. Clinical Trials Registration Number: NCT02113592. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Interdisciplinary team-based care for patients with chronic pain on long-term opioid treatment in primary care (PPACT) – Protocol for a pragmatic cluster randomized trial

PubMed Central

DeBar, Lynn; Benes, Lindsay; Bonifay, Allison; Deyo, Richard A.; Elder, Charles R.; Keefe, Francis J.; Leo, Michael C.; McMullen, Carmit; Mayhew, Meghan; Owen-Smith, Ashli; Smith, David H.; Trinacty, Connie M.; Vollmer, William M.

2018-01-01

Background Chronic pain is one of the most common, disabling, and expensive public health problems in the United States. Interdisciplinary pain management treatments that employ behavioral approaches have been successful in helping patients with chronic pain reduce symptoms and regain functioning. However, most patients lack access to such treatments. We are conducting a pragmatic clinical trial to test the hypothesis that patients who receive an interdisciplinary biopsychosocial intervention, the Pain Program for Active Coping and Training (PPACT), at their primary care clinic will have a greater reduction in pain impact in the year following than patients receiving usual care. Methods/design This is an effectiveness-implementation hybrid pragmatic clinical trial in which we randomize clusters of primary care providers and their patients with chronic pain who are on long-term opioid therapy to 1) receive an interdisciplinary behavioral intervention in conjunction with their current health care or 2) continue with current health care services. Our primary outcome is pain impact (a composite of pain intensity and pain-related interference) measured using the PEG, a validated three-item assessment. Secondary outcomes include pain-related disability, patient satisfaction, opioids dispensed and health care utilization. An economic evaluation assesses the resources and costs necessary to deliver the intervention and its cost-effectiveness compared with usual care. A formative evaluation employs mixed methods to understand the context for implementation in the participating health care systems. Discussion This trial will inform the feasibility of implementing interdisciplinary behavioral approaches to pain management in the primary care setting, potentially providing a more effective, safer, and more satisfactory alternative to opioid-based chronic pain treatment. Clinical Trials Registration Number: NCT02113592 PMID:29522897

Impact of Interventions to Increase the Proportion of Medical Students Choosing a Primary Care Career: A Systematic Review.

PubMed

Pfarrwaller, Eva; Sommer, Johanna; Chung, Christopher; Maisonneuve, Hubert; Nendaz, Mathieu; Junod Perron, Noëlle; Haller, Dagmar M

2015-09-01

Increasing the attractiveness of primary care careers is a key step in addressing the growing shortage of primary care physicians. The purpose of this review was to (1) identify interventions aimed at increasing the proportion of undergraduate medical students choosing a primary care specialty, (2) describe the characteristics of these interventions, (3) assess the quality of the studies, and (4) compare the findings to those of a previous literature review within a global context. We searched MEDLINE, EMBASE, ERIC, CINAHL, PsycINFO, The Cochrane Library, and Dissertations & Theses A&I for articles published between 1993 and February 20, 2015. We included quantitative and qualitative studies reporting on primary care specialty choice outcomes of interventions in the undergraduate medical curriculum, without geographic restrictions. Data extracted included study characteristics, intervention details, and relevant outcomes. Studies were assessed for quality and strength of findings using a five-point scale. The review included 72 articles reporting on 66 different interventions. Longitudinal programs were the only intervention consistently associated with an increased proportion of students choosing primary care. Successful interventions were characterized by diverse teaching formats, student selection, and good-quality teaching. Study quality had not improved since recommendations were published in 1995. Many studies used cross-sectional designs and non-validated surveys, did not include control groups, and were not based on a theory or conceptual framework. Our review supports the value of longitudinal, multifaceted, primary care programs to increase the proportion of students choosing primary care specialties. Isolated modules or clerkships did not appear to be effective. Our results are in line with the conclusions from previous reviews and add an international perspective, but the evidence is limited by the overall low methodological quality of the included studies. Future research should use more rigorous evaluation methods and include long-term outcomes.

VA health service utilization for homeless and low-income Veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles.

PubMed

Gabrielian, Sonya; Yuan, Anita H; Andersen, Ronald M; Rubenstein, Lisa V; Gelberg, Lillian

2014-05-01

The US Department of Housing and Urban Development (HUD)-VA Supportive Housing (VASH) program-the VA's Housing First effort-is central to efforts to end Veteran homelessness. Yet, little is known about health care utilization patterns associated with achieving HUD-VASH housing. We compare health service utilization at the VA Greater Los Angeles among: (1) formerly homeless Veterans housed through HUD-VASH (HUD-VASH Veterans); (2) currently homeless Veterans; (3) housed, low-income Veterans not in HUD-VASH; and (4) housed, not low-income Veterans. We performed a secondary database analysis of Veterans (n=62,459) who received VA Greater Los Angeles care between October 1, 2010 and September 30, 2011. We described medical/surgical and mental health utilization [inpatient, outpatient, and emergency department (ED)]. We controlled for demographics, need, and primary care use in regression analyses of utilization data by housing and income status. HUD-VASH Veterans had more inpatient, outpatient, and ED use than currently homeless Veterans. Adjusting for demographics and need, HUD-VASH Veterans and the low-income housed Veterans had similar likelihoods of medical/surgical inpatient and outpatient utilization, compared with the housed, not low-income group. Adjusting first for demographics and need (model 1), then also for primary care use (model 2), HUD-VASH Veterans had the greatest decrease in incident rates of specialty medical/surgical, mental health, and ED care from models 1 to 2, becoming similar to the currently homeless, compared with the housed, not low-income group. Our findings suggest that currently homeless Veterans underuse health care relative to housed Veterans. HUD-VASH may address this disparity by providing housing and linkages to primary care.

VA Health Service Utilization for Homeless and Low-income Veterans

PubMed Central

Gabrielian, Sonya; Yuan, Anita H.; Andersen, Ronald M.; Rubenstein, Lisa V.; Gelberg, Lillian

2016-01-01

Background The US Department of Housing and Urban Development (HUD)-VA Supportive Housing (VASH) program—the VA’s Housing First effort—is central to efforts to end Veteran homelessness. Yet, little is known about health care utilization patterns associated with achieving HUD-VASH housing. Objectives We compare health service utilization at the VA Greater Los Angeles among: (1) formerly homeless Veterans housed through HUD-VASH (HUD-VASH Veterans); (2) currently homeless Veterans; (3) housed, low-income Veterans not in HUD-VASH; and (4) housed, not low-income Veterans. Research Design We performed a secondary database analysis of Veterans (n = 62,459) who received VA Greater Los Angeles care between October 1, 2010 and September 30, 2011. We described medical/surgical and mental health utilization [inpatient, outpatient, and emergency department (ED)]. We controlled for demographics, need, and primary care use in regression analyses of utilization data by housing and income status. Results HUD-VASH Veterans had more inpatient, outpatient, and ED use than currently homeless Veterans. Adjusting for demographics and need, HUD-VASH Veterans and the low-income housed Veterans had similar likelihoods of medical/surgical inpatient and outpatient utilization, compared with the housed, not low-income group. Adjusting first for demographics and need (model 1), then also for primary care use (model 2), HUD-VASH Veterans had the greatest decrease in incident rates of specialty medical/surgical, mental health, and ED care from models 1 to 2, becoming similar to the currently homeless, compared with the housed, not low-income group. Conclusions Our findings suggest that currently homeless Veterans underuse health care relative to housed Veterans. HUD-VASH may address this disparity by providing housing and linkages to primary care. PMID:24714583

Validating office-based screening for psychosocial strengths and difficulties among youths in foster care.

PubMed

Jee, Sandra H; Szilagyi, Moira; Conn, Anne-Marie; Nilsen, Wendy; Toth, Sheree; Baldwin, Constance D; Szilagyi, Peter G

2011-05-01

To assess the effectiveness of social-emotional screening in the primary care setting for youths in foster care. The setting was a primary care practice for all youth in home-based foster care in 1 county. Subjects were youths, aged 11 to 17 years, and their foster parents; both completed a Strengths and Difficulties Questionnaire at well-child visits. The Strengths and Difficulties Questionnaire is a previously validated 25-item tool that has 5 domains: emotional symptoms; conduct problems; hyperactivity/inattention; peer problems; and prosocial behaviors and an overall total difficulties score. We first compared youth versus parent Strengths and Difficulties Questionnaire scores and then assessed the accuracy of these Strengths and Difficulties Questionnaire scores by comparing them in a subsample of youths (n = 50) with results of home-based structured clinical interviews using the Children's Interview for Psychiatric Syndromes. Of 138 subjects with both youth and parent reports, 78% had prosocial behaviors (strengths), and 70% had 1 or more social-emotional problems. Parents reported significantly more conduct problems (38% vs 16%; P < .0001) and total difficulties (30% vs 16%; P = .002) than did youth. The Strengths and Difficulties Questionnaire had better agreement with the Children's Interview for Psychiatric Syndromes (n = 50) for any Strengths and Difficulties Questionnaire-identified problem for combined youth and foster-parent reports (93%), compared with youth report alone (54%) or parent report alone (71%). Although most youths in foster care have social-emotional problems, most have strengths as well. Youth and foster-parent perspectives on these problems differ. Systematic social-emotional screening in primary care that includes both youth and parent reports can identify youths who may benefit from services.

Evaluation of a combined lifestyle intervention for overweight and obese patients in primary health care: a quasi-experimental design.

PubMed

Verberne, Lisa D M; Hendriks, Marike R C; Rutten, Geert M; Spronk, Inge; Savelberg, Hans H C M; Veenhof, Cindy; Nielen, Mark M J

2016-12-01

Combined lifestyle interventions (CLIs) are designed to reduce risk factors for lifestyle-related diseases through increasing physical activity and improvement of dietary behaviour. To evaluate the effects of a CLI for overweight and obese patients on lifestyle-related risk factors and health care consumption, in comparison to usual care. Data on anthropometric and metabolic measurements, morbidity, drugs prescriptions and general practitioner (GP) consultations were extracted from electronic health records (timeframe: July 2009-August 2013). Using a quasi-experimental design, health outcomes of 127 patients who participated in a 1-year CLI were compared to a group of 254 matched patients that received usual care. Baseline to post-intervention changes in health outcomes between intervention and comparison group were evaluated using mixed model analyses. Compared to baseline, both groups showed reductions in body mass index (BMI), blood pressure, total cholesterol and low density lipoprotein cholesterol in year post-intervention. For these outcome measures, no significant differences in changes were observed between intervention and comparison group. A significant improvement of 0.08 mmol/l in high density lipoprotein (HDL) cholesterol was observed for the intervention group above the comparison group (P < 0.01). No significant intergroup differences were shown in drugs prescriptions and number of GP consultations. A CLI for overweight and obese patients in primary health care resulted in similar effects on health outcomes compared to usual care. Only an improvement on HDL cholesterol was shown. This study indicates that implementation and evaluation of a lifestyle intervention in primary health care is challenging due to political and financial barriers. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Providers' preferences for pediatric oral health information in the electronic health record: a cross-sectional survey.

PubMed

Shea, Christopher M; Turner, Kea; White, B Alex; Zhu, Ye; Rozier, R Gary

2018-01-11

The majority of primary care physicians support integration of children's oral health promotion and disease prevention into their practices but can experience challenges integrating oral health services into their workflow. Most electronic health records (EHRs) in primary care settings do not include oral health information for pediatric patients. Therefore, it is important to understand providers' preferences for oral health information within the EHR. The objectives of this study are to assess (1) the relative importance of various elements of pediatric oral health information for primary care providers to have in the EHR and (2) the extent to which practice and provider characteristics are associated with these information preferences. We surveyed a sample of primary care physicians who conducted Medicaid well-child visits in North Carolina from August - December 2013. Using descriptive statistics, we analyzed primary care physicians' oral health information preferences relative to their information preferences for traditional preventive aspects of well-child visits. Furthermore, we analyzed associations between oral health information preferences and provider- and practice-level characteristics using an ordinary least squares regression model. Fewer primary care providers reported that pediatric oral health information is "very important," as compared to more traditional elements of primary care information, such as tracking immunizations. However, the majority of respondents reported some elements of oral health information as being very important. Also, we found positive associations between the percentage of well child visits in which oral health screenings and oral health referrals are performed and the reported importance of having pediatric oral health information in the EHR. Incorporating oral health information into the EHR may be desirable for providers, particularly those who perform oral health screenings and dental referrals.

Improving family medicine resident training in dementia care: an experiential learning opportunity in Primary Care Collaborative Memory Clinics.

PubMed

Lee, Linda; Weston, W Wayne; Hillier, Loretta; Archibald, Douglas; Lee, Joseph

2018-06-21

Family physicians often find themselves inadequately prepared to manage dementia. This article describes the curriculum for a resident training intervention in Primary Care Collaborative Memory Clinics (PCCMC), outlines its underlying educational principles, and examines its impact on residents' ability to provide dementia care. PCCMCs are family physician-led interprofessional clinic teams that provide evidence-informed comprehensive assessment and management of memory concerns. Within PCCMCs residents learn to apply a structured approach to assessment, diagnosis, and management; training consists of a tutorial covering various topics related to dementia followed by work-based learning within the clinic. Significantly more residents who trained in PCCMCs (sample = 98), as compared to those in usual training programs (sample = 35), reported positive changes in knowledge, ability, and confidence in ability to assess and manage memory problems. The PCCMC training intervention for family medicine residents provides a significant opportunity for residents to learn about best clinical practices and interprofessional care needed for optimal dementia care integrated within primary care practice.

Resource allocation and organisational features in Swedish primary diabetes care: Changes from 2006 to 2013.

PubMed

Husdal, Rebecka; Rosenblad, Andreas; Leksell, Janeth; Eliasson, Björn; Jansson, Stefan; Jerdén, Lars; Stålhammar, Jan; Steen, Lars; Wallman, Thorne; Adolfsson, Eva Thors

2017-02-01

To compare the resource allocation and organisational features in Swedish primary diabetes care for patients with type 2 diabetes mellitus (T2DM) between 2006 and 2013. Using a repeated cross-sectional study design, questionnaires covering personnel resources and organisational features for patients with T2DM in 2006 and 2013 were sent to all Swedish primary health care centres (PHCCs) during the following year. In total, 684 (74.3%) PHCCs responded in 2006 and 880 (76.4%) in 2013. Compared with 2006, the median list size had decreased in 2013 (p<0.001), whereas the median number of listed patients with T2DM had increased (p<0.001). Time devoted to patients with T2DM and diabetes-specific education levels for registered nurses (RNs) had increased, and more PHCCs had in-house psychologists (all p<0.001). The use of follow-up systems and medical check-ups had increased (all p<0.05). Individual counselling was more often based on patients' needs, while arrangement of group-based education remained low. Patient participation in setting treatment targets mainly remained low. Even though the diabetes-specific educational level among RNs increased, the arrangement of group-based education and patient participation in setting treatment targets remained low. These results are of concern and should be prioritised as key features in the care of patients with T2DM. Copyright © 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

A protocol for a trial of homeopathic treatment for irritable bowel syndrome

PubMed Central

2012-01-01

Background Irritable bowel syndrome is a chronic condition with no known cure. Many sufferers seek complementary and alternative medicine including homeopathic treatment. However there is much controversy as to the effectiveness of homeopathic treatment. This three-armed study seeks to explore the effectiveness of individualised homeopathic treatment plus usual care compared to both an attention control plus usual care and usual care alone, for patients with irritable bowel syndrome. Methods/design This is a three-armed pragmatic randomised controlled trial using the cohort multiple randomised trial methodology. Patients are recruited to an irritable bowel syndrome cohort from primary and secondary care using GP databases and consultants lists respectively. From this cohort patients are randomly selected to be offered, 5 sessions of homeopathic treatment plus usual care, 5 sessions of supportive listening plus usual care or usual care alone. The primary clinical outcome is the Irritable Bowel Syndrome Symptom Severity at 26 weeks. From a power calculation, it is estimated that 33 people will be needed for the homeopathic treatment arm and 132 for the usual care arm, to detect a minimal clinical difference at 80 percent power and 5 percent significance allowing for loss to follow up. An unequal group size has been used for reasons of cost. Analysis will be by intention to treat and will compare homeopathic treatment with usual care at 26 weeks as the primary analysis, and homeopathic treatment with supportive listening as an additional analysis. Discussion This trial has received NHS approval and results are expected in 2013. Trial registration Current Controlled Trials ISRCTN90651143 PMID:23131064

Managing Depression Among Homeless Mothers: Pilot Testing an Adapted Collaborative Care Intervention.

PubMed

Weinreb, Linda; Upshur, Carole C; Fletcher-Blake, Debbian; Reed, George; Frisard, Christine

2016-01-01

Although depression is common among homeless mothers, little progress has been made in testing treatment strategies for this group. We describe pilot test results of an adapted collaborative care model for homeless mothers with depression. We conducted a pilot intervention study of mothers screening positive for depression in 2 randomly selected shelter-based primary care clinics in New York over 18 months in 2010-2012. Study participants completed a psychosocial, health, and mental health assessment at baseline, 3 months, and 6 months. One-third of women screened positive for depression (123 of 328 women). Sixty-seven women (63.2% of the eligible sample) enrolled in the intervention. At 6 months, compared to usual-care women, intervention group women were more likely to be receiving depression treatment (40.0% vs 5.9%, P = .01) and antidepressant medication (73.3% vs 5.9%, P = .001, respectively) and had more primary care physician and care manager visits at both 3 months (74.3% vs 53.3%, P = .009 and 91.4% vs 26.7%, P < .001, respectively) and 6 months (46.7% vs 23.5%, P = .003 and 70% vs 17.7%, P = .001, respectively). More women in the intervention group compared to usual-care women reported ≥ 50% improvement in depression symptoms at 6 months (30% vs 5.9%, P = .07). This pilot study found that implementing an adapted collaborative care intervention was feasible in a shelter-based primary care clinic and had promising results that require further testing. ClinicalTrials.gov identifier: NCT02723058.

Population-Tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-Experimental Trial

PubMed Central

Johnson, Erin E.; Borgia, Matthew; Noack, Amy; Yoon, Jean; Gehlert, Elizabeth; Lo, Jeanie

2018-01-01

Introduction Although traditional patient-centered medical homes (PCMHs) are effective for patients with complex needs, it is unclear whether homeless-tailored PCMHs work better for homeless veterans. We examined the impact of enrollment in a Veterans Health Administration (VHA) homeless-tailored PCMH on health services use, cost, and satisfaction compared with enrollment in a traditional, nontailored PCMH. Methods We conducted a prospective, multicenter, quasi-experimental, single-blinded study at 2 VHA medical centers to assess health services use, cost, and satisfaction during 12 months among 2 groups of homeless veterans: 1) veterans receiving VHA homeless-tailored primary care (Homeless-Patient Aligned Care Team [H-PACT]) and 2) veterans receiving traditional primary care services (PACT). A cohort of 266 homeless veterans enrolled from June 2012 through January 2014. Results Compared with PACT patients, H-PACT patients had more social work visits (4.6 vs 2.7 visits) and fewer emergency department (ED) visits for ambulatory care-sensitive conditions (0 vs 0.2 visits); a significantly smaller percentage of veterans in H-PACT were hospitalized (23.1% vs 35.4%) or had mental health–related ED visits (34.1% vs 47.6%). We found significant differences in primary care provider–specific visits (H-PACT, 5.1 vs PACT, 3.6 visits), mental health care visits (H-PACT, 8.8 vs PACT, 13.4 visits), 30-day prescription drug fills (H-PACT, 40.5 vs PACT, 58.8 fills), and use of group therapy (H-PACT, 40.1% vs PACT, 53.7%). Annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036). In logistic regression model of acute care use, assignment to the H-PACT model was protective as was rating health “good” or better. Conclusion Homeless veterans enrolled in the population-tailored primary care approach used less acute care and costs were lower. Tailored-care models have implications for care coordination in the US Department of Veterans Affairs VA and community health systems. PMID:29451116

The influence of an intermediate care hospital on health care utilization among elderly patients--a retrospective comparative cohort study.

PubMed

Dahl, Unni; Johnsen, Roar; Sætre, Rune; Steinsbekk, Aslak

2015-02-01

An intermediate care hospital (ICH) was established in a municipality in Central Norway in 2007 to improve the coordination of services and follow-up among elderly and chronically ill patients after hospital discharge. The aim of this study was to compare health care utilization by elderly patients in a municipality with an ICH to that of elderly patients in a municipality without an ICH. This study was a retrospective comparative cohort study of all hospitalized patients aged 60 years or older in two municipalities. The data were collected from the national register of hospital use from 2005 to 2012, and from the local general hospital and two primary health care service providers from 2008 to 2012 (approx. 1,250 patients per follow-up year). The data were analyzed using descriptive statistics and analysis of covariance (ANCOVA). The length of hospital stay decreased from the time the ICH was introduced and remained between 10% and 22% lower than the length of hospital stay in the comparative municipality for the next five years. No differences in the number of readmissions or admissions during one year follow-up after the index stay at the local general hospital or changes in primary health care utilization were observed. In the year after hospital discharge, the municipality with an ICH offered more hour-based care to elderly patients living at home (estimated mean = 234 [95% CI 215-252] versus 175 [95% CI 154-196] hours per person and year), while the comparative municipality had a higher utilization of long-term stays in nursing homes (estimated mean = 33.3 [95% CI 29.0-37.7] versus 21.9 [95% CI 18.0-25.7] days per person and year). This study indicates that the introduction of an ICH rapidly reduces the length of hospital stay without exposing patients to an increased health risk. The ICH appears to operate as an extension of the general hospital, with only a minor impact on the pattern of primary health care utilization.

A new corps of trained Grand-Aides has the potential to extend reach of primary care workforce and save money.

PubMed

Garson, Arthur; Green, Donna M; Rodriguez, Lia; Beech, Richard; Nye, Christopher

2012-05-01

Because the Affordable Care Act will expand health insurance to cover an estimated thirty-two million additional people, new approaches are needed to expand the primary care workforce. One possible solution is Grand-Aides®, who are health care professionals operating under the direct supervision of nurses, and who are trained and equipped to conduct telephone consultations or make primary care home visits to patients who might otherwise be seen in emergency departments and clinics. We conducted pilot tests with Grand-Aides in two pediatric Medicaid settings: an urban federally qualified health center in Houston, Texas, and a semi-rural emergency department in Harrisonburg, Virginia. We estimated that Grand-Aides and their supervisors averted 62 percent of drop-in visits at the Houston clinic and would have eliminated 74 percent of emergency department visits at the Virginia test site. We calculated the cost of the Grand-Aides program to be $16.88 per encounter. That compares with current Medicaid payments of $200 per clinic visit in Houston and $175 per emergency department visit in Harrisonburg. In addition to reducing health care costs, Grand-Aides have the potential to make a substantial impact in reducing congestion in primary care practices and emergency departments.

Cardiovascular disease treatment among patients with severe mental illness: a data linkage study between primary and secondary care.

PubMed

Woodhead, Charlotte; Ashworth, Mark; Broadbent, Matthew; Callard, Felicity; Hotopf, Matthew; Schofield, Peter; Soncul, Murat; Stewart, Robert J; Henderson, Max J

2016-06-01

Suboptimal treatment of cardiovascular diseases (CVD) among patients with severe mental illness (SMI) may contribute to physical health disparities. To identify SMI characteristics associated with meeting CVD treatment and prevention guidelines. Population-based electronic health record database linkage between primary care and the sole provider of secondary mental health care services in south east London, UK. Cardiovascular disease prevalence, risk factor recording, and Quality and Outcomes Framework (QOF) clinical target achievement were compared among 4056 primary care patients with SMI whose records were linked to secondary healthcare records and 270 669 patients without SMI who were not known to secondary care psychiatric services, using multivariate logistic regression modelling. Data available from secondary care records were then used to identify SMI characteristics associated with QOF clinical target achievement. Patients with SMI and with coronary heart disease and heart failure experienced reduced prescribing of beta blockers and angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACEI/ARB). A diagnosis of schizophrenia, being identified with any indicator of risk or illness severity, and being prescribed with depot injectable antipsychotic medication was associated with the lowest likelihood of prescribing. Linking primary and secondary care data allows the identification of patients with SMI most at risk of undertreatment for physical health problems. © British Journal of General Practice 2016.

Using Meta-analyses for Comparative Effectiveness Research

PubMed Central

Ruppar, Todd M.; Phillips, Lorraine J.; Chase, Jo-Ana D.

2012-01-01

Comparative effectiveness research seeks to identify the most effective interventions for particular patient populations. Meta-analysis is an especially valuable form of comparative effectiveness research because it emphasizes the magnitude of intervention effects rather than relying on tests of statistical significance among primary studies. Overall effects can be calculated for diverse clinical and patient-centered variables to determine the outcome patterns. Moderator analyses compare intervention characteristics among primary studies by determining if effect sizes vary among studies with different intervention characteristics. Intervention effectiveness can be linked to patient characteristics to provide evidence for patient-centered care. Moderator analyses often answer questions never posed by primary studies because neither multiple intervention characteristics nor populations are compared in single primary studies. Thus meta-analyses provide unique contributions to knowledge. Although meta-analysis is a powerful comparative effectiveness strategy, methodological challenges and limitations in primary research must be acknowledged to interpret findings. PMID:22789450

Nontraditional or noncentralized models of diabetes care: models in which other HCPs take on a leading role in managing patients' diabetes.

PubMed

Arnold, K C

2011-11-01

Nurse practitioners (NPs) are advanced practice nurses who have increased responsibility,such as prescribing authority. In the NP-led model, the NP is the primary care provider for clinic patients and takes on an autonomous role in patient management. In some states, NP-led clinics are required to have a supervising or collaborating physician. There is evidence that NP-led and physician-led primary care is comparable for multiple health outcomes. The NP-led model emphasizes the strong interaction between health care provider and patient. Challenges of NP-led care include physician resistance, legal restrictions, inaccessibility and cost of malpractice insurance, and limited payouts from insurance companies

How Important Is Intrinsic Spirituality in Depression Care?

PubMed Central

Cooper, Lisa A; Brown, Charlotte; Thi Vu, Hong; Ford, Daniel E; Powe, Neil R

2001-01-01

We used a cross-sectional survey to compare the views of African-American and white adult primary care patients (N = 76) regarding the importance of various aspects of depression care. Patients were asked to rate the importance of 126 aspects of depression care (derived from attitudinal domains identified in focus groups) on a 5-point Likert scale. The 30 most important items came from 9 domains: 1) health professionals' interpersonal skills, 2) primary care provider recognition of depression, 3) treatment effectiveness, 4) treatment problems, 5) patient understanding about treatment, 6) intrinsic spirituality, 7) financial access, 8) life experiences, and 9) social support. African-American and white patients rated most aspects of depression care as similarly important, except that the odds of rating spirituality as extremely important for depression care were 3 times higher for African Americans than the odds for whites. PMID:11556945

Basal insulin initiation in primary vs. specialist care: similar glycaemic control in two different patient populations.

PubMed

Orozco-Beltran, D; Pan, C; Svendsen, A L; Faerch, L; Caputo, S

2016-03-01

To investigate the effect of healthcare provider (HCP) type (primary vs. specialist) on glycaemic control and other treatment parameters. Study of Once-Daily Levemir (SOLVE(™) ) is an international, 24-week, observational study of insulin initiation in people with type 2 diabetes. A total of 17,374 subjects were included, comprising 4144 (23.9%) primary care subjects. Glycaemic control improved in both HCP groups from baseline to final visit [glycated haemoglobin (HbA1c) -1.2 ± 1.4% (-13.1 ± 15.3 mmol/mol) and -1.3 ± 1.6% (-14.2 ± 17.5 mmol/mol), respectively]. After adjustment for known confounders, there was no statistically significant effect of HCP group on final HbA1c [-0.04%, 95% confidence interval (CI) -0.09 to -0.01 (-0.4 mmol/mol, 95% CI -1.0-0.1 mmol/mol), p = 0.1590]. However, insulin doses at the final visit were higher in primary care patients (+0.06, 95% CI 0.06-0.07 U/kg, p < 0.0001). Logistic regression demonstrated a significant effect of HCP type (primary vs. specialist care) on hypoglycaemia risk [odds ratio (OR) 0.75, 95% CI 0.64-0.87, p = 0.0002]. Primary care physicians took more time to train patients and had more frequent contact with patients than specialists (both p < 0.0001). Primary care physicians and specialists achieved comparable improvements in glycaemic control following insulin initiation. © 2016 The Authors. International Journal of Clinical Practice Published by John Wiley & Sons Ltd.

Policy Levers Key for Primary Health Care Organizations to Support Primary Care Practices in Meeting Medical Home Expectations: Comparing Leading States to the Australian Experience.

PubMed

Takach, Mary

2016-10-01

Several countries with highly ranked delivery systems have implemented locally-based, publicly-funded primary health care organizations (PHCOs) as vehicles to strengthen their primary care foundations. In the United States, state governments have started down a similar pathway with models that share similarities with international PHCOs. The objective of this study was to determine if these kinds of organizations were working with primary care practices to improve their ability to provide comprehensive, coordinated, and accessible patient-centered care that met quality, safety, and efficiency outcomes-all core attributes of a medical home. This qualitative study looked at 4 different PHCO models-3 from the United States and 1 from Australia-with similar objectives and scope. Primary and secondary data included semi-structured interviews with 26 PHCOs and a review of government documents. The study found that the 4 PHCO models were engaging practices to meet a number of medical home expectations, but the US PHCOs were more uniform in efforts to work with practices and focused on arranging services to meet the needs of complex patients. There was significant variation in level of effort between the Australian PHCOs. These differences can be explained through the state governments' selection of payment models and use of data frameworks to support collaboration and incentivize performance of both PHCOs and practices. These findings offer policy lessons to inform health reform efforts under way to better capitalize on the potential of PHCOs to support a high-functioning primary health foundation as an essential component to a reformed health system.

Inequality in the distribution of health resources and health services in China: hospitals versus primary care institutions.

PubMed

Zhang, Tao; Xu, Yongjian; Ren, Jianping; Sun, Liqi; Liu, Chaojie

2017-03-03

Equity is one of the major goals of China's recent health system reform. This study aimed to evaluate the equality of the distribution of health resources and health services between hospitals and primary care institutions. Data of this study were drawn from the China Health Statistical Year Books. We calculated Gini coefficients based on population size and geographic size, respectively, for the indicators: number of institutions, number of health workers and number of beds; and the concentration index (CI) for the indicators: per capita outpatient visits and annual hospitalization rates. The Gini coefficients against population size ranged between 0.17 and 0.44 in the hospital sector, indicating a relatively good equality. The primary care sector showed a slightly higher level of Gini coefficients (around 0.45) in the number of health workers. However, inequality was evident in the geographic distribution of health resources. The Gini coefficients exceeded 0.7 in the geographic distribution of institutions, health workers and beds in both the hospital and the primary care sectors, indicating high levels of inequality. The CI values of hospital inpatient care and outpatient visits to primary care institutions were small (ranging from -0.02 to 0.02), indicating good wealth-related equality. The CI values of outpatient visits to hospitals ranged from 0.16 to 0.21, indicating a concentration of services towards the richer populations. By contrast, the CI values of inpatient care in primary care institutions ranged from -0.24 to -0.22, indicating a concentration of services towards the poorer populations. The eastern developed region also had a high internal inequality compared with the other less developed regions. Significant inequality in the geographic distribution of health resources is evident, despite a more equitable per capita distribution of resources. Richer people are more likely to use well-resourced hospitals for outpatient care. By contrast, poorer people are more likely to use poorly-resourced primary care institutions for inpatient care. There is a risk of the emergence of a two-tiered health care delivery system.

Comparing the knowledge, attitude and practices of health care workers in public and private primary care facilities in Lagos State on Ebola virus disease.

PubMed

Idris, Bilqisu Jibril; Inem, Victor; Balogun, Mobolanle

2015-01-01

The West African sub-region is currently witnessing an outbreak of EVD that began in December 2013. The first case in Nigeria was diagnosed in Lagos, at a private medical facility in July 2014. Health care workers are known amplifiers of the disease. The study aimed to determine and compare EVD knowledge, attitude and practices among HCWs in public and private primary care facilities in Lagos, Nigeria. This was a comparative cross-sectional study. Seventeen public and private primary care facilities were selected from the 3 senatorial districts that make up Lagos State. 388 respondents from these facilities were selected at random and interviewed using a structured questionnaire. Proportion of respondents with good knowledge and practice among public HCWs was 98.5% and 93.8%; and among private HCW, 95.9% and 89.7%. Proportion of respondents with positive attitude was 67% (public) and 72.7% (private). Overall, there were no statistically significant differences between the knowledge, attitude and preventive practices of public HCWs and that of private HCWs, (p≤0.05). Timely and intense social mobilization and awareness campaigns are the best tools to educate all segments of the community about public health emergencies. There exists significant surmountable gaps in EVD knowledge, negative attitude and sub-standard preventive practices that can be eliminated through continued training of HCW and provision of adequate material resources.

Comparing the knowledge, attitude and practices of health care workers in public and private primary care facilities in Lagos State on Ebola virus disease

PubMed Central

Idris, Bilqisu Jibril; Inem, Victor; Balogun, Mobolanle

2015-01-01

Introduction The West African sub-region is currently witnessing an outbreak of EVD that began in December 2013. The first case in Nigeria was diagnosed in Lagos, at a private medical facility in July 2014. Health care workers are known amplifiers of the disease. The study aimed to determine and compare EVD knowledge, attitude and practices among HCWs in public and private primary care facilities in Lagos, Nigeria. Methods This was a comparative cross-sectional study. Seventeen public and private primary care facilities were selected from the 3 senatorial districts that make up Lagos State. 388 respondents from these facilities were selected at random and interviewed using a structured questionnaire. Results Proportion of respondents with good knowledge and practice among public HCWs was 98.5% and 93.8%; and among private HCW, 95.9% and 89.7%. Proportion of respondents with positive attitude was 67% (public) and 72.7% (private). Overall, there were no statistically significant differences between the knowledge, attitude and preventive practices of public HCWs and that of private HCWs, (p≤0.05). Conclusion Timely and intense social mobilization and awareness campaigns are the best tools to educate all segments of the community about public health emergencies. There exists significant surmountable gaps in EVD knowledge, negative attitude and sub-standard preventive practices that can be eliminated through continued training of HCW and provision of adequate material resources. PMID:26740847

Stigmatizing attitudes of primary care professionals towards people with mental disorders: A systematic review.

PubMed

Vistorte, Angel O Rojas; Ribeiro, Wagner Silva; Jaen, Denisse; Jorge, Miguel R; Evans-Lacko, Sara; Mari, Jair de Jesus

2018-07-01

Objective To examine stigmatizing attitudes towards people with mental disorders among primary care professionals and to identify potential factors related to stigmatizing attitudes through a systematic review. Methods A systematic literature search was conducted in Medline, Lilacs, IBECS, Index Psicologia, CUMED, MedCarib, Sec. Est. Saúde SP, WHOLIS, Hanseníase, LIS-Localizador de Informação em Saúde, PAHO, CVSO-Regional, and Latindex, through the Virtual Health Library portal ( http://www.bireme.br website) through to June 2017. The articles included in the review were summarized through a narrative synthesis. Results After applying eligibility criteria, 11 articles, out of 19.109 references identified, were included in the review. Primary care physicians do present stigmatizing attitudes towards patients with mental disorders and show more negative attitudes towards patients with schizophrenia than towards those with depression. Older and more experience doctors have more stigmatizing attitudes towards people with mental illness compared with younger and less-experienced doctors. Health-care providers who endorse more stigmatizing attitudes towards mental illness were likely to be more pessimistic about the patient's adherence to treatment. Conclusions Stigmatizing attitudes towards people with mental disorders are common among physicians in primary care settings, particularly among older and more experienced doctors. Stigmatizing attitudes can act as an important barrier for patients to receive the treatment they need. The primary care physicians feel they need better preparation, training, and information to deal with and to treat mental illness, such as a user friendly and pragmatic classification system that addresses the high prevalence of mental disorders in primary care and community settings.

Defining upper gastrointestinal bleeding from linked primary and secondary care data and the effect on occurrence and 28 day mortality

PubMed Central

2012-01-01

Background Primary care records from the UK have frequently been used to identify episodes of upper gastrointestinal bleeding in studies of drug toxicity because of their comprehensive population coverage and longitudinal recording of prescriptions and diagnoses. Recent linkage within England of primary and secondary care data has augmented this data but the timing and coding of concurrent events, and how the definition of events in linked data effects occurrence and 28 day mortality is not known. Methods We used the recently linked English Hospital Episodes Statistics and General Practice Research Database, 1997–2010, to define events by; a specific upper gastrointestinal bleed code in either dataset, a specific bleed code in both datasets, or a less specific but plausible code from the linked dataset. Results This approach resulted in 81% of secondary care defined bleeds having a corresponding plausible code within 2 months in primary care. However only 62% of primary care defined bleeds had a corresponding plausible HES admission within 2 months. The more restrictive and specific case definitions excluded severe events and almost halved the 28 day case fatality when compared to broader and more sensitive definitions. Conclusions Restrictive definitions of gastrointestinal bleeding in linked datasets fail to capture the full heterogeneity in coding possible following complex clinical events. Conversely too broad a definition in primary care introduces events not severe enough to warrant hospital admission. Ignoring these issues may unwittingly introduce selection bias into a study’s results. PMID:23148590

What are the similarities and differences in structure and function among the three main models of community health centers in China: a systematic review.

PubMed

Li, Haitao; Qian, Dongfu; Griffiths, Sian; Chung, Roger Yat-Nork; Wei, Xiaolin

2015-11-10

There are three major models of primary care providers (Community Health Centers, CHCs) in China, i.e., government managed, hospital managed and privately owned CHCs. We performed a systematic review of structures and health care delivery patterns of the three models of CHCs. Studies from relevant English and Chinese databases for the period of 1997-2011 were searched. Two independent researchers extracted data from the eligible studies using a standardized abstraction form. Methodological quality of included articles was assessed with the Mixed Methods Appraisal Tool (MMAT). A total of 13 studies was included in the final analysis. Compared with the other two models, private CHCs had a smaller health workforce and lower share of government funding in their total revenues. Private CHCs also had fewer training opportunities, were less recognized by health insurance schemes and tended to provide primary care services of poor quality. Hospital managed CHCs attracted patients through their higher quality of clinical care, while private CHCs attracted users through convenience and medical equipment. Our study suggested that government and hospital managed CHCs were more competent and provided better primary care than privately owned CHCs. Further studies are warranted to comprehensively compare performances among different models of CHCs.

Nurse practitioner and physician assistant staffing in the patient-centered medical homes in New York State.

PubMed

Park, Jeongyoung

2015-01-01

A cornerstone of patient-centered medical homes (PCMHs) is team-based care; however, there is little information about the composition of staff who deliver direct primary care in PCMHs. The purpose of this study was to examine the number and distribution of primary care physicians (PCPs), nurse practitioners (NPs), and physician assistants (PAs) in PCMH and non-PCMH practices located in New York State (N = 7,431). Practice based ratios of primary care NPs and PAs to PCP were calculated and compared by PCMH designations. Designated PCMHs had more NPs and PAs per PCP relative to non-PCMHs. The ratios of NPs to PCPs were almost twice as high in PCMHs compared with non-PCMHs (0.20 and 0.11), and ratios were similarly different for PAs to PCPs (0.16 and 0.09, respectively). The multivariate analyses also support that higher NP and PA staffing was associated with PCMH designation (i.e., there was one additional NP and/or PA for every 25 PCPs). The growth of PCMHs may require more NPs and PAs to meet the anticipated growth in demand for health care. Policy- and practice-level changes are necessary to use them in the most effective ways. Copyright © 2015 Elsevier Inc. All rights reserved.

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.

Where are we on the diffusion curve? Trends and drivers of primary care physicians' use of health information technology.

PubMed

Audet, Anne-Marie; Squires, David; Doty, Michelle M

2014-02-01

To describe trends in primary care physicians' use of health information technology (HIT) between 2009 and 2012, examine practice characteristics associated with greater HIT capacity in 2012, and explore factors such as delivery system and payment reforms that may affect adoption and functionality. We used data from the 2012 and 2009 Commonwealth Fund International Health Policy Surveys of Primary Care Physicians. The data were collected in both years by postal mail between March and July among a nationally representative sample of primary care physicians in the United States. We compared primary care physicians' HIT capacity in 2009 and 2012. We employed multivariable logistic regression to analyze whether participating in an integrated delivery system, sharing resources and support with other practices, and being eligible for financial incentives were associated with greater HIT capacity in 2012. Primary care physicians' HIT capacity has significantly expanded since 2009, although solo practices continue to lag. Practices that are part of an integrated delivery system or share resources with other practices have higher rates of electronic medical record (EMR) adoption, multifunctional HIT, electronic information exchange, and electronic access for patients. Receiving or being eligible for financial incentives is associated with greater adoption of EMRs and information exchange. Federal efforts to increase adoption have coincided with a rapid increase in HIT capacity. Delivery system and payment reforms and federally funded extension programs could offer promising pathways for further diffusion. © Health Research and Educational Trust.

Characteristics of Indigenous primary health care service delivery models: a systematic scoping review.

PubMed

Harfield, Stephen G; Davy, Carol; McArthur, Alexa; Munn, Zachary; Brown, Alex; Brown, Ngiare

2018-01-25

Indigenous populations have poorer health outcomes compared to their non-Indigenous counterparts. The evolution of Indigenous primary health care services arose from mainstream health services being unable to adequately meet the needs of Indigenous communities and Indigenous peoples often being excluded and marginalised from mainstream health services. Part of the solution has been to establish Indigenous specific primary health care services, for and managed by Indigenous peoples. There are a number of reasons why Indigenous primary health care services are more likely than mainstream services to improve the health of Indigenous communities. Their success is partly due to the fact that they often provide comprehensive programs that incorporate treatment and management, prevention and health promotion, as well as addressing the social determinants of health. However, there are gaps in the evidence base including the characteristics that contribute to the success of Indigenous primary health care services in providing comprehensive primary health care. This systematic scoping review aims to identify the characteristics of Indigenous primary health care service delivery models. This systematic scoping review was led by an Aboriginal researcher, using the Joanna Briggs Institute Scoping Review Methodology. All published peer-reviewed and grey literature indexed in PubMed, EBSCO CINAHL, Embase, Informit, Mednar, and Trove databases from September 1978 to May 2015 were reviewed for inclusion. Studies were included if they describe the characteristics of service delivery models implemented within an Indigenous primary health care service. Sixty-two studies met the inclusion criteria. Data were extracted and then thematically analysed to identify the characteristics of Indigenous PHC service delivery models. Culture was the most prominent characteristic underpinning all of the other seven characteristics which were identified - accessible health services, community participation, continuous quality improvement, culturally appropriate and skilled workforce, flexible approach to care, holistic health care, and self-determination and empowerment. While the eight characteristics were clearly distinguishable within the review, the interdependence between each characteristic was also evident. These findings were used to develop a new Indigenous PHC Service Delivery Model, which clearly demonstrates some of the unique characteristics of Indigenous specific models.

Cost-Effectiveness of Primary Care Management With or Without Early Physical Therapy for Acute Low Back Pain: Economic Evaluation of a Randomized Clinical Trial.

PubMed

Fritz, Julie M; Kim, Minchul; Magel, John S; Asche, Carl V

2017-03-01

Economic evaluation of a randomized clinical trial. Compare costs and cost-effectiveness of usual primary care management for patients with acute low back pain (LBP) with or without the addition of early physical therapy. Low back pain is among the most common and costly conditions encountered in primary care. Early physical therapy after a new primary care consultation for acute LBP results in small clinical improvement but cost-effectiveness of a strategy of early physical therapy is unknown. Economic evaluation was conducted alongside a randomized clinical trial of patients with acute, nonspecific LBP consulting a primary care provider. All patients received usual primary care management and education, and were randomly assigned to receive four sessions of physical therapy or usual care of delaying referral consideration to permit spontaneous recovery. Data were collected in a randomized trial involving 220 participants age 18 to 60 with LBP <16 days duration without red flags or signs of nerve root compression. The EuroQoL EQ-5D health states were collected at baseline and after 1-year and used to compute the quality adjusted life year (QALY) gained. Direct (health care utilization) and indirect (work absence or reduced productivity) costs related to LBP were collected monthly and valued using standard costs. The incremental cost-effectiveness ratio was computed as incremental total costs divided by incremental QALYs. Early physical therapy resulted in higher total 1-year costs (mean difference in adjusted total costs = $580, 95% CI: $175, $984, P = 0.005) and better quality of life (mean difference in QALYs = 0.02, 95% CI: 0.005, 0.35, P = 0.008) after 1-year. The incremental cost-effectiveness ratio was $32,058 (95% CI: $10,629, $151,161) per QALY. Our results support early physical therapy as cost-effective relative to usual primary care after 1 year for patients with acute, nonspecific LBP. 2.

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.

Effectiveness of an on-site health clinic at a self-insured university: a cost-benefit analysis.

PubMed

McCaskill, Sherrie P; Schwartz, Lisa A; Derouin, Anne L; Pegram, Angela H

2014-04-01

This study assessed the impact and cost-effectiveness of an on-site health clinic at a self-insured university. Health care costs and number of claims filed to primary care providers were trended before and after the clinic was established to determine savings. A retrospective chart review of all full-time, insured employees treated for upper respiratory tract infections (URIs) during a 1-year study period was conducted. On-site clinic costs for the treatment of URIs were compared to costs at outside community providers for similar care. Community cost norms for the treatment of URIs were provided by Primary Physicians Care, the administrator of insurance claims for the University. A cost-benefit analysis compared the cost of services on-site versus similar services at an outside community provider. Based on the results of this study, the University's on-site health care services were determined to be more cost-effective than similar off-site health care services for the treatment of URIs. [Workplace Health Saf 2014;62(4):162-169.]. Copyright 2014, SLACK Incorporated.

Defining Team Effort Involved in Patient Care from the Primary Care Physician's Perspective.

PubMed

Hwang, Andrew S; Atlas, Steven J; Hong, Johan; Ashburner, Jeffrey M; Zai, Adrian H; Grant, Richard W; Hong, Clemens S

2017-03-01

A better understanding of the attributes of patients who require more effort to manage may improve risk adjustment approaches and lead to more efficient resource allocation, improved patient care and health outcomes, and reduced burnout in primary care clinicians. To identify and characterize high-effort patients from the physician's perspective. Cohort study. Ninety-nine primary care physicians in an academic primary care network. From a list of 100 randomly selected patients in their panels, PCPs identified patients who required a high level of team-based effort and patients they considered complex. For high-effort patients, PCPs indicated which factors influenced their decision: medical/care coordination, behavioral health, and/or socioeconomic factors. We examined differences in patient characteristics based on PCP-defined effort and complexity. Among 9594 eligible patients, PCPs classified 2277 (23.7 %) as high-effort and 2676 (27.9 %) as complex. Behavioral health issues were the major driver of effort in younger patients, while medical/care coordination issues predominated in older patients. Compared to low-effort patients, high-effort patients were significantly (P < 0.01 for all) more likely to have higher rates of medical (e.g. 23.2 % vs. 6.3 % for diabetes) and behavioral health problems (e.g. 9.8 % vs. 2.9 % for substance use disorder), more frequent primary care visits (10.9 vs. 6.0 visits), and higher acute care utilization rates (25.8 % vs. 7.7 % for emergency department [ED] visits and 15.0 % vs. 3.9 % for hospitalization). Almost one in five (18 %) patients who were considered high-effort were not deemed complex by the same PCPs. Patients defined as high-effort by their primary care physicians, not all of whom were medically complex, appear to have a high burden of psychosocial issues that may not be accounted for in current chronic disease-focused risk adjustment approaches.

Evaluating a complex model designed to increase access to high quality primary mental health care for under-served groups: a multi-method study.

PubMed

Dowrick, Christopher; Bower, Peter; Chew-Graham, Carolyn; Lovell, Karina; Edwards, Suzanne; Lamb, Jonathan; Bristow, Katie; Gabbay, Mark; Burroughs, Heather; Beatty, Susan; Waheed, Waquas; Hann, Mark; Gask, Linda

2016-02-17

Many people with mental distress are disadvantaged because care is not available or does not address their needs. In order to increase access to high quality primary mental health care for under-served groups, we created a model of care with three discrete elements: community engagement, primary care training and tailored wellbeing interventions. We have previously demonstrated the individual impact of each element of the model. Here we assess the effectiveness of the combined model in increasing access to and improving the quality of primary mental health care. We test the assumptions that access to the wellbeing interventions is increased by the presence of community engagement and primary care training; and that quality of primary mental health care is increased by the presence of community engagement and the wellbeing interventions. We implemented the model in four under-served localities in North-West England, focusing on older people and minority ethnic populations. Using a quasi-experimental design with no-intervention comparators, we gathered a combination of quantitative and qualitative information. Quantitative information, including referral and recruitment rates for the wellbeing interventions, and practice referrals to mental health services, was analysed descriptively. Qualitative information derived from interview and focus group responses to topic guides from more than 110 participants. Framework analysis was used to generate findings from the qualitative data. Access to the wellbeing interventions was associated with the presence of the community engagement and the primary care training elements. Referrals to the wellbeing interventions were associated with community engagement, while recruitment was associated with primary care training. Qualitative data suggested that the mechanisms underlying these associations were increased awareness and sense of agency. The quality of primary mental health care was enhanced by information gained from our community mapping activities, and by the offer of access to the wellbeing interventions. There were variable benefits from health practitioner participation in community consultative groups. We also found that participation in the wellbeing interventions led to increased community engagement. We explored the interactions between elements of a multilevel intervention and identified important associations and underlying mechanisms. Further research is needed to test the generalisability of the model. Current Controlled Trials, reference ISRCTN68572159 . Registered 25 February 2013.

Effectiveness of certified diabetes educators following pre-approved protocols to redesign diabetes care delivery in primary care: Results of the REMEDIES 4D trial.

PubMed

Zgibor, Janice C; Maloney, Maura A; Malmi, Markku; Fabio, Anthony; Kuo, Shihchen; Solano, Francis X; Tilves, Debra; Tu, Lichuan; Davidson, Mayer B

2018-01-01

To evaluate changes in HbA1c, blood pressure, and LDLc levels in participants from practices where certified diabetes educators (CDEs) implemented standardized protocols to intensify treatment compared with those receiving usual care. This clustered, randomized, clinical trial was implemented in community-based primary care practices. Fifteen primary care practices and 240 patients with type 2 diabetes were randomized to the intervention (n=175) or usual care (n=65). Participants had uncontrolled HbA1c, blood pressure, or LDLc. The one-year intervention included CDEs implementing pre-approved protocols to intensify treatment. Diabetes self-management education was also provided in both study groups. The population was 50.8% male with a mean age of 61years. The HbA1c in the intervention group decreased from 8.8% to 7.8%, (p=0.001) while the HbA1c in the usual care group increased slightly from 8.2% to 8.3%. There was also a significant difference in HbA1c between the two groups (p=0.004). There was not a significant difference between groups for systolic blood pressure (SBP) or LDLc at the end of the intervention. Those in the intervention group were more likely to have glucose-lowering medications intensified and were more likely to have their HbA1c (35% vs 15%), SBP (80% vs 77%) and HbA1c, SBP, and LDLc at goal (11% vs 1.5%) compared with the usual care group. There was no significant difference in intensification of blood pressure or cholesterol medication. Findings suggest that CDEs following standardized protocols in primary care is feasible and can effectively intensify treatment and improve glycemic control. Copyright © 2017 Elsevier Inc. All rights reserved.

Building capacity for research in family medicine: is the blueprint faulty?

PubMed

Curtis, Peter; Dickinson, Perry; Steiner, John; Lanphear, Bruce; Vu, Kieu

2003-02-01

This study compared the training programs and career paths of family medicine graduates in the National Research Service Award (NRSA) Program for Research in Primary Medical Care with general internal medicine and general pediatric peers. We mailed a survey to NRSA fellows graduating from 23 programs nationally between 1988-1997. Personal characteristics, fellowship experience, current professional activities, and academic productivity were compared among primary care disciplines. Of 215 NRSA participants, 146 (68%) completed the survey. Of the 131 primary care respondents, 25% were family physicians. During the fellowship, family physician trainees spent significantly less time in hands-on research activity (32% +/- 12%) than internists and pediatricians (39% +/- 17%). Family physician graduates also had less post-fellowship mentoring and were less likely to hold clinician/researcher faculty positions in academic centers. Family physician faculty spent far more time on clinical work and less time on research. Only 12.5% of family physician fellowship graduates published one or more articles per year, compared with 36.5% of their peers, and 30% had published nothing since graduation. Family physician graduates of this research training program did not achieve academic success comparable to their peers. Family physicians need more protected time for conducting research in their faculty positions and more sustained mentorship.

Challenges to the Israeli healthcare system: attracting medical students to primary care and to the periphery.

PubMed

Weissman, Charles; Zisk-Rony, Rachel Yaffa; Avidan, Alexander; Elchalal, Uriel; Tandeter, Howard

2018-05-29

The greatest challenges facing healthcare systems include ensuring a sufficient supply of primary care physicians and physicians willing to work in rural or peripheral areas. Especially challenging is enticing young physicians to practice primary care in rural/peripheral areas. Identifying medical students interested in primary care and in residencies in Israel's periphery should aid the healthcare leadership. It may be particularly important to do so during the clinical years, as this is the stage at which many future physicians begin to crystallize their specialty and location preferences. Questionnaires, distributed to 6 consecutive 5th-year classes of the Hebrew University - Hadassah School of Medicine, from 2010 to 2016, elicited information on criteria for choosing a career specialty, criteria for choosing a residency program and whether one-time monetary grants authorized in the 2011 physicians' union contract would attract students to residencies in the periphery. Completed questionnaires were returned by 511 of 740 (69%) students. Ninety-eight (19%) were interested in a primary care residency, 184 (36%) were unsure and 229 (45%) were not interested. Students interested in primary care were significantly less interested in specialties that perform procedures/surgeries and in joining a medical school faculty, while being more inclined towards specialties dealing with social problems, controllable lifestyles and working limited hours. The percentage of students interested in primary care was stable during the study period. Forty-eight of the students indicated interest in residencies in the country's periphery, and 42% of them were also interested in primary care residencies. Overall, only 3.7% of students were interested in both a primary care residency and a residency in the periphery. Thirty percent of the students indicated that the monetary incentives tempted them to consider a residency in the periphery. Fifty-three percent of these students reported that they did not yet know the geographic area where they wished to do their residency, as compared to only 22% among those not interested in incentives. This study provides the healthcare leadership with information on the characteristics of the students at a centrally-located medical school who tend to be more interested in primary care and in working in the periphery. Specifically, the study found that students interested in primary care desire a positive life/work balance, something that Israeli non-hospital primary care practice provides. Students considering residencies in the periphery were similarly inclined. Moreover, about a third of students had positive thoughts about monetary incentives for residencies in peripheral hospitals. These students should be identified early during their clinical experience so that attempts to recruit them to the periphery can commence before their specialty and location preferences have fully crystallized. Parallel studies should be performed at additional Israeli medical schools.

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.

Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study

PubMed Central

Harrison, Mark J; Dusheiko, Mark; Sutton, Matt; Gravelle, Hugh; Doran, Tim

2014-01-01

Objective To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs). Design Controlled longitudinal study. Setting English National Health Service between 1998/99 and 2010/11. Participants Populations registered with each of 6975 family practices in England. Main outcome measures Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs. Results Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11. Conclusions The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities. PMID:25389120

Impact of different approaches of primary care mental health on the prevalence of mental disorders.

PubMed

Moscovici, Leonardo; de Azevedo-Marques, Joao Mazzoncini; Bolsoni, Lívia Maria; Rodrigues-Junior, Antonio Luiz; Zuardi, Antonio Waldo

2018-05-01

AimTo compare the impact of three different approaches to primary care mental health on the prevalence of mental disorders. Millions of people suffer from mental disorders. As entry point into the health service, primary healthcare plays an important role in providing mental health prevention and treatment. Random sample of households in three different areas of the city of Ribeirão Preto (state of São Paulo, Brazil) were selected, and 20 trained medical students conducted interviews using a mental health screening instrument, the Mini-Screening of Mental Disorders, and a socio-demographic datasheet. Primary care mental health was provided in each area through a specific approach. The influence of the area of residence and the socio-demographic variables on the prevalence of mental disorder was explored and analyzed by univariate binary logistic regression and then by a multiple logistic regression model.FindingsA total of 1545 subjects were interviewed. Comparison between the three areas showed a significantly higher number of people with mental disorders in the area covered by the primary care team that did not have physicians with specific primary care mental health training, even when this association was adjusted for the influence of age, education, and socio-economic status.Our results suggest that residing in areas with family physicians with mental health training is associated with a lower prevalence of mental disorders.

Impact of the California breast density law on primary care physicians.

PubMed

Khong, Kathleen A; Hargreaves, Jonathan; Aminololama-Shakeri, Shadi; Lindfors, Karen K

2015-03-01

To investigate primary physician awareness of the California Breast Density Notification Law and its impact on primary care practice. An online survey was distributed to 174 physicians within a single primary care network system 10 months after California's breast density notification law took effect. The survey assessed physicians' awareness of the law, perceived changes in patient levels of concern about breast density, and physician comfort levels in handling breast density management issues. The survey was completed by 77 physicians (45%). Roughly half of those surveyed (49%) reported no knowledge of the breast density notification legislation. Only 32% of respondents noted an increase in patient levels of concern about breast density compared to prior years. The majority were only "somewhat comfortable" (55%) or "not comfortable" (12%) with breast density questions, and almost one-third (32%) had referred patients to a breast health clinic for these discussions. A total of 75% of those surveyed would be interested in more specific education on the subject. Awareness among primary care clinicians of the California Breast Density Notification Law is low, and many do not feel comfortable answering breast density-related patient questions. Breast imagers and institutions may need to devote additional time and resources to primary physician education in order for density notification laws to have significant impact on patient care. Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Detection and genotyping of HPV in urine samples from Chilean women attending primary health care centers.

PubMed

Vergara, Nicolás; Balanda, Monserrat; Hidalgo, Wilma; Martín, Héctor San; Aceituno, Alexis; Roldán, Francisco; Villalón, Tania; Hott, Melissa; Espinoza, Gloria; Quiero, Andrea; Valenzuela, María T; Ramírez, Eugenio

2018-04-01

Cervical cancer is the second most common malignant neoplasm in women worldwide representing approximately 10% of all types of cancers. Triage of women through cervical cytology has been an important strategy for the surveillance and control of new cases of cervical cancer. However, in many regions around the world cervical cytology has a low coverage compared to developed countries. The molecular detection of HPV is the most effective method to increase the screening sensitivity of women at risk of developing cervical cancer. There are very few studies about the efficacy of urine testing for detection of HPV in women followed up in primary health care centers. Consequently, the efficacy of using urine HPV screening in these populations has not been addressed yet. Here, we compared the detection of HPV in simultaneous urine and cervical samples of women followed up in primary health care centers. Urine and cervical samples were analyzed in 543 women attending at primary health care centers. HPV was detected by real time PCR, and HPV typing performed by PCR-RLB. A general HPV concordance of 86.2% (κ = 0.72) was determined between urine and cervical samples. The concordance for HPV-16 and 18 was almost perfect (κ = 0.82) and strong (κ = 0.77), respectively. The sensitivity and specificity for all HPV genotypes in urine using cervical samples as reference were 82.1 and 93.7%, respectively. The results showed that urine is a good alternative as clinical sample for HPV screening in women attending primary health care centers. Therefore, urine should be used as an alternative sample for increasing triage coverage either in refractory women participating in Pap surveillance programs or when cervical samples are not available.

Concurrent Validity of a Self-Reported Physical Activity “Vital Sign” Questionnaire With Adult Primary Care Patients

PubMed Central

Joy, Elizabeth A.; Gren, Lisa H.; Shaw, Janet M.

2016-01-01

Introduction No tool currently used by primary health care providers to assess physical activity has been evaluated for its ability to determine whether or not patients achieve recommended levels of activity. The purpose of this study was to assess concurrent validity of physical activity self-reported to the brief (<30 sec) Physical Activity “Vital Sign” questionnaire (PAVS) compared with responses to the lengthier (3–5 min), validated Modifiable Activity Questionnaire (MAQ). Methods Agreement between activity reported to the PAVS and MAQ by primary care patients at 2 clinics in 2014 was assessed by using percentages and κ coefficients. Agreement consisted of meeting or not meeting the 2008 Aerobic Physical Activity Guidelines for Americans (PA Guidelines) of the US Department of Health and Human Services. We compared self-reported usual minutes per week of moderate-to-vigorous physical activity among patients at a primary care clinic in 2014 who reported to PAVS and to MAQ by using Pearson correlation and Bland–Altman plots of agreement. Results Among 269 consenting patients who reported physical activity, PAVS results agreed with those of MAQ 89.6% of the time and demonstrated good agreement in identifying patients who did not meet PA Guidelines recommendations (κ = 0.55, ρ = 0.57; P < .001). Usual minutes per week of moderate-to-vigorous physical activity reported to PAVS had a high positive correlation with the same reported to MAQ (r = 0.71; P < .001). Conclusion PAVS may be a valid tool for identifying primary care patients who need counseling about physical activity. PAVS should be assessed further for agreement with repeated objective measures of physical activity in the patient population. PMID:26851335

Community nursing needs more silver surfers: a questionnaire survey of primary care nurses' use of information technology

PubMed Central

Chan, Tom; Brew, Sarah; de Lusignan, Simon

2004-01-01

Background In the UK the health service is investing more than ever before in information technology (IT) and primary care nurses will have to work with computers. Information about patients will be almost exclusively held in electronic patient records; and much of the information about best practice is most readily accessible via computer terminals. Objective To examine the influence of age and nursing profession on the level of computer use. Methods A questionnaire was developed to examine: access, training received, confidence and use of IT. The survey was carried out in a Sussex Primary Care Trust, in the UK. Results The questionnaire was sent to 109 nurses with a 64% response rate. Most primary care nurses (89%) use their computer regularly at work: 100% of practice nurses daily, compared with 60% of district nurses and 59% of health visitors (p < 0.01). Access to IT was not significantly different between different age groups; but 91% of practice nurses had their own computer while many district nurses and health visitors had to share (p < 0.01). Nurses over 50 had received more training that their younger colleagues (p < 0.01); yet despite this, they lacked confidence and used computers less (p < 0.001). 96% of practice nurses were confident at in using computerised medical records, compared with 53% of district nurses and 44% of health visitors (p < 0.01.) One-to-one training and workshops were the preferred formats for training, with Internet based learning and printed manuals the least popular (p < 0.001). Conclusions Using computers in the surgery has become the norm for primary care nurses. However, nurses over 50, working out in the community, lack the confidence and skill of their younger and practice based colleagues. PMID:15469616

"What they see is what you get": Prescribing antibiotics for respiratory tract infections in primary care: Do high prescribers diagnose differently? An analysis of German routine data.

PubMed

Hueber, Susann; Kuehlein, Thomas; Gerlach, Roman; Tauscher, Martin; Schedlbauer, Angela

2017-01-01

Characteristics of high and low prescribers of antibiotics in German primary care were analysed using population data. We aimed to evaluate differences in prescribing rates and factors being associated with high prescribing, and whether high prescribers made the diagnosis of perceived bacterial infections more often. Routine data were provided by the Bavarian Association of Statutory Health Insurance Physicians. Routine data are delivered by primary care practices on a quarterly basis. We analysed data from 2011 and 2012. Patients older than 15 years with respiratory tract infections consulting a primary care physician were selected (6.647 primary care practices). Patient and physician characteristics associated with high prescribing were identified using stepwise logistic regression. Mean prescribing rate of antibiotics was 24.9%. Prescribing rate for high prescribers was 43.5% compared to 8.5% for low prescribers. High prescribers made the diagnosis of perceived bacterial infections more often (Mhigh = 64.5%, Mlow = 45.2%). In the adjusted regression model, perceived bacterial infections were strongly associated with high prescribing (OR = 13.9, 95% CI [10.2, 18.8]). Treating patients with comorbidities was associated with lower prescribing of antibiotics (OR = 0.6, 95% CI [0.4, 0.8]). High prescribers had a higher practice volume, a higher degree of prescribing dominance, and were situated more often in deprived areas and in rural settings. Compared to findings of studies in other European countries, prescribing rates were low. There was a considerable difference between prescribing rates of high and low prescribers. Diagnostic labelling was the best predictor for high prescribing. Current guidelines recommend considering antibiotic treatment for patients with co-morbidities. In our study, treating a large number of high-risk patients was not associated with high prescribing.

Independence, institutionalization, death and treatment costs 18 months after rehabilitation of older people in two different primary health care settings

PubMed Central

2012-01-01

Background The optimal setting and content of primary health care rehabilitation of older people is not known. Our aim was to study independence, institutionalization, death and treatment costs 18 months after primary care rehabilitation of older people in two different settings. Methods Eighteen months follow-up of an open, prospective study comparing the outcome of multi-disciplinary rehabilitation of older people, in a structured and intensive Primary care dedicated inpatient rehabilitation (PCDIR, n=202) versus a less structured and less intensive Primary care nursing home rehabilitation (PCNHR, n=100). Participants: 302 patients, disabled from stroke, hip-fracture, osteoarthritis and other chronic diseases, aged ≥65years, assessed to have a rehabilitation potential and being referred from general hospital or own residence. Outcome measures: Primary: Independence, assessed by Sunnaas ADL Index(SI). Secondary: Hospital and short-term nursing home length of stay (LOS); institutionalization, measured by institutional residence rate; death; and costs of rehabilitation and care. Statistical tests: T-tests, Correlation tests, Pearson’s χ2, ANCOVA, Regression and Kaplan-Meier analyses. Results Overall SI scores were 26.1 (SD 7.2) compared to 27.0 (SD 5.7) at the end of rehabilitation, a statistically, but not clinically significant reduction (p=0.003 95%CI(0.3-1.5)). The PCDIR patients scored 2.2points higher in SI than the PCNHR patients, adjusted for age, gender, baseline MMSE and SI scores (p=0.003, 95%CI(0.8-3.7)). Out of 49 patients staying >28 days in short-term nursing homes, PCNHR-patients stayed significantly longer than PCDIR-patients (mean difference 104.9 days, 95%CI(0.28-209.6), p=0.05). The institutionalization increased in PCNHR (from 12%-28%, p=0.001), but not in PCDIR (from 16.9%-19.3%, p= 0.45). The overall one year mortality rate was 9.6%. Average costs were substantially higher for PCNHR versus PCDIR. The difference per patient was 3528€ for rehabilitation (p<0.001, 95%CI(2455–4756)), and 10134€ for the at-home care (p=0.002, 95%CI(4066–16202)). The total costs of rehabilitation and care were 18702€ (=1.6 times) higher for PCNHR than for PCDIR. Conclusions At 18 months follow-up the PCDIR-patients maintained higher levels of independence, spent fewer days in short-term nursing homes, and did not increase the institutionalization compared to PCNHR. The costs of rehabilitation and care were substantially lower for PCDIR. More communities should consider adopting the PCDIR model. Trial registration Clinicaltrials.gov ID NCT01457300 PMID:23150906

Smartphone threshold audiometry in underserved primary health-care contexts.

PubMed

Sandström, Josefin; Swanepoel, De Wet; Carel Myburgh, Hermanus; Laurent, Claude

2016-01-01

To validate a calibrated smartphone-based hearing test in a sound booth environment and in primary health-care clinics. A repeated-measure within-subject study design was employed whereby air-conduction hearing thresholds determined by smartphone-based audiometry was compared to conventional audiometry in a sound booth and a primary health-care clinic environment. A total of 94 subjects (mean age 41 years ± 17.6 SD and range 18-88; 64% female) were assessed of whom 64 were tested in the sound booth and 30 within primary health-care clinics without a booth. In the sound booth 63.4% of conventional and smartphone thresholds indicated normal hearing (≤15 dBHL). Conventional thresholds exceeding 15 dB HL corresponded to smartphone thresholds within ≤10 dB in 80.6% of cases with an average threshold difference of -1.6 dB ± 9.9 SD. In primary health-care clinics 13.7% of conventional and smartphone thresholds indicated normal hearing (≤15 dBHL). Conventional thresholds exceeding 15 dBHL corresponded to smartphone thresholds within ≤10 dB in 92.9% of cases with an average threshold difference of -1.0 dB ± 7.1 SD. Accurate air-conduction audiometry can be conducted in a sound booth and without a sound booth in an underserved community health-care clinic using a smartphone.

Poverty and response to treatment among panic disorder patients in primary care.

PubMed

Roy-Byrne, Peter; Sherbourne, Cathy; Miranda, Jeanne; Stein, Murray; Craske, Michelle; Golinelli, Daniela; Sullivan, Greer

2006-08-01

Despite well-established links between poverty and poor mental illness outcome as well as recent reports exploring racial and ethnic health disparities, little is known about the outcomes of evidence-based psychiatric treatment for poor individuals. Primary care patients with panic disorder (N=232) who were participating in a randomized controlled trial comparing a cognitive behavior therapy (CBT) and pharmacotherapy intervention to usual care were divided into those patients above (N=152) and below (N=80) the poverty line. Telephone assessments at 3, 6, 9, and 12 months were used to compare the amount of evidence-based care received as well as clinical and functional outcomes. Poor subjects were more severely ill at baseline, with more medical and psychiatric comorbidity. The increases in the amount of evidence-based care and reductions in clinical symptoms and disability were comparable in the two groups such that poorer individuals, although responding equivalently, continued to be more ill and disabled at 12 months. The comparable response of poor individuals in this study suggests that standard CBT and pharmacotherapy treatments for panic disorder do not need to be "tailored" to be effective in poor populations. However, the more severe illness both at baseline and follow-up in these poor individuals suggests that treatment programs may need to be extended in order to treat residual symptoms and disability in these patients so that they might achieve comparable levels of remission.

Cost-effectiveness of a Primary Care Intervention to Treat Obesity

PubMed Central

Tsai, Adam G.; Wadden, Thomas A.; Volger, Sheri; Sarwer, David B.; Vetter, Marion; Kumanyika, Shiriki; Berkowitz, Robert I.; Diewald, Lisa; Perez, Joanna; Lavenberg, Jeffrey; Panigrahi, Eva R.; Glick, Henry A.

2013-01-01

Background Data on the cost-effectiveness of the behavioral treatment of obesity are not conclusive. The cost-effectiveness of treatment in primary care settings is particularly relevant. Methods We conducted a within-trial cost-effectiveness analysis of a primary care-based obesity intervention. Study participants were randomized to: Usual Care (quarterly visits with their primary care provider); Brief Lifestyle Counseling (Brief LC; quarterly provider visits plus monthly weight loss counseling visits; or Enhanced Brief Lifestyle Counseling (Enhanced Brief LC; all above interventions, plus choice of meal replacements or weight loss medication). A health care payer perspective was used. Intervention costs were estimated from tracking data obtained prospectively. Quality adjusted life years (QALYs) were estimated with the EuroQol-5D. We estimated cost per kilogram-year of weight loss and cost per QALY. Results Weight losses after 2 years were 1.7, 2.9, and 4.6 kg for Usual Care, Brief LC, and Enhanced Brief LC, respectively (p = 0.003 for comparison of Enhanced Brief LC vs. Usual Care). The incremental cost per kilogram-year lost was $292 for Enhanced Brief LC compared to Usual Care (95% CI $38 to $394). The incremental cost per QALY was $115,397, but the 95% CI were undefined. Comparison of short term cost per kg with published estimates of longer term cost per QALYs suggested that the intervention could be cost-effective over the long term (≥ 10 years). Conclusions A primary care intervention that included monthly counseling visits and a choice of meal replacements or weight loss medication could be a cost-effective treatment for obesity over the long term. However, additional studies are needed on the cost-effectiveness of behavioral treatment of obesity. PMID:23921780

Intimate partner violence and HIV risk among urban minority women in primary health care settings.

PubMed

Wu, Elwin; El-Bassel, Nabila; Witte, Susan S; Gilbert, Louisa; Chang, Mingway

2003-09-01

This study describes the associations between intimate partner violence (IPV) and HIV risk among urban, predominantly minority women. Interviews were conducted with 1,590 women, predominantly African American and Latina, attending hospital-based health care clinics. Approximately 1 in 5 women reported experiencing IPV in their current primary heterosexual relationships; about 1 in 8 women reported experiencing IPV in the preceding 6 months. Compared to women who reported no IPV in their primary relationships, women reporting past or current IPV perpetrated by their primary partners were more likely to report having multiple sexual partners, a past or current sexually transmitted infection (STI), inconsistent use or nonuse of condoms, and a partner with known HIV risk factors. These findings indicate that urban minority women experiencing IPV are at elevated risk for HIV infection, results that carry important implications in the efforts to improve HIV and IPV risk assessment protocols and intervention/prevention strategies for women in primary health care settings.